Bone Augmentation

Bone Augmentation
• For dental implants to be successful, the jawbone
must have enough bone to support them. You may
not have enough bone because of tooth loss from
periodontal (gum) disease, injury or trauma, or a
developmental defect. If your jaw is too short (up
and down), too narrow (side to side), or both, you
will need a procedure to add bone to your jaw before
implants can be placed.
• Bone augmentation is a term that is used to
describe a variety of procedures that are used to
"build" bone so that dental implants can be
placed. These procedures typically involve
grafting (adding) bone or bonelike materials to
the jaw, and waiting for the grafted material to
fuse with the existing bone over several months.
• There are several different procedures that can
be used for bone augmentation. The dentist will
select a procedure depending on the type,
location and number of implants to be used.  If it
needs a bone graft, it is important that the
patient and the dentist discuss all of the options
available.
• After a bone-augmentation procedure, the
dentists usually wait 6 to 12 months before
placing implants, although some dentists may
place them sooner.
Where Does the Bone Come From?
• Most bone-augmentation procedures involve the use of bone
grafts. The best material for a bone graft is our own bone,
which most likely will come from our chin or ramus (the back
part of the lower jaw). If the oral surgeon cannot get enough
bone from these areas, he may need to get bone from the hip
or shin bone (tibia) instead. The hip is considered to be a
better source because the hip bone has a lot of marrow (soft
tissue within the bone), which contains bone-forming cells.
• If the patient don't like the idea of having bone removed from
their body to be placed in their jaw, there are other options
available. The dentist can use materials made from the bone of
human cadavers or cows. There are also synthetic materials
that can be used for bone grafting. While most dentists prefer
using a person's own bone, possibly in combination with other
materials. The dentist and the patient should discuss their
options and their risks and benefits before any procedures are
done.
A Typical Bone-Augmentation
Procedure

• Local anesthesia will be used to numb the area

where the bone augmentation is needed
(recipient site) as well as the area from where
bone will be removed (donor site). The specialist
first will make an incision in the gum where the
implant will be placed to determine how much
and what type of bone is needed.
• Then will make an incision in the gum below the
lower front teeth to expose the chin bone. A block of
bone will be removed from the chin along with any
bone marrow. The specialist will fill the spot where
the bone was removed with another type of bone-
graft material, and will cover this with a membrane
to keep soft tissue from filling the space as it heals.
The incision then will be stitched closed.
• To place the removed bone in the recipient site, the specialist
first will drill little holes in the existing bone to cause bleeding.
This is done because blood provides cells that help the bone
heal. The block of bone that was removed from the chin will be
anchored in place with titanium screws. A mixture of the
patient's bone marrow and some other bone-graft material
will then be placed around the edges of bone block. Finally,
the specialist will place a membrane over the area and will
stitch the incision closed.
• After a bone-augmentation procedure, the patient will be
given antibiotics, pain medication and an antibacterial
mouthwash. He will be asked to avoid certain foods, and
will be told how to avoid putting pressure on the area
while it heals. If the patient wear a denture, he may not
be able to wear it for a month or longer while the area
heals. If you have natural teeth near the bone graft, your
dentist may make a temporary removable bridge or
denture to help protect the area.
• The bone graft will take about 6 to 12 months to
heal before dental implants can be placed. At
that time, the titanium screws used to anchor the
bone block in place will be removed before the
implant is placed.
Success of Bone Grafting
• The success rate for bone grafts in the jaws for the
purpose of placing dental implants is very high.
However, there is always a chance that the bone
graft will fail, even if your own bone was used. Bone
grafts are not rejected like organ transplants. When
they fail, it is usually because of an infection or
because the grafted bone wasn't stabilized and has
come loose from your jaw.
• Dentists don't know why some bone grafts fail,
but they do know that certain people — such as
those who smoke and those with certain medical
conditions — have a higher risk of graft failure
than others.
• A failed graft will be removed. Once the area has
healed, your dentist can place a second graft.
Other Types of Bone-Augmentation
Procedures
Sinus Lift
• One type of bone-augmentation procedure,
called a sinus lift (or elevation), increases the
height of your upper jaw by filling part of your
maxillary sinus (the area above your jaw on
either side of your nose) with bone. This is done
when there is not enough bone to allow implants
to be placed in the back part of the upper jaw.
Ridge Expansion
• A ridge expansion is a type of bone graft that can be done
when the jaw is not wide enough to support implants.
Your oral surgeon uses a special saw to split the top of
thejaw ridge, and then packs graft material into the
newly created space. Some dentists will place implants
directly after this procedure. Others will wait several
months for the ridge to heal. This procedure can be done
in the dental office under local anesthesia.
Distraction Osteogenesis
• One of the newest procedures for augmenting areas of bone is called distraction

osteogenesis. This procedure originally was used for lengthening the bones of patients

with abnormally short legs. It now has been adapted for use in the mouth. A surgeon

makes cuts in your jawbone to separate a piece of bone from the rest of the jaw. A

titanium device inserted into the jaw with pins or screws holds the piece of bone apart

from the rest of the jawbone. Over time, the space between the piece of bone and the

jawbone is widened slightly by unscrewing the device, and the area between the pieces

gradually fills in with bone. "Distraction" refers to the process of separating the two

pieces of bone, and "osteogenesis" refers to the forming of new bone. Distraction

osteogenesis is used more often to make the jawbone taller, but it can be used to

increase the bone in any direction. The procedure is becoming more common.
Nerve Repositioning
• A nerve called the inferior alveolar nerve runs through the
lower jaw. This nerve gives feeling to the lower lip and chin. In
patients who have lost significant amounts of lower jawbone,
it may not be possible to place implants without damaging this
nerve. To address this problem, an oral surgeon can drill a
small window in the bone and move the nerve to one side. The
implants then can be placed through the bony canal
previously filled by the nerve. This technique is not used very
often because it is possible to damage the nerve just by
moving it.
Case Report
• A 53-year-old female patient came to the Clinic
of Oral and Maxillofacial Surgery of the Ribeirão
Preto Dental School, University of São Paulo,
Brazil, complaining of impairment of her
masticatory function associated with the
instability of the mandibular complete denture.
• The clinical exam revealed edentulism in both
arches, while the mandibular arch presented severe
reabsorption resulting in denture instability and
chronic trauma to the oral mucosa. The
radiographic exam showed a mandibular atrophy
class VI, according Cawood and Howell (12), that
made unpredictable any rehabilitation based on
osseointegrated implants.
• Figure 1. Panoramic radiograph exhibiting a
class VI Cawood and Howell (18) mandibular
resorption.
The treatment plan proposed consisted of 3 steps:

• 1) to apply the modified visor osteotomy technique

together with autogenous bone graft harvested from the
iliac crest;

• 2) the placement of at least 5 osseointegrated implants

with a minimum length of 13 mm; and

• 3) to construct a fixed Brånemark’s protocol prosthesis.

• The first surgical procedure was applied under
general anesthesia at the Hospital of Clinics at
the Medical School, University of São Paulo,
Brazil.
• Figure 2. Visor shape of mandibular distal
segment after the mobilizing the segments.
• Figure 3. Autogenous corticocancellous bone
grafts placed in an intepositional fashion, fixed
with 2.0 titanium screws. Only particulated bone
was placed in the posterior aspect of the
mandible.
•
• After 6 months, 6 osseointegrated implants with dimension of 3.75 x 15 mm

were implanted according to a previous prosthetic treatment plan. Four

months later, these implants were exposed to the oral cav-ity using abutment

healings preserving the keratinized gingiva, and 3 weeks after that the patient

was referred to the prosthesist. Twelve months after the installation of the final

Brånemark protocol prosthesis, the evaluation of the osseointegrated implants

revealed suc-cess according to the previously established criteria (15).

• Figure 4. Different views of modified visor
osteotomy in a dry mandible.
Figure 5. Uniform augmentation
both in anterior and posterior
region of the mandible, as
demonstrated in a panoramic radiograph. 

Figure 6. Placement of long

implants for rehabilitation
of the edentulous mandible.
• Figure 7. Good oral health after 12 months of
follow up.
• The modified visor osteotomy technique, applied
together with autogenous bone graft harvested
from the iliac crest, offers predictable results for
reconstruction of the severely resorbed
edentulous mandible and posterior
rehabilitation with osseointegrated implants.
Video Presentation:

Box Technique - Vertical Ridge

Augmentation Procedure in
Severe Mandibular Atrophy.
Box Technique
• Box technique was invented in November 2008
by Dr. Andrea Menoni. It is the first
prosthetically guided by bone regeneration
technique aimed at fully restoring the lost bone
volume by using only Polylactic acid absorbable
materials.
• The technique allows bone regenration in 3
dimension of space without the need for bone
grafts to the patients, thus minimizing the
trauma of surgery.
• The aim of box technique is to fully restore the
bone to approximately its original condition so
that it is not only functional but also
aesthetically pleasing.
• The use af absorbable material is beneficial for
the following reasons:
• 1. a second operation for their removal is not
required.
• 2. the surgical intervention is far less traumatic
for the patient
• 3. in cases of osseointegrated implants, the
rehabilitation period is significantly reduced.
• The poly DL lactic acid is an absorbable material
which is completely amorphous as both components
are present in equal proportions. As a result, the
biodegration process is completely predictable and
safe. This new material is fully tolerated by human
tissue and does not result in inflammation after
contact with the PDLLA after application sonic weld
methodology.
• The degredation of PDLLA and its componentsis
through the metabolic process of hydrolysis, where
upon the final product is water and carbondioxide,
both of which are physiologically eliminated from
the body. This innovative material presents the
prime advantage of being reabsorbed while
simultaneously maintaining its structural strength
for the time necessary to ensure the stability of the
dot, the graft, and the load resistance. All of which is
important in GBR (guided bone regeneration).
• The box technique is a new technique which
prosthetically used a guided bone regeneration and
only uses absorbable materials which are processed
naturally by the body. This revolutionary method
does not require the use of the patient’s bone in the
regeneration process. Instead it uses a choice of
either XENOGRAFT or ALLOGRAFT creating
discomfort to the patient.