S.M.A.R.T. procedure for ridge augmentation?

Hi. My concern is that there is no decortication done at the graft site (is this correct?), so I am somewhat dubious of the viability of the graft material and the incorporation to the underlying alveolar bone. Any research on this technique to show results of graft incorporation compared to conventional onlay grafting? Thanks!

S.M.A.R.T. is the best for horizontal augmentation. I've never heard it is suitable for ridge augmentation. And SMART can have best result with bovine GBR such as BioOss & InterOss which have more porosity on surface. For ridge augmentation, you would like to have allograft in the socket and little bit of bovine on ridge (about 25% or 20%) right under membrane. Bovine GBR will help keeping volume through years.

Dr. Lee's claim of developing the Technique is incorrect. I have been doing this technique since 1995 and presented the technique at the American Academy of Implant Dentistry 50th Anniversary Annual Meeting ( New Orleans 2001) If properly done it is an excellent bone grafting technique. docjj1 comment on decortication is correct, I use a long straight #6 Surgical Burr with extreme care not to damage the soft tissue. The technique can be done with bone particles as well as with donor blocks, depending if the desire is horizontal or vertical augmentation. A combination of particle and block is also used with extreme positive result. Depending on the case sometimes the blocks need to be secure with screws and in other cases the bone is secure by the soft tissue. The membrane that I use is the patients own periosteum, since it has a candmium layer that as we all know generates bone. Usually in 4 month the graft turns into D1 to D3 bone, and it turns from 56 to 95% of new bone. Histology to back this claim was done in several cases by Dr. Mohamed Sharaway at the Medical College of Georgia School of Dentistry. I am available to answer any question.

Raul R. Mena, how is access achieved to the bone? Where is the point of entry for the incision made(apical to mucogingival junction) ?

How is this procedure any different than the tunneling technique which has been described by others? I think the issue that some had with the tunneling technique was particulate migration, but you can solve that problem nowadays by using a demineralized cancellous sponge strip or some other type of allograft block.

I can visualize horizontal defect augmentation simply by converting a concavity to a convexity BUT How is vertical augmentation achieved predictably without periosteal release?

Tunneling techniques for bone grafting have been around since the work of Kent et al at LSU in the early 80's, using HA to augment posterior mandibular segments in an effort to improve retention in denture wearers. In 2004 Block and Degen published on the use of particulate graft material using a tunneling technique, prior to implant placement in the mandibular posterior region. There have been other papers as well (Hasson 2007, Kfir et al 2007). In spite of the existing publications, plus all manner of anecdotal claims, the reality is that tunneling techniques for bone grafting have never enjoyed acceptance because of issues related to graft migration, inadequate graft integration and dimensional stability. Otherwise we would all be performing these procedures today. The S.M.A.R.T. protocol we developed includes a number of refinements that increase predictability while decreasing morbidity. It is a minimally invasive, growth factor mediated regenerative protocol, with a biologic rationale based on the work of Nevins et al 2009, Simion et al, 2009 and Simion et al 2006. It requires no decortication, no tenting screws, and no membranes. In the March/April 2017 issue of IJPRD, we published the results of 60 treated sites in 21 patients, with up to 30 month follow up and human histology. I stand by the data presented. For more information, please visit www.smartbonegraft.com where a number of clinical cases are available for review, including vertical augmentations. We have harvested several cores and will be publishing additional human histologic results in the future. I want to thank Osseo News and its readers for their continued support. Regards to all.

Access is obtained by a vertical incision both in the maxillary and the mandibular area. In the mandibular area it can be either performed distal or mesial to the mental foramen. Careful elevation needs to be performed after the nerve is located, one of the most difficult situation is on the severe vertical resorption when the nerve is exposed at the crest. Migration can be controlled easier when performing horizontal augmentation. For vertical augmentation a block graft is usually required. Decortication is not required, but is highly recommended, and with proper training and the right burr and handpiece it can be accomplished. If necessary Careful periosteal release can be performed. My bone to go is Irradiated Cancellous particles and Irradiated Cortico Cancellous blocks from Rocky Montain tissue bank. My other choice is also Cancellous particles and or Cortico Cancellous Block from Maxxeus Tissue Bank. As I mentioned before I have histology on different cases by obtaining cores from different grafted sites. We have fallow up of well documented cases up to 23 years in function, and records of before and after PA XRays, Panoramic and CT Scaning and Photograph before during and after the surgery on every Patient. Some of them documented with CT 23 years after treatment. Also Histolgy by Dr. Mohamed Sharaway. (Documentation Way beyond Anecdotal). I don’t use any growth factors except the one provided by the Biology of the patient. Drs. Visiting Fort Lauderdale Florida are welcome to share some of these well documented cases. I am glad to hear the good result that Dr. Lee has obtained using the Sponge technique, I am sure that he probably obtains good results.

If I remember correctly, from dr Lee's lecture, decortication is done manually using back action chisels. I know how ludicrous it sounds. For vertical augmentation, dr Lee uses Ossif demineralized sponge strip, that is being compressed during application, and springs back to original volume by its inherent elastic properties. I know, this sounds even more unbelieveable. For lateral augmentation he said , he firstly inserts collagen membrane, dry and rigid, to tent tunnelized mucoperiosteum and then uses bone graft material packed in syringe.

You can watch Dr. Samuel Lee's video here: https://www.osseonews.com/topic/techniques-demineralized-sponge-strip-and-tunnel/

All the talk of "95% " new host bone is interesting .... where is the Histo and Histomorphometry ???? Talk is easy science separates the chaff .. Kind Regards

Peter let me know how to attach a jpg to the posting and I will posted. Raul Mena

There is clearly some confusion here, as it seems that some of the comments do not refer to our work. The S.M.A.R.T. protocol has never included the use of any sponge or membranes. I am unable to comment on unpublished claims and would encourage everyone to submit their data to an appropriate journal for scientific scrutiny and the benefit of our profession. To view a description of the S.M.A.R.T. technique and download a copy of the original article please visit www.smartbonegraft.com. A distinction must be made between a lateral pouch approach, and the laparoscopic tunnel access utilized in the S.M.A.R.T. method. Some of the cases displayed in the S.M.A.R.T. website gallery section require tunnels 25-30 mm in length. The dimensions of these tunnels need to be controlled in order to avoid graft migration. As tunnel length increases, it becomes unrealistic to control the position of a membrane, or to perform decortication without risk of periosteum injury or excessive release. Additionally, S.M.A.R.T. is based on growth factor mediated regeneration, where the use of membranes is not required and may actually be detrimental. (Simion et al 2006, Simion et al 2009, Nevins et al 2009). With regards to decortication, a review published in 2009 by Greenstein, Greenstein, Cavallaro and Tarnow, found no conclusive evidence that it may improve GBR outcomes. We have human histology from a S.M.A.R.T. treated site at 2 months, that clearly shows bone proliferation starting from the periphery of the graft, including the portion facing the unprepared bone surface. At the appropriate time, we will share human histology samples at different healing points with OsseoNews readers. Thanks again for your support. Regards to all.