vertical bone augmentation: methods and prognosis by chulmin bae
DESCRIPTION
University Hospital of Muenster Department of Cranio-Maxillofacial Surgery Director: MD, DMD, DHC, PhD U. JoosVertical bone augmentation: methods and prognosisMaster ThesisMaster of Oral Medicine in ImplantologyInternational Medical College Medical Faculty Of the Westphalian Wilhelms-University of MuensterSubmitted by:Chulmin Bae Seoul, Korea 2008-2-Table of ContentsExecutive Summary ............................................................................... 3I. IntroducTRANSCRIPT
University Hospital of MuensterDepartment of Cranio-Maxillofacial Surgery
Director: MD, DMD, DHC, PhD U. Joos
Vertical bone augmentation: methods and prognosis
Master Thesis
Master of Oral Medicine in Implantology
International Medical CollegeMedical Faculty
Of the Westphalian Wilhelms-University of Muenster
Submitted by:
Chulmin BaeSeoul, Korea
2008
Table of Contents
Executive Summary ................................................................................. 3
I. Introduction .......................................................................................... 4
II. Materials and Methods ....................................................................... 5
III. Results ................................................................................................ 6
IV. Discussion .......................................................................................... 19
V. Conclusion .......................................................................................... 21
Executive Summary
Vertical bone augmentation: Methods and Prognosis
Project objectives
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To review all the existing methods for the vertical augmentation used in dental
implant and evaluate the prognosis and complication according to the different methods.
Materials and methods
The comprehensive overview of English literature is done through the Pubmed site
and the literatures related to various bone augmentation techniques is outlined. The key
word for the search was vertical augmentation and dental implant .The limitation for
this review was 10 years and dental journals.The number of literature reviewed was
167 and the databases were Medline and Pubmed , with non-peer-reviewed articles
eliminated as much as possible.
Results
Several techniques have been developed to treat insufficient volume, but only four
of the most commonly performed are described. Three are frequently used: (1) sinus
floor elevation and (2) bone block graft, involving either a cortical or cortico-cancellous
graft and (3) GBR .The fourth is the technique of bone distraction, which is still in
development and may show promising results in the future because of its great
biological pertinence.
Depending on the implantation site, the morphology of the bone defect and the
quantity of bone to be repaired determine the techniques used in oral surgery.
Conclusion
Many different techniques for reconstruction of bony defect exist for effective bone
augmentation. The approach is largely dependent on the extent of the defect and specific
procedures to be performed for the implant reconstruction It is most appropriate to use
an evidence-based approach when a treatment plan is being developed for bone
augmentation cases.
Key words: vertical augmentation, dental implant, bone substitute, bone graft,
membrane
I. Introduction
As the prevalence of implants has increased, so has the challenge to augment the
remaining osseous structure to house those implants. Therefore, lots of different
methods for vertical bone augmentation have developed and the purpose of this article
is to review the existing methods and prognosis of that according to these respective
methods.
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Several techniques have been developed to treat insufficient volume, but only four
of the most commonly performed are described. Three are frequently used: (1) sinus
floor elevation and (2) bone block graft, involving either a cortical or cortico-cancellous
graft and (3) GBR .The fourth is the technique of bone distraction, which is still in
development and may show promising results in the future because of its great
biological pertinence.
The expectations of dimensional gain and bone quality are unique to each technique,
as well as the potential complications. Distraction osteogenesis has had the greatest
potential for vertical gain, while guided-bone regeneration and monocortical onlay
grafting achieve similar results and bicortal onlay graftin has better results than
monocortical and GTR .
The choice of procedure is to be based upon the patient's existing anatomy, degree
of vertical deficiency, and willingness to participate in treatment.Volume insufficiency
at the maxillary and mandibular incisors is usually related to a lack of thickness, while
molar sectors more often present with height. Depending on the implantation site, the
morphology of the bone defect and the quantity of bone to be repaired determine the
techniques used in oral surgery. The following question should be considered: in light
of the current information available, is a particular therapeutic approach adapted to
reach the treatment objectives?
II. Materials and Methods
The biggest surgical challenge clinically is to augment lost bone vertically. The
purpose of this article is to review currently available techniques for achieving greater
vertical dimension before implant placement. A literature search was conducted using
Pubmed to find all articles published between 1998 and 2008 regarding vertical bone
augmentation. Following the literature search, all articles were reviewed and
summarized in this review article of vertical bone augmentation. The results of the
research showed that guided-bone regeneration, monocortical onlay grafting, bicortical
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onlay graftig ( 3D bone augmentation) and distraction osteogenesis have the potential to
be applied to augment deficient areas vertically.
The comprehensive overview of the English literature is done through the Pubmed
site and the literatures related to various bone augmentation techniques is outlined. The
key word for the search was vertical augmentation , bone substitute, bone graft,
membrane and dental implant .The limitation for this review was 10 years and dental
journals.The number of literature reviewed was 167 and the databases were Medline
and Pubmed , with non-peer-reviewed articles eliminated as much as possible.
The focus was done about the pre-existing methods for vertical augmentation and
the prognosis of the respective methods. So single clinical trial methods are excluded
and the mothods which was done by different clinicians and institutes are included. As
many as possible, most of the methods are reviewed and the methods and prognosis of
the methods are reviewed and described.
The general aim of the present review was to test the hypotheis tha there is no
difference between the method of vertical augmentation and the material used to that
purpose. And more specific objectives were to determine whether and when
augmentation procedures are necessary and which is the most effective augmentation
technique for the specific clinical indication.
III. Results
The technique for reconstruction of bony defects that are reviewed in this paper
included the use of particulate bone grafts and bone graft substitute, barrier membranes
for GBR(guided bone regeration) , autogenous and allogenic block grafts, and the
application of distraction osteogenesis
Biology of bone regeneration
Bones and teeth are the only structures within the body where calcium and
phosphate participate as functional pillars. Despite their mineral nature, both organs are
vital and dynamic. The histogenesis of bone is directly from mesenchymal connective
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tissue (intramembranous bone formation) or from preexisting cartilage (endochondral
bone formation). Intramembranous bones are found in the mandibulo-craniofacial
complex, ilium, clavicle, and scapula. The intramembranous bone formation pathway is
used when intraoral bone augmentation techniques are used by the surgeon
Bone is composed of the outer cortical layer and the inner cancellous layer. The
dense haversian systems of cortical bone provide skeletal strength. Interposed between
the cortices is a three – dimensional lattice network of trabecula that acts as a resorvior
for active bone metabolism. This bony architecture is dynamic with a continous
remodeling to repair and shape the bone to ensure renewal of form and function.
The principles of osteogenesis, osteoconduction, and osteoinductio can be used to
optimize therapeutic approaches to bone regeneration. Osteogenesis has been described
as the direct transfer of vital cells to the area that will regenerate new bone.
Osteoconduction embraces the principles of providing the space and a substratum for
the cellular and biochemical events progressing to bone formation. The space
maintenance requirement for many of intraoral bone augmentation procedues allows the
correct cells to populate the regenerate zone. Osteoinduction embodies the principles of
converting pluripotential, mesenchymal-derived cells along an osteoblast pathway with
the subsequent formation of bone. This concept was established in 1965, with
heterotopic ossicle formation induced by the glycoprotein family of morphogens known
as the bone morphogenetic proteins(BMPs). Therapeutic bone reconstruction
approaches use some or all of these principles in an attempt to maximize the clinical
bone augmentation results.
1. Bone augmentation with barrier membrane technique
In 1988, Dahlin et al. showed that bone could be reconstructed around implants
using the principle of guided tissue regeneration(GTR). The concept of GTR was
established by Nyman et al. in 1982 with the aim of reconstruciong deep periodontium
destroyed by periodontal disease.
The biological principle is based on the healing rate of different periodontal tissues
and the necessity to prevent colonization of the damaged site by tissues that might
inhibit healing. Bone has a unique capacity for restoring its original structure. Any bone
lesion create osteoinduction. In fact, osseous or neighboring cells release growth factors
and bone-inducing factors such as bone morphogenic proteins(BMPs)
This induction leads to cellular reactions in osteoprecursor cells, which are found in
the periosteum and in endosteal and medullary spaces. These cells differentiate into
osteoblasts, which can promote bone formation.
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This bone regeneration capacity has some limitations. It can fail in some situation:
lack of vascularization, mechanical instability, defects that are too large, and
competition with inhibiting tissues.
Utilizing a membrane can thus be a key step in the GBR technique. The membrane
isolates the osseous site that requires reconstruction and allows free expression of the
osteoinductor potential, without the influence of external factors such as the mucosal
connective tissue that can inhibit this potential.
Thus, a Teflon membrane(expanded polytetrafluoroethylene, e-PTFE) is placed to
create a barrier between the epithelial and connective tissue of the oral mucosa and the
bony defect. Osseous and desmodontal cells can then colonize the healing site and
promote the formation of new tissue, which leads to a new attachment. This technique
was referred to as guided bone regeneration(GBR)
This technique has widened the indications for implant placement. However, several
questions arise as to the duration of membrane placement, the aspect and transformation
of newly formed tissue, tissue maturation, and the quality of implant osseointegration in
regenerated osseous tissue.
Membranes
Non- resorbable membranes
The use of non-resorbable expanded polytetrafluoroethylene membrane in the
reconstrucion of bone defects was first developed for periodonal regeneration by a
Scandinavian team. These are GTAM (GoreTex augmentation material) membranes
made of e-PTFE fibers. These membranes offer different properties, such as flexibility,
an effective cellular barrier and the maintenance of adequate space. However, the most
important property is biocompatibility, and thus the abscence of cytotoxicity at the
healing site, and to osseous cells in particular.
Successful vertical ridge augmentation with the GBR technique, using titanium
reinforced e-PTFE membranes, was shown in human and animal studies. Both studies
demonstrated up to 4 mm of vertical augmentation was feasible without the use of any
grafting material under the membranes. Addition of grafting material to the GBR
technique increases the amount of achievable vertical regeration.
Non-resorbabe barriers are available as e-PTFE, titanium reinforced e-PTFE, high-
density PTFE, or titanium mesh.The e-PTFE membrane has been studied extensively in
animals and humans and is considered a standard for bone augmentation. The high–
density PTFE membranes are entirely cell occlusive, show minimal inflammation when
exposed to the oral cavity, do not integrate with the tissue for membrane stabilization,
and were effectvie in a rat mandible model and in human case reports. The use of
titanium mesh as a barrier maximazes graft containment and eliminates the space
maintenance collapse problems that are associated with conventional membranes. In
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circumstances where the defect is too large to generate a biomechanically stable central
scaffold, bone formation is limited to the marginal stable zone with central zone of
disorganized loose connective tissue. Thus, combined use of bone grafts or bone
replacement substitutes with barrier membranes are advocated in bone regeneration of
larger defects.
Resorbable membranes
To overcome some of the limitation of non-resorbable membranes, such as the need
for a second surgical procedure for their removal with the added risk of loss of some of
the regenerated bone further to flap reflection, they largely have been replaced with
bioabsorbable membranes. Bioresorbable membranes currently in clinical use fall into
two broad categories: natural or synthetic. Natural products are made of various types
of collagen of animal origin. Synthetic products are made of aliphatic polyesters,
primarily poly(lactic) and poly(glycolic) acid copolymers. They differ in their mode of
resorption: collagen products undergo enzymatic degradation, whereas synthetic barries
are degraded by hydrolysis. However, commmunicatio with the oral cavity accelerates
their resorption rate, and thus , reduces prolonged contamination of the regenerated
bone matrix. Although collagen barriers offered improved soft tissue response, they
lacked the abilityt to maintain adequate defect space. Collagen barriers promoted human
osteoblast proliferation and alkaline phosphate activity. Degradation of synthetic
copolymers elicited a soft tissue inflammatory response that resulted in resorption of
some of the regenerated bone. In addition, there is high variablity and lack of control
over the rate of membrane resorption, which is influlenced by factors such as the local
pH and material composition.
Bioabsorbable barries have been developed in synthetic polymer forms(Epi-Guide,
Resolut, Atrisorb, Guidor, Ossix)( including polygalctin 910 mesh(vicryl), collagen
(Biomend, Biomend extended, Colla tape, Colla cote, Collaplug, RCM, Bio-Gide),
calcium sulfate(Capset), or intact connective tissue( Alloderm).
One of the collagen membranes (Bio-Gide) had a barrier function in animal studies
up to 4months. These collagen products (colla tape, colla cote, colla plug) are used only
for initial graft material containment and clot stabilization because of their rapid 1 to 2
week resorption time. A polymer membrane (Guidor) was evaluated and found to be
successful in humans for use as a GBR barrier in combination with particulate grafting.
Because of a lack of rigidity, in all but the smallest defects, most of these bioabsorbable
membranes must be used in combination with a graft material for space maintenance in
bone augmentation applications.
Choice of membrane depends largely on the required duration of membrane
function for tissue regeneration(~ 6 months) . The volume of regenerated bone generally
is more encouraging with non-resorbable e-PTFE membrane than with bioabsorbable
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membranes. When no premature membrane exposure occurred, nearly complete defect
fill resulted. However, in 16% of the collagen membrane cases and 24%of the e-PTFE
cases, membrane exposure was present at the time of suture removal; ultimately, 44% of
the e-PTFE membranes had to be removed prematurely.
Perforation of the cortical bone layer has been advocated in GBR, because it was
postulated that this increases the vascularity of the wound and releases growth factors
and cells with angiogenic and osteogenic potential. Although no evidence exists in the
literature regarding a performance advantage, numerous membrane fixation products
exist for improved graft containment and minimization of membrane micromotion.
Membrane micromotion was hypothesized to decrease the regenerative response by
forming a layer of soft tissue under the membrane. Products that are available to
stabilize membranes include non-resorbable mini screws and tacks and bioabsorbable
tacks made from polylactic acid.
Membranes associated with bone grafts
Sometimes, reconstruction of large bone defects may require the use of a bone graft.
When applied to the graft, a membrane preserves and maintains the graft.
Bone grafts fall into four general categories: autograft, allografts, xenografts, and
alloplasts. The use of these materials in regnerative procedures is based on the
assumption that they posses osteogenic potential (contain bone-forming cell), are
osteoinductive (containing bone- inducing substances), or simply are osteoconductive
(serve as a scaffold for bone formation). Autogenous bone harvested from intraoral or
extraoral sites is the most predictable osteogenic organic graft for osseous tissue
regeneration.
1) Autogenous bone
Extraoral sites, such as the iliac crest, provide adequate quantity of graft material
with excellent osteogenic, osteoinductive, and osteoconductive properties, but have a
high morbidity related to second surgical sites. With the limited availability of intraoral
sites, donor site morbidities, and inadequate quantity of the harvested bone, the use of
other grafting materials has been advocated whenever possible.
Even though the particulated autograft is the gold standard for most craniofacial
bone grafitng, including the treatment of dental implant-related defects, autografts have
recognized limitation, such as donor site morbidity, increased cost, potential resorption,
size mismatch, and an inadequate volume of graft material.
2) Allogenic bone
There are several clinical reasons explaining the failure of DFDBA to induce new
bone formation. One of them is DFDBA does not contain enough BMP/NPC and
moreover, osteoclasts need mineralized bone to initiate the process of resorption. The
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other thing is osteoclast cannot fix to implanted bone, as this bone is already
demineralized. Grafted bone can eventually be resorbed by macrophages: however, this
proces is time –consuming and macrophages cannot initiate a new osteogenesis process.
The conclusion was that combining allogenic bone does not add any value to GBR. It is
thus increasingly evident that DFDBA is more osteoconductive that osteoinductive. Its
use does not seem to be justified. Also, although the risk for disease transmission
essentially is non-existent, concern still exist for some patients and estimates for the risk
were reported.
3) Alloplastic material
Alloplastic grafts include dense and porous hydroxyapatites, tricalcium phosphastes,
a mixture of both materials and a derivatives of natural coral. It is available in different
forms: resorbable or non-resorble, particles or block, porous or non-porous. These
synthetic bone graft materials are osteoconductive and have no intrinsic potential for
osteogenesis or induction. Additionally, there is no practical restriction to the available
quantity of graft, and the risk for disease transmission and need for harvesting bone
tissue are eliminated. Calsum sulfate (Capset) and calcium phosphate compounds
(Cerasorb) are attractive alternatives to autografts because of their biocompatibility,
handling characteristics, porosity, different rates of dissolution, chemical and physical
resemblance to bone mineral and potentially unlimited supply at a modern cost.
Grandular porous HA (Biogran) has been considered a unique alloplast, in that it is
formed by the hydrothermal chemical conversion of sea coral form biogenic carbonate
to HA. The second generation of calcium phosphate bone cements has shown promise
in implant dentisty.
4) Xenograft
Xenografs are animal bone substitution materials. Bovine hydroxyapatite(BH),
which is the most widely used and reported xenograft material is chemically treated to
eliminate any trace of organic material and conserve the mineral part. Owing to its
natural origin, this bone offers great similarity to human bone. The material is 60 to
70% porous per volume unit, which facilitates osteoblast migration and stimulates better
vascularization. The crystal size is 10nm and the granule size is 0.25- 1mm. Bovine
hydroapatite completely integrates within regenerated bone and resorption of bovine
hydroapatite is active but seems to be very slow. Finally the long-term fate of BH is still
unknown, since the literature is not conclusive on whether the material is completely
resorbed with time or not.
Bovine hydroapatite fulfills most of the expected objectives from the use of a bone
substitues materal with robust scientific documentation, and can thus be considered as a
material of choice. Even though the long term results with Bovine hydroapatite are still
uncertain, the incomplete or abscence of resorption does not prevent implant
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osseointegration or high implant survival rates in different clinical situations. However,
bovine bone still deserve further evaluation in large controlled studies.
Method of GBR
The implant and membrane can be placed seperately or simultaneously, depending
on the size of the bone defect and the possibility of achieving primary implant stability.
Simultaneous implant and membrane placement
Simultaneous implant and membrane placement is indicated when:
1. Crestal width is insufficient
2. Ideal implant positioning leads to exposure of one of its faces and
3. The implant is placed in an extraction socket.
Staged implant and membrane placement
This technique is used when implant placement is required, but primary implant
stability is difficult to achieve. Membranes, used alone or combined with bone grafts,
remains totally covered for 9-12 months, depending on the size of the bone defect.
Success depends on factors such as
- the volume of regenerated bone: if this volume is insufficient, it will induce
technical difficuties because of a risk of membrane collapse
- the real possibility of bone cells invading the space created by the membrane,
without being inhibited by other cells, and in particular cells from the mucosal
connective tissue.
- The type of bone defect: vertical augmentation is a difficult process, which is
sometimes impossible to achieve
- Membrane placement time without any exposure: a period of 8-12 months is
necessary
- The density of the newly formed tissue: there is a significant relation between
membrane placement time and the density of the newly formed tissue.
Post surgical GBR complications
The major complication of GBR is membrane colonization by pathogens and an
infected membrane cannot remain covered and is rapidly exposed. The causes for
premature exposure is inadequate surgical protocol, anatomic defect factors, prosthetic
irritation and host factors (uncontrolled DM, alteration of the immune system, stress or
smoking).
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2. Block grafting approaches
Although the evolution of alloplastc and allogenic materials and GBR techniques
seems to be promising, information on the healing processes involved and predictable
prognosis in comparision with autogenous bone is still lacking. The superiority of
autogenous bone has been demonstrated with respect to other bone substitues on a
biological, immunological, and even medico-legal basis.. Several donor sites have been
described , such as the cranium, tibia, ribs, maxillary tuberosity, palatal bone, torus,
zygomatic arch, iliac crest and mandibular sites. Resorption observed for the latter
seems to be lower than for the other sites.
The primary location for harvesting intraoral block grafts include the external
oblique ridge of the posterior mandible, symphysis, and ramus. With bone defects > 2
cm, an extraoral autogenous bone harvest from the iliac crest, cranium, or tibia is used
often. In addition to to the ease of intraoral harvest, grafts derived from
intramembranous bone have less resorption than endochondral bone. For the less
resorption, membrane could be used with block bone grafts. Another concern related to
the grafted block bone is retained vitality of the block autografts. Block grafts are
harvested as corticocancellous or cortical bone autografts. The revascularization fo
corticocancellous block grafts takes at much faster rate than in cortical bone
autograftsand at a slower rate than particulate autografts. Revascularization of block
grafts enables maintenance of their vitality, and , hence, reduces chances of graft
infection and necrosis.
1) Monocortical approaches
This technique is traditional block bone graft method and success of this method
ususally depends on the stabilization and intimate contact of these block grafts to the
recipient bed. This can be achieved with the use of bone fixation screws or the
simultaneous placement of dental implants. Aggressive recipient bed preparation with
decortication, intramarrow penetration, and inlay shaping also has been supported,
because of increases in the rate of revascularization, the availability of osteoprogenitor
cells, and the increased rate of remodeling. The healing of autogenous block grafts has
been described as „ creeping substitution“ where viable bone replaced the necrotic bone
within the graft and is highly dependent on graft angiogenesis and revascularization.
Although results have improved from the initially reported 50% failure rate, graft
resorption, complication, and implant survival rates are still a concern for these full-arch
grafting procedures. A recent study showed 17% resorption of mandibular block grafts
used in combination with particulate autograft and xenograft for vertical ridge
augmentation, with an average gain of ~ 5mm.
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2) 3D reconstruction technique using special instrument
( Microsaw, dentsply Friadent)
The concept of this methods lies in that increasing the surface of the grafted bone
has a positve influence on new bone formation and regeneration. This method uses a
combination of a thin block graft and particulate small pieces of cancellous and cortical
bone. The thin cortical block acts as an autogenous biological membrane for
stabilization of the small pieces of particulate bone. From a practical point of view, the
bone graft is placed in two layers of different shape: the first layer consists of a thin
bone blcok that creates the alveolar crest shape, giving it form and volulme. This block
graft is screwed at a distance from the recipient site rather that in close contact, leaving
a free space between the graft and the atrophic alveolar crest. The space between the
block graft and the recipient site is then filled wih mandibular cancellous and small
particulate bones, which possess high revascularization and regeneration potential. This
leads to an ideal graft, with a high regenerative capacity comparable to iliac bone and an
osseointegration potential close to that of the mandible. The bone could be harvested
from ramus, chin and mandibualr edenturous areas.
Fig) Preparation of bone blocks and access windows
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3. Distraction osteogenesis
Distraction osteogenesis is a surgical process for reconstruction of skeletal
deformities. It involves gradual, controlled displacement of surgically created fractures
which results in simultaneous expansion of soft tissue and bone volume. It is the ability
to reconstruct combined deficiencies in bone and soft tissue that makes this process
unique and invaluable to all types of reconstructive surgeons. Gavriel Ilizarov, a
Russian orthopedic surgeon, is credited with developing the armamentarium and
describing the biologic basis of this process for the management of orthopedic limb
deformities. The concepts described by Ilizarov have been adapted and modified for use
in maxillofacial surgery. Although the majority of surgical experience with distraction
technology has been in orthopedics, early results indicate the process to be equally
effective in facial skeletal reconstruction. It is now possible to apply distraction
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technology to deformities of the jaws and dentoalveolar process. Development of
miniature, internal distraction devices have made this clinically feasible and practical.
The Process of Alveolar Distraction Osteogenesis
The process of alveolar distraction osteogenesis involves mobilization, transport,
and fixation of a healthy segment of bone adjacent the deficient site. A mechanical
device, the alveolar distraction device, is used to provide gradual, controlled transport of
a mobilized alveolar segment. When the desired repositioning of the bone segment is
achieved, the distraction device is left in a static mode to act as a fixation device.
Displacement of the osseous segment results in positioning of a healthy portion of bone
into a previously deficient site. Because the soft tissue is left attached to the transport
segment, the movement of the bone also results in expansion of the soft tissue adjacent
the bone segment. At the original location of the segment is left a regeneration chamber
which has a natural capacity to heal by filling with bone. This propensity of the
regeneration chamber to heal by filling with bone instead of fibrous tissue is a function
of the surrounding, healthy cancellous bone walls and location within the skeletal
functional matrix. As a result of the gradual distraction, the alveolar housing, including
the osseous and soft tissue components are enlarged in a single, simultaneous process.
Alveolar Distraction Device
Development of miniature, internal distraction devices has made transport of
alveolar segments possible. The alveolar distraction device has been developed for
reconstruction of alveolar process deformities using the distraction osteogenesis
process. The implantable components of the alveolar distraction device consists three
components.
When placed into a properly formed segmental osteotomy, the distraction device
allows for controlled elevation of the segment resulting in coronal displacement of the
alveolar crest. The transport slowly displaces the overlying soft tissue producing
expansion. A regeneration chamber is established in the portion of the osteotomy that is
perpendicular to the transport axis. The portion of the osteotomy that is parallel to the
transport acts to maintain alignment of the segment. After the desired amount of
transport has been achieved, the lead screw is left in place until bone healing occurs
across the sliding component of the osteotomy. The regeneration chamber fills with
bone of several weeks.
As a result of the distraction process the volume of both bone and soft tissue has
been increased. The reconstructed site is them suitable for further rehabilitation with
osseointegrated implants, prosthetic pontic placement, or movement of a tooth with
orthodontics.
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Indications:
Primary indications
- Combined deficiencies in bone and soft tissue.
- Compromised wound healing environment.
Secondary indications
Alternative treatments
Expansion of the alveolar housing for:
- Create site for dental implant placement
- Improve ridge esthetics for pontic
- Improve periodontal environment of adjacent teeth
- Expand alveolus for orthodontic tooth movement
Limitations
- Must have a minimum quantity of bone
- transport and anchorage segment must have adequate strength to withstand
- forces of mobilization and transport
- Expansion occurs only in the direction of transport.
- Patient must cooperate with activation process
Complications
- fracture of transport segment
- fracture of anchorage segment
- premature consolidation
- undesirable transport vector
Objectives of Distraction Process
- expansion of bone and soft tissue volume
- displacement of bone into deficient site
Conclusion of distraction osteogenesis
Distraction osteogenesis is a proven technique for vertical augmentation of the
alveolar crest. The surgical procedure requires some standardized techniques to avoid
failures. Owing to the preparation of the alveolar crest as for a fracture, the direction of
the osteotomy determines the subsequent prosthetic outcome. This technique utilizes the
natural healing capacity, which requires high patient compliance and a strict recall. The
biological regeneration of new bone shows a negligible rate of infection and wound
healing disturbances, which do not influence the success rate of the implants.
4. Other developing approaches
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There have been lots of attempts to develop a new method for bone augmentation
and most of them would be molecular, cellular, and genetic tissue engineering
technologies. The molecular approach using BMPs has received the most attention over
the past decade. BMPs are differentiation factors that are part of the transforming
growth factor superfamily. Although BMP- 2 has ben approved by the FDA for spinal
fusion application, for human intraoral application the carriers and dosage of BMP- 2
and -7 are still regulatory review and investigation. Another promising growth factors
now being evaluated actively is platelet-derived growth factor(PDGF).
Another growth factor approach is to use patient’s own blood, seperating out the
platelet-rich plasma(PRP) and adding this concentrated group of autogenous growth
factors to the grafting material. The addition of PRP to autograft showed a more rapid
and dense bone formation compared to autograft used alone for bone augmentation. An
improvement in bone formation when PRP is added to other graft materials has not been
demonstrated clearly. Still now, there was no reliable evidence supporting the efficacy
of acitve agents, such as PRP in conjuction with implant treatment.
5. Complication of Bone augmentation technique
Complications in bone grafting procedures are relatively rare, but may be severe and
of concern for the patient, because they may jeopardize the whole procedure and
somtimes leave a situation worse than that at the start. This requires careful
communication with the patient and written consent. Bone grafting procedures require
extensive surgical training and have a relatively flat learing curve. Soft tissue surgery is
as important as bone surgery and should be considered during proper preoperative
planning. A subsequent protocol involving antibiotic prophylaxis, chemical plaque
control, anti-inflammator y agents and postoperative care must be followed. Major risk
factors such as smoking, mechanical irritation dut to temporary restoration, and patient
non-compliance have to be eliminated.
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IV. Discussion
There is evidence that nonresorbable and resorbable barriers allow statistically
significantly more bone regeneration than no barrier and the choices between
nonresorbable and resorbable usually depend on clinician’s preference and the special
need related to the cases.
Bone substitutes (Bio-Oss and Cerasorb) might be effective as autogenous bone
grafts for augmenting extremely ridge and sinuses. Therefore, they might be used as a
replacement for autogenous bone graftss, although these preliminary findings need to be
confirmed by large multicenter trials.
A vertical alveolar defect reconstructed with a mandibular graft in the form of one
cortical sometimess represents a poor site for osseointegration of titanium implants
because of the low revascularization potential of cortical bone. A partculate bone graft
seems to yield better revascularization, giving good quality regeneration of the
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augmented area. Based on the reasons for biological grafting previously described,
vertical boe augmentation is performed in a 3D form by combining thin mandibular
cortical blocks with particulate bone grafts. Thick blocks from the ramus area are cut
longitudinally with the Microsaw into two thin pieces with the same surface area. These
two thin blocks are used to rebuild the two walls of the future alveolar crest (buccal and
palatal, or occlusa and vestibular) and stabilized with osteosynthesis screw. The
remaining space is filled with particulate and cancellous bone. The method for 3D
reconstruction seems to be a good alternative to the reconstruction of vertical defects
with one cortical block or with membranes using the GBR technique. Relatively low
rate of complications, the good bone regeneration and the big gain of vertical
augmentation make it promising and encouraging.
Osteodistraction is a proven technique for vertical augmentation of the alveolar
crest. The surgical procedure require some standardized techniques to avoid failures.
Owing to the preparation of the alveolar crest as for a fracture, the direction of the
osteotomy determines the subsequent prosthetic outcome. This technique utilizes the
natural healing capacity, which requires high patient compliance and a strict recall
protocol. The biological regeneration of new bone shows a negligible rate of infection
and wound healing disturbances, which do not influence the success rate of the implants
Osteodistraction and various GBR techniques are able to regenerate bone in a
vertical direction; however, there is insufficient evidence to indicate whether one of
these technique is preferable. Osteodistraction is of little use in the presence of thin
ridges but may allow more vertical regeneration. Complication with GBR techniques
are common and in some cases determined the failure of the augmentation procedure.
Clincians and patients should carefully evaluate the benefits and risks in relation to the
desired outcome when deciding whether to use vertical ridge augmentation techniques.
BMPs used in conjunction with Bio-Oss and resorbable barriers may promote bone
formation in need of ridge augmentation.
19
V. Conclusion
Many different techniques exist for effective bone augmentation. The approach is
largely dependent on the extent of the defect and specific procedues to be performed for
the implant reconstrcution. It is most appropriate to use an evidence-based approach
when a treratment plan is developed for bone augmentation cases.
Successful vertical ridge augmentation with the GBR technique, using titanium
reinforced ePTFE membranes, was shown in human and animal studies. Both studies
demonstrated up to 4 mm of vertical augmentation was feasible without the use of any
grafting material under the membranes. Addition of grafting material to the GBR
technique increases the amount of achievable vertical regeration
Autogenous bone still represents the gold standard in reconstruction surgery. The
results are mostly predictable and reproducible. Biomaterials with their osteoconductive
property are used only as a space maintainer. Autogenous block grafts harvested from
the mandible can be very useful for reconstructing complicated defects. A 3D
reconstruction of vertical bone defects seems to represent a better alternative than an
onlay graft with thick cortical bone.
20
Finally, from a purely biological standpoint, distraction seems to be the surgical
procedure best adapted to the problem of volume augmentation of bone and
surrounding tissue. In fact, distraction is a biological process that takes into account
local signaling and can locally induce the formation of a volume and structure adapted
to bone loading that will allow implant osseointegration with an appropriate reaction to
local stress and strain.
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