Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Surgical Techniques to
Increase Bone Augmentation
Success
Authored by Randy R. Resnik, DMD, MDS
Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment
and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.
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I
n implant dentistry today, bone grafting has become a com- temic coverage. Another modality for antimicrobial prophylaxis
mon treatment modality. It is imperative to have adequate is the use of 0.12% chlorhexidine digluconate (Peridex [3M ESPE]).
hard- and soft-tissue volume to allow for ideal implant Chlorhexidine gluconate is a potent antibacterial, which causes
placement, decreased morbidity, and increased success rates for lysis by binding to bacterial cell membranes. It has high substan-
both the surgical and prosthetic phases of treatment. The bone tivity, which at high concentrations exhibits bactericidal qualities,
grafting options of materials and techniques are very numerous thereby causing bacterial cytoplasm precipitation and cell death.
in implant dentistry. Consistent bone grafting success has been Unfortunately for allograft bone grafts, there exists minimal
difficult to achieve on a continuous basis because practitioners immediate blood supply with an absence of the hosts cellular
often use similar techniques, regardless of the existing condi- defense mechanisms. This results in the graft site being prone
tions, bone volume, and graft loca- a b c
tion. Thus, this article will discuss
techniques and principles that will
increase bone grafting success rates
with decreased complications.
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Figure 2. (a) A large, broad-based flap design to minimize tension on graft site, and (b) post-op Bio-Oss (Geistlich) zenograft. (c) When lack of attached
tissue exists, an incision should be made toward the lingual to maximize attached tissue on facial, and (d) vertical releases should be made over bone
and lateral to the margins of the membrane (CopiOs Pericardium Membrane [Zimmer Dental]).
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Figure 4. (a) Socket graft with Puros and CollaTape membrane (Zimmer Dental), (b, c) Mineross + Alloderm membrane (BioHorizons), (d) titanium mesh
membrane, and (e) polytetrafluoroethylene (PTFE) membrane.
integration of the graft to the host bone. The technique includes leucocytes, cytokines, and circulating stem cells that are gradually
the use of a small fissure bur drill (eg, 702 L [Salvin Dental Spe- released to accelerate physiologic healing. It is easily obtained and
cialties]) with copious amounts of irrigation to prevent thermal does not require any biochemical blood handling.10 After drawing
trauma (Figure 3). blood and placing in a centrifuge for 12 minutes, the coagulation
cascade will be triggered. The end result is a fibrin clot in the middle
GRAFT CONTAINMENT AND MAINTAINING SPACE layer, situated between the accelular platelet-poor plasma and the red
For the graft to heal and form new bone, it must be contained blood cells. Thus, when the fibrin clot (PRF) is used as a membrane,
at the site of the defect. The concept of bone growth is based on it will protect the wound and serves as a matrix to accelerate heal-
space (anatomic size and contour of the desired augmentation) ing. When the PRF is mixed with the graft material (allograft),
and maintenance (space must exist long enough for bone to fill in the fibrin clot will act as a biological connector between all the
the desired area). A barrier membrane is used to prevent soft-tis- elements of the graft, while also acting as a matrix that initiates
sue growth into the graft. There exist many options available angiogenesis, stem cell accumulation, and migration of osteopro-
today in implant dentistry to contain the graft. The ideal partic- genitor cells to the graft. Thus, the synergistic effects of the fibrin
ulate containment system would maintain the graft, assist with matrix and growth factors allow for the enhanced healing of the
maintaining space, prevent exposure to the oral environment hard and soft tissues. Studies have shown PRF with freeze-dried
and soft-tissue ingrowth, and also possess the ability to slowly bone allograft (FDBA) heal faster than FDBA alone.11
resorb or easily be removed.9 Many resorbable membranes are
available which are derived from zenogenic collagen sources Recombinant Human Bone Morphogenetic Proteins
or cadaver dermis. These membranes are popular because they The rhBMP-2 are a group of sequentially arranged amino acids
are slowly resorbed; however, they are not ideal for space main- and polypeptides that are osteoinductive proteins, acting to initi-
tenance. Non-resorbable membranes include various forms of ate, stimulate, and amplify bone morphogenesis. BMPs stimulate
polytetrafluoroethylene (PTFE) and titanium mesh. They are ex- mesenchymal stem cells to induce bone formation via differenti-
cellent for graft containment as well as space maintenance. How- ation to osteoblasts, which form and mineralize new bone. BMP-2
ever, they do have the disadvantage of needing to be removed via has been purified, sequenced, and cloned, and is marketed as
a second surgical procedure (Figure 4). rhBMP-2 (Infuse Bone Graft [Medtronic]). Infuse Bone Graft con-
sists of 2 components: a 1.5 mg/mL concentration of rhBMP-2 and
USE OF BONE GROWTH FACTORS an absorbable collagen sponge. Studies have shown rhBMP-2 with
The use of bone growth factors in implant dentistry has been titanium mesh to be an effective treatment for augmentation of
shown to be advantageous, as they enhance bone healing and the posterior mandible prior to implant placement.12 The new
improve success rates. The types and various techniques for bone formed by rhBMP-2 has been shown to be similar to native
implementing these factors into grafting procedureseg, plate- bone and can withstand the stresses of implant placement and
let-rich fibrin (PRF), recombinant human bone morphogenetic prosthetic function13 (Figure 5).
proteins (rhBMP-2)have increased substantially.
TENSION-FREE SOFT TISSUE
Platelet-Rich Fibrin Incision line opening is the most common postoperative com-
PRF is an autologous fibrin matrix that is used as a healing bioma- plication to be reported during intraoral bone grafting.14 When
terial in implant dentistry. This fibrin matrix incorporates platelets, the incision line breaks down, the graft often will become
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f g h i
Figure 5. Platelet-rich fibrin (PRF) protocol: (a, b) Draw 10 mL of blood with vacutainer; (c) place in centrifuge for 10 minutes at 3,000 rpm; (d) resultant
3 layers: top layerplatelet-poor plasma, middle layerPRF, and bottom layerred blood cells; (e) PRF middle layer removed; (f) placed in Salvin
Bio-Compress forceps which creates a one-mm thick membrane; (g) liquid and/or fragments of PRF placed with allograft; (h) PRF membrane placed
over graft; and (i) rhBMP-2 + collagen sponge.
contaminated or infected, leading to decreased vascularization and material should be used. The suture material of choice
and lack of bone growth.15 The most common reason for incision should have high tensile strength so that muscle pull and ten-
line opening is tension on the incision line. When tension-free sion are resisted with low probability of inflammation and
soft-tissue closure is obtained, the graft area will heal by primary wicking effect. Thus, plain gut, chromic gut, and silk should
intention, which encourages osteo-competent cell proliferation. not be used. Polyglycolic acid (PGA, vicryl), because it maintains
To obtain primary wound closure, the tissue must be manipulated sufficient tension during the first 2 weeks and has been shown
to remove all tension. to have minimal tissue reaction, is an ideal suture material for
Stretching the tissueThe submucosal space technique devel- bone grafts.17 Another alternative is the use of nonresorbable
oped by Misch in 1980 is an effective method to expand the tissue PTFE monofilament sutures (ie, Cytoplast PTFE suture). These
over graft sites. An incision (one to 2 mm deep) is made through sutures are biologically inert, high tensile strength, nonwicking,
the periosteum parallel to the crestal incision, approximately 3 and have excellent knot security.
to 5 mm above the vestibular height of the mucoperiosteum. Tis- The sutures should be placed approximately 3 mm from the
sue scissors (eg, Metzenbaum) are then used in a blunt dissection margin of the tissue. Sutures placed less than 3 mm away increase
technique to create a tunnel apical to the vestibule and above the possibility of tearing the flap. Also, care should be exercised to
the unreflected periosteum. The scissors are placed in a closed make sure that sutures are placed approximately 3 to 5 mm from
position and pushed through the initial scalpel incision approx- each other and not too tight, as this may lead to tissue ischemia and
imately 5 to 10 mm deep, then opened. This submucosal space a devitalized zone. No allograft material should be present within
is parallel to the surface mucosa (not deep toward the overlying the incision line as this may delay healing. After the tissues are su-
bone) and above the unreflected periosteum. Ideally, the facial tured, the incision line is inspected for any open areas or particles
flap should be able to advance over the lingual flap margin by 5 (Figure 7).
mm (Figure 6).16
PROVISIONAL RESTORATION
IDEAL SUTURING Bone graft stabilization is paramount to predictable bone aug-
To maintain closure of the graft site, the ideal suturing technique mentation to ensure blood clot adhesion and the introduction of
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Figure 6. (a) Periosteum stretching and incision with 15 blade, (b) blunted tissue scissors placed in Figure 7. (a) Non-ideal closure as primary closure
the incised tissue and blunt dissection performed, and (c) tissue should be free of tension and able is not obtained and high tension is present on the
to stretch approximately 5 mm over lingual tissue margin. suture line. (b) Ideal suturing with primary closure
and no tension present.
a b c d
Figure 8. Snap-On Smile (DenMat): (a) bone graft site, (b) Snap-On Smile Prosthesis, (c) prosthesis in place exhibiting no pressure on graft site, and
(d) Essix Appliance (DENTSPLY Raintree Essix) example.
associated growth factors for predictable healing. As little as 20 m practices. As the discipline of implantology grows, the prevalence
of movement will result in a nonfixated graft and fibrous encap- of bone grafting will become more significant. Restoring the lost
sulation as the graft cannot develop a blood supply for new bone hard-tissue volume to allow ideal implant placement is crucial
formation. Graft immobility is vital to capillary ingrowth and graft to decrease the morbidity of implants and the restorations they
revascularization. One of the most common and challenging road- support. Bone augmentation comprises a wide range of materials,
blocks to implant treatment acceptance is the patients perception donor sites, and surgical approaches, with new advances arriving at
of the temporization (provisionalization) of the edentulous areas a staggering rate. With all of the materials and varying techniques
after bone grafting. In most cases, pressure directly or indirectly on available today, the practitioner must have a solid understanding
the surgical site can lead to bone loss and increased morbidity of of adjunct techniques to increase the success of bone grafting.F
the graft site. Ideally, no provisionalization after surgery is the best
treatment. However, because of patient requests, many types of References
provisionalization techniques are being utilized. The 2 prosthesis 1. Misch CE, Misch-Dietsh F. Keys to bone grafting and bone graft
types that minimize pressure on the graft site are the Essix Appli- ing materials. In: Misch CE. Contemporary Implant Dentistry. 3rd
ance (DENTSPLY Raintree Essix) and the Snap-On Smile (DenMat) ed. St. Louis, MO: Mosby; 2008:467 (chapter 21).
concept. The thermoformed Essix Appliance is easily fabricated, 2. Altemeier WA, American College of Surgeons Committee on
inexpensive, and prevents pressure from being placed on the graft Control of Surgical Infections. Manual on Control of Infection in
Surgical Patients. 2nd ed. Philadelphia, PA: Lippincott; 1984.
site. A Snap-On Smile is a noninvasive partial or full-arch remov-
3. Peterson LJ. Antibiotic prophylaxis against wound infec
able prosthesis that is placed over the patients dentition. This tions in oral and maxillofacial surgery. J Oral Maxillofac Surg.
interim prosthesis is aesthetic, has excellent retention, no impinge- 1990;48:617-620.
ment on the soft tissues, and allows the adjacent teeth to absorb the 4. Urist MR, Silverman BF, Bring K, et al. The bone induction princi
occlusal force (Figure 8). ple. Clin Orthop Relat Res. 1967;53:243-283.
5. Mabry TW, Yukna RA, Sepe WW. Freeze-dried bone allografts com
SUMMARY bined with tetracycline in the treatment of juvenile periodontitis. J
Oral implantology has grown into a widely accepted and ever Periodontol. 1985;56:74-81.
expanding discipline. Due to this phenomenon, more and more 6. Beardmore AA, Brooks DE, Wenke JC, et al. Effectiveness of local
clinicians are offering dental implant surgery in their respective antibiotic delivery with an osteoinductive and osteoconductive
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2. If proper asepsis and prophylactic antimicrobial treatment 6. Incision line opening is the least common postoperative
is utilized, the infection rate may decrease to less than complication to be reported during intraoral bone grafting.
1.0%. a. True b. False
a. True b. False
7. Bone morphogenetic proteins (BMPs) stimulate mesenchy-
3. Numerous studies have shown many serious deleterious mal stem cells to induce bone formation via differentiation
effects on bone growth from locally delivered antibiotics. to osteoblasts, which form and mineralize new bone.
a. True b. False a. True b. False
4 The larger the bone graft site, the larger and more distal 8. Graft immobility is not really vital to capillary ingrowth and
the vertical incisions. graft revascularization.
a. True b. False a. True b. False
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