Ridge Augmentation

Don´t take unnecessary risks. Perform a block bone graft and wait.

I agree. . .especially with a 10mm fixture. 50% thread exposure is a risk I wouldn't be willing to take. I, too, would block graft obtaining the graft from the external oblique ridge. That said, I am never sure if I should use a resorbable membrane with a block graft. Some have worked fine without, but recently, I lost 2/3 of a graft in the Maxillary central area.

I recommend performing a ramus block graft first. You do not have to use a membrane. I have done a few hundred of these with and without membranes. I only use a membrane if I'm also using some particulate graft on the periphery.

Take a look at C-Graft. This is a natural marine algae graft material. No other material has the research or long term clinical use behind it - see Journal of Oral and Maxillofacial Surgery Dec 2005 issue

i think if you can be sure about pimary stability and even with 50%of thread exposed try xenograft materials with resorbable membrane .i did it it works perfectly ,but unfortunately you have to wait around 6 month

It is risky. I suggest to play safe. I usually use Bio-Oss with a Biomend extend membrane. It is best firmly attached with tacks or screws. But you also have to be sure that the flap covers the membrane completely. And use as an aid aclorhexidine gel and/or mouthrinse. Also, prophylactic antibiotic therapy will be recommendable. Also if the patients agree you should use autogenous bone graft from the chin or the ramus

Well, interesting question. I used to do it in two stages, but now I do it one-stage using plasma rich in growth factors (an evolution of PRP), and mix it with ridge bone harvested during the drilling, which I do at 50 rpm with special, more sharpened, drills. Bone harvested this way is, from a cellular point of view, alive, duly trabeculated and a better material for grafting (never use bone from the filter, it´s full of bacteria!!!). If additional bone is required, I get bone from the ramus with a trephine, or even the tibia or the hip. Hope this helps.

i have been using Beta-tricalcium phosphate (alloplast) which is in a hydroxl sulphate matrix which makes it set hard thus no need for a membrane,thus improved blood supply for healing.In the last 2 years with this have had impressive results...truely osseoinductive and safe and easy to use...

Dr. Neale asks about treatment for ridge augmentation to replace teeth #'s 29 & 30 use Allograft Puro. Dr. Hahn has a suggestion to use a 50/50 mixture of Pepgen Flow and Pepgen Particulate. Mixing the two together results in a marshmallow form easy to place. The pepgen flow allows spacing of the particles to enhance blood supply. I have used this mixture for the last three years and the results are predictable allowing implant placement in good quality bone after 120 days. I also would suggest smoothing the facial threads, flap the tissue, decorticate the bone surrounding the threads and place the above mentioned material. Interested to learn more, phone Jan at 888-898-2583.

The decision to perform a guided bone regeneration procedure synchronous with placement of a submerged or non-submerged implant in non- esthetic areas, is based upon many factors including the following; the ability to obtain adequate primary implant stability, quality of soft tissue cover at the site, ability to obtain passive coronal advancement of the cover flap over the graft/membrane complex, postoperative patient compliance during phase one bone healing, use of autogenous particulate cancellous marrow graft, use of suitable osteoconductive graft material, and stabilization of the graft and membrane. Nevertheless, the most critical factors for predicting the successful reconstruction of the osseous defect and bone regeneration is the morphology of the defect, and in the case where synchronous implant placement is desired, whether the implant surgeon is able to place the implant within the confines of the existing alveolar housing. This information was detailed very well by Drs. Buser, Dahlin, and Schenk in their textbook; Guided Bone Regeneration in Implant Dentistry (Quintessence 1994). Preoperative CT images allow the surgeon to make this assessment prior to surgery. If a CT is not possible or practical, the surgeon can begin the osteotomy preparation and place a depth gauge to asses whether the fixture will be placed within the alveolar housing from a horizontal perspective. If so, the surgeon proceeds with autogenous bone graft harvest and preparation ( rehydration etc.) of the xenograft, Allograft, or synthetic bone graft expander, and shapes the selected membrane for a custom fit at the site and around the implant neck or abutment or over the crest of the ridge. Once the surgeon verifies passive flap coaptation and the site is isolated from saliva, the implant is placed and the GBR procedure is performed. Use of PRP greatly facilitates the delivery and stabilization of the graft and membrane. I use a 1:1 ratio of autogenous graft with the bone expander as well as a slowly resorbable collagen membrane. As a general guideline, I look for 75% of the fixture to be within the alveolus and recognize that the wider the defect, the more challenging the case. This approach has yielded predictable results for the last 12 years with both synchrounous submerged and non-submerged implant placements. If these conditions do not exist, I follow a staged approach with block and particulate grafting performed 4 months in advance of implant placement. If soft tissue cover is poor, soft tissue grafting is performed 3 months prior to bone grafting. If shallow vestibular depth is a problem , I compensate with an exaggerated curvilinear flap design as described in my textbook; Soft Tissue and Esthetic Considerations in Implant Therapy ( Quintessence 2003). In esthetic areas, I follow a completely different algoritm for reconstreuction of alveolar ridge defects

Can anybody convince me why one should go to all this troble and still risk failure when staged approach can gauranty better predictability?

Great book Antony,I bought it recently..what are your thoughts on Beta tri-ca products as the results are very impressive in defect repair and sinus lift procedures over the last 2 years using the material..

Peri-operative risk is the most important variable in this case. If you are skilled like Dr. Sclar and similar surgeons with extensive experience with GBR methods and simultaneous implant placement, you can certainly consider combining the procedures. If you are not experienced in GBR methods, the safest approach is to first graft the site with a mono-cortical, autlogous bone graft with rigid screw osteosynthesis followed by implant placement 5 months later. Definetely consider the latter approach in risk-averse patients and patients with co-morbid conditions that may pre-dispose the patient to higher risk of infection or wound failure

Being a boarded periodotnist and having been doing these procedures for the last 16 years, I would like to pose a perspective that has evolved for me. This came mostly from listening and seeing the acknowledged leaders in the surgical fields. From a results point of view, it is almost always best to do the staged procedure. You can always add more bone either a second grafting, at the implant placement or the uncovering procedure. In addition, the soft tissue can be modified at every surgical opening as well. The worst problem is when the implant integrates and there is exposed fixture surface or only soft tissue(thick or thin) on the facial aspect of the titanium. Now you have a real mess. In the esthetic region I almost always graft and then return for placement. However if the esthetic case has an intact socket or has an integrity break with adequate dimension, these can be immediately placed and most likely flapless.

Good comments on the subjects. I have been doing these procedures for the last 10 years, and used to do exclusively 2 stages (one for gratf, one for implant). With the advancement of slow resorbable membranes, I now use both approaches. IF you can get good primary stability, and place the implant in the correct 3D position regarding the esthetic restoration, the technique used by Dr. Buser and explained by Dr. Sclar is great, and still allow us to do soft tissue correction later if necessary. Conical implants, specially the 12 or 14 mm Straumann 3.3x4.8 TE is excellent for that, giving regular neck restorative emergency with small body,and great primary stability. I also do soft tissue augmentation at the same time as the bone regeneration with particulate autogenous bone, bone replacement (Algipore or C-Graft) and membrane (3I Ossix). However, if the defect does not allow correct 3D position and stability, then autogenous block from the ramus with GBR is the best choice, and 4-5 months later the implant is placed. Agree with Sclar's comments.

send me more imformationabout bio oss

why would the procedure be so different as long as implant stays buried under primary closure or primary closure with a resorbable membrane such as biomend or such as Tefgen. I can understand that possibility of complication will be more with a membrane such as tefgen since one does not have a primary closure but in reality, why would placement of implant would make such a big difference for buccal onlay graft? as one of the dr suggected, osteotomy site can produce some autogenous mixture which can be more beneficial, implant can provide some rigid support for the graft material. combine that with a graft material such as reginoform, I think it can be a success.

Simultaneous implant placement and grafting over the implant could be problematic because the graft material lacks contact with host bone tissue at the area that the graft is in contact with the implant. Blood supply, antibiotic penetration, osteoconduction, osteogenesis, osteoinduction, and other vital bone graft healing physiology processes are compromised when the graft material is placed over implant instead of host bone.

The tricalcium phosphats are not suitable nevertheless they cost only 0,25 € Kg. It is generaly used in the finishing of the walls of our homes and you can buy it in local markets. It is great material for periodontic treatments but is absorbable in 3 weeks. when using onlay grafs the only suitable and success technique is autografts in bloks without membrane. Other way you have to use titanium membranes and any alograft absorbable for 4 to 6 months (i mean any - it is just to help keeping the space from gum cels and fibroblasts). The bone formation wou can read it in Lindle Books is between 2,5 and 4 months - that is the time to wait to put your implant and the wait another 4 to 6 month. To put the implant and the graft you have to be sure you have primary stability in at least 4 mm of the implant but the succes rate is worst. You can use osteotomes and GBR only with few bone needing, if you want success! Remember your pacients pay you to do a job not to try out, if you can not do it don´t. If anything fails you have a problem, a 1 to 2 year to resolve it, is is not suitable.

Can anyone tell me why a membrane to prepare the bone regeneration would cause an accumulation of a mass in the lower gum line as well in the facial area?

The use of beta TCP for ridge augmentation will soon become a new modality. We are currently using TCP blocks infused with rhPDGF and stem cell aspirates with beautiful results. We will be publishing our results in the near future. I am of the opinion that the days of autogenous block grafting will be coming to an end. We will see a new era of alloplastic bone substitutes, infused with the appropriate cocktail of growth factors, that will become a new "platinum standard" for augmentation in the maxillofacial complex.

I am patient and I have received conflicting views from 2 different oral surgeons on the most appropriate grafting material for my implant. One of the oral surgeons insisted that autogenous is the ONLY way to graft. But, that involves additional surgery, healing time and risk of infection at donor site. Any thoughts from the experts?

Of all the available bone grafting materials, autogenous bone has the most studies. It doesn't mean that other materials are not good. Currently, with the ongoing case of a tissue harvesting company obtained bone and other tissue by stealing from funeral homes, it highlights the potential risks of using donated bone. Other man-made materials come and go, and any new material needs to withstand the test of rigorous studies which are not common in the dental field and/or the test of time. As an oral surgeon, I believe the other important question beyound the ones concerning graft material is soft tissue break-down. This is one of the most common cause of bone graf failures. Ask your surgeon his/her view on this. The other question to ask, regardless of source of graft material, is the overall sucess rate when implant is placed in grafted bone.

I am a patient with a most unusual case. I have lost 75% of the bone around my teeth; most are somewhat mobile. Absolutely no perio- dontal disease--just disappearing bone. I do not know how to proceed. Am assuming the teeth cannot be saved. Should extraction sockets be filled with non-resorbable material? Thank you for any comments. Judy

Judy: No non resorbable material. Probably implants and grafts inmediately after extractions and hopefully you can get a temporary implant supported fixed prosthesis for your healing process.

Judy: Filling the sockets, or "socket perservation" doesn't work any better than letting the sockets heal naturally. This conclusions is from my reading of the available studies, my own experiences as an oral surgeon, and cases that I have seem for second opinion when the patients who had "socket perservation" done by other dentists still didn't have enough bone for implants. On the other hand, grafting with placement of guided tissue membrane and primary closure may work, subject to all the concerns of bone grafting. Non-resorbable material will most likely exclude these areas from implants, as there is the possibility of less nature bone for the implants to heal to. Also, the material is usually of the type that is very brittle (Hydroxyapatite) and therefore not suited ideally for loading.

The first commentn (Dr.Callamand) is the key of this problem.I would add to use a good implant company and not the "cheap" new companies, that are only taking advantage of the traditional companies.Doctors beleive that when they save some pennies in implants are doing a big deal, but it is not!Cheap companies turned doctors into buyers like in the open Market from a trditional old town when they buy lettuce and onions......"how much for that? " "I get better price there...."Which is the last price?...."It is too expensive? "....and when they get the right price they do not reduce the implant fee for the patients and have no opportunity to sell more implant treataments. It is really absurd that we think in that way.....

Best material to use is a material that will give living bone. There is NO synthetic material that will cause the body to produce LIVING bone to support the implant. Also, DBM bone will produce real bone, why put the patient through a chin or ramus graft when there are better materials to use?

I agree with Dr Callan. Allografts will give you the vital bone needed for implant placement. However,instead of using just demineralized bone (collagen) adding the scaffold component to it will provide both the osteoinduction and the osteoconduction to maintain the augmented dimension of the graft. Instead of mixing two materials, there is now a single syringe of a paste that has both min and demin called OrthoBlast. Handles well and gives what us what we need in these sockets.

Does anyone have experience using Emdogain (Straumann) in these situations? I noticed they launched a combo pack of Emdogain and their synthetic bone in Europe, mainly for large defects.

I Used TefGen (Lifecore) for extarction site preservation before implanting them with an acceptable success rate. Anyone familiar with that?

To Robert Miller, is this beta TCP on the market? As a patient and assuming Im understanding what you are saying and besides needing a block graft, I am horrified that my oral surgeon suggested grafting from the chin and am now looking into the hip block which for a single, tall, attractive middle class gal, this petrifies me! Time is running out for me as Ive had #9 upper reglued 6 times in the last year and the endodontist tried to do what he could. In your opinion, will this be available soon if not already? I would surely commit to the procedure before the alternatives. Thanks

Pardon my ignorance, what is DBM bone? I need bone graft in #9,10 & 11 area.

Dentist put Osteogen in wisdom tooth extraction site without asking me. I have had infection, excruciating pain. Dentist dismissed me. I went for 1 year before finding someone to remove. It is healed over now but have pain for 2-1/2 years. What can I do?

DBM is Demineralized Bone Matrix and it comes from cadavers. I personally would not use this due to the possibility of disease transmission. I would either go with autogenous (your own bone graft) or some type of synthetic bone graft or maybe Bio-Oss (cow bone graft.)

whats the differrence of Bio-oss, Beta TCP and other grafting materials? Is it not that their function is the same for all of them? to provide scaffolds for the bone formation?

Bio-Oss is a bovine substitute. It holds the ridge form well but has an exceedingly long turnover rate. bTCP is available in both particulate and block forms from the company Curasan. The advantage to this alloplastic material is that it will resorb completely within 6-8 months resulting in total autogenous replacement. More bone to implant contact is the desired result.

Choice between ramus vs symphysis bone for block graft augmentation of maxillary anterior buccal defects....opinions?

Re:ramus vs symphysis, I am using more ramus block grafts these days as it's not uncommon for patients to report,"woody feeling teeth" after symphysis harvests. The tibia is also an easy place to get some good bone.

Look at histologic slides, bio-oss never truly turnsover but get incorporated into the bone matrix but is essential dead. Good for graft stability and some volume. TCP good volume agents as well as the puros products but nothing is better than autogenous bone. One must be careful and choose their products wisely. One must always consider what they are trying to accomplish. No product fits every situation. In order for non-autogenous tissue to work, the patient and/or the recipient site has to have the necessary osteogenic potential to match the material and the clinical defect and the desired outcome. For instance and young person with a simple extraction with no soft tissue defects and solid bony walls around the entire socket, you probably could graft with shavings from your dental stone and it would work for a graft (don't try it...just stating with a high osteogenic potential--almost anything works). If you have a frail old women, not in the best of health with poor quality bone and in need of soft tissue augmentation as well as a 3-D reconstruction of the osseous contours, very few if any non-autogenous products alone will solve this low osteogenic potential situation. Time after time I see reps from company's tell me and others that their product is better than the patient's bone !! So I am to assume I should remove all the bone in the patient and put in their product as it is better? Nothing today is more effective and reproducible than grafting with autogenous bone. Unfortunately autogenous bone has no sponser, corporation, marketing team and good looking representatives selling it !!!!!! Just food for thought. Biomaterials are a nice adjunctive tool for bone grafting, but it has to be used in the proper situation.

Thanks for the post Dr. Miller. Also, excellent post Dr. Bohannan (how are you by the way?) You're still the smart guy. Hope all is well. Are you using much Ct imaging with your implant cases? Scott

Sorry to see that this site has not been updated with comments for a while...

I have recently had (~1.5 weeks ago) oral surgery to place Infuse (BMP-2 in a collagen matrix protected with a screen held by tacks in the maxillary and palatal regions - also added bone material) in the maxillary region from 8 to 11. Possibly my temporary prosthesis is/was malformed and applied pressure to part of the surgical region and caused necrosis of part of the surgical flap covering 8 and 9. Is it advisable to get a soft tissue graft to replace the part of tissue lost to necrosis?

make removal and be sure there is blood supply around and let it heal by 2nd intention. Go back use CT graft to bulk soft tissue or allodermis . I would use PDGF for soft tissue enhancement. BMP is good bone graft but expensive compared to other biomaterials. whomever did your graft , ihope they had previous experience with managing this type of material, I have used for sinus graft, it change to type 1-1 bone very dense.

make removal and be sure there is blood supply around and let it heal by 2nd intention. Go back use CT graft to bulk soft tissue or allodermis . I would use PDGF for soft tissue enhancement. BMP is good bone graft but expensive compared to other biomaterials. whomever did your graft , ihope they had previous experience with managing this type of material, I have used for sinus graft, it change to type 1-1 bone very dense.

make removal and be sure there is blood supply around and let it heal by 2nd intention. Go back use CT graft to bulk soft tissue or allodermis . I would use PDGF for soft tissue enhancement. BMP is good bone graft but expensive compared to other biomaterials. whomever did your graft , ihope they had previous experience with managing this type of material, I have used for sinus graft, it change to type 1-1 bone very dense.

My understanding is that BMP is expensive due to the amount that must be purchased though not that much is needed. (The BMPs on the market now - InFuse and OP-1 that I know of - are sold in volumes that are required for spinal fusion surgeries) I saw that Dr. Miller is using the TCP blocks infused with rhPDGF and stem cell aspirates. Am I correct in assuming that he is recruiting mesenchymal stem cells? I recently had a thought that it would be useful and beneficial in many ways to extract these stem cells from the patients own marrow. (Also with the patients permission of course, to allow the marrow to be typed to increase the pool of potential marrow donors.) Anyway, I was thinking that one would use the stem cells along with a cocktail of hr PDGF, FGF, IGF-1, and BMP. I suppose you would want some type of HA/Ca Phosphate that would possibly be delivered in some kind of collagen vehicle. It seems like this kind of approach would make allograft superfluous and would yield very good osseointegration. I am just a biochemist and I'd like to hear some feedback on this idea.

Any opinions on Emdogain vs GBR for perio intrabony pockets?

I appreciate the post of dr. Bohnnan, I would like to ask about the combination of Bio-oss with Emdogain. Is it worth the mixture?

You may consider a ridge split, graft with Osteogen and plase the implants at the same time. Cover with a collogen membrane, protect the site and call it a day. Doing it this way will make it a 5 wall defect not a 4 wall defect treatment.

CORRECTION: Makes it a 5 walled defect vs a 1 wall defect.