Ridge Augmentation Procedures

DR : HAMED BAKRI

CHAPTER OUTLINE
Principles in alveolar bone regeneration
Treatment objectives
Diagnosis and treatment planning
Biologic principles of guided bone regeneration
Regenerative materials
Evidencebased results for ridge augmentation procedures
Emerging technologies
Conclusion

Ridge Augmentation Procedures

:Introduction
alveolar bone loss can be congenital, trauma, pathology, infection, or a consequence of periodontal disease and tooth
extraction
approximately 25% bone loss after the first year of the bone and 4060% loss of alveolar volume during the first 3 years
after a tooth is lost. The resulting ridge deficiency is primarily the result of the gradual loss of the horizontal dimension
accompanied by a rapid loss of bone height (Carlsson et al. 1967).

*
The placement of bone grafting materials to favor healing in osseous defects or to augment edentulous ridges to allow
dental implant installation become a gold standard treatment in implant dentistry

Factors Assist in proper wound healing

Promoting primary wound closure
.passive and tensionfree wound closure . To reduce the risk of membrane exposure, wound contraction, patient discomfort

Enhancing cell proliferation and differentiation

provides blood, oxygen, and nutrients to the tissues also acts as a source of angiogenic and osteogenic cells

Protecting initial wound stability and integrity

Principles in alveolar bone regeneration

Cell Exclusion used to prevent gingival fibroblasts and / or epithelial cells
from gaining access to the wound site
Space is created beneath the membrane, completely isolating the defect to
be regenerated from the overlying soft tissue.
Scaffolding : space initially becomes occupied by a fibrin clot, which serves
as a scaffold for the bone cells.
protect the clot is important for the formation of granulation tissue and
subsequent formation of bone (Schenk et al. 1994).

*Treatment Objectives
The rationale behind any crestal bone augmentation procedure is to establish sufficient bone availability for safe and
predictable dental implant therapy , as well as for getting adequate bone thickness around the installed implant.
To achieve longterm stability of periimplant health and good esthetics and avoid complications around functional
implants by get at least 2 mm of bone on the buccal side

Diagnosis and Treatment Planning*

:There are some relative contraindications that need to be taken into consideration
medical conditions that may impair normal bone healing as diabetes mellitus
(Colombo et al. 2011; Schlegel et al. 2013). when compared between controls diabetic to healthy pt. in osseointegration was
achieved in both groups
(Retzepi et al. 2010). The uncontrolled diabetes showed an increased rate of infection complications and a less predictable
outcome

 Smoking has also been found to negatively affect the longterm prognosis of Osseointegration
Clinical studies have reported that in smokers
higher rates of implant failure
Great numbers of complications around successfully integrated implants (RoosJansaker et al. 2006),
higher incidence of periimplant mucositis and periimplantitis (HeitzMayfield 2008)
(Bain &Moy 1993). nonsmokers, the augmentation procedure was successful in 95% of the cases, whereas in

smokers it was successful in only 63%

Defect classification*
According to Seibert (1983), alveolar crest defects
Class 1 defects: when the bone deficiency is predominantly in the horizontal dimension
Class 2 defects: when the bone deficiency is predominantly in the vertical dimension
.Class 3 defects: when the bone deficiency affects both the vertical and horizontal dimensions

Defect classification
:Hmmerle and Jung have classified crest defects in fresh extraction sockets
Class I: extraction socket that has intact bone walls after tooth extraction
Class II: extraction socket that has a marginal dehiscence fenestration of the buccal bone wall after tooth extraction

.Class III: extraction socket that has a large dehiscence of the buccal bone wall after tooth extraction

Bone Augmentation Therapies

Melcher (1976), who developed the concept of using barrier membranes to guide the biologic process of wound
.healing
early experimental studies demonstrated that the exclusion of soft tissue invasion of the defect by means of a barrier
membrane, allowed the cells with regenerative potential to migrate to the site (derived from the periodontal ligament
.or bone marrow) and promoted periodontal regeneration (Nyman et al. 1982)

Regenerative materials

Regenerative materials

Barrier membranes

Bone grafts and bone substitutes

Barrier membranes
:Purpose
. membrane is to prohibit the penetration of cells, primarily epithelial, through its structure

There are five criteria which are considered to be important in the design of barrier
membranes used for GBR
1.
2.
3.
4.
5.

biocompatibility,
cell occlusion properties,
integration by the host tissue,
Space making capacity.
clinical manageability

 Types of membranes :
:Barrier membranes have been derived to two principal varieties
1- Non resorbable As e-PTFE
nondegradable barrier membranes require a second
surgical intervention to remove them.

The choice of membrane material usually depends on the amount of bone regeneration needed, mainly in
the vertical dimension. ePTFE barrier membranes have demonstrated more favorable results when
compared with resorbable devices, mainly due to their better
spacemaking capacity,
longer barrier function
lack of a resorption process that may negatively affect bone formation
).Hmmerle & Jung 2003(

Bone grafts and bone substitutes

Types of Bone Grafts

Types of Bone Grafts

Autograft
Allograft
Xenograft
alloplast

Autogenous
Intraoral

Exrtaoral

Max.
tuberosity
Ramus
chin

rib
tibia
Iliac crest

Autogenous
Considered the gold standard by which other materials are Osteoinductive,
osteoconductive, and osteogenic properties No risk of infection

Disadvantages

Low availability of bone volume

Require a second operative site
Morbidity associated with their harvesting, mainly from the chin
particulate autografts, resorption rate is high

Allograft
Allografts are bone grafts harvested from cadaver donors and processed by freezing or demineralization and freezing.
These allografts are usually used in combination with barrier membranes following the principles of GBR.

Disadvantages
Possible infections, and antigenicity risks

Xenograft
biomaterials of animal origin, mainly bovine and equine. These graft materials are
deproteinized in order to completely remove the organic component and thus avoid any
immunogenic reaction.

alloplast
are synthetic bone substitutes that include different combinations of calcium phosphates
fabricated under different conditions, which yields different physical properties and resorption
rates

Cancellous Bone

Coralline hydroxyapatite

Choice of material
. This choice should be based on the clinical indication
For small bone defects requiring mainly horizontal bone augmentation, the use of xenografts and
alloplasts has demonstrated excellent results.
use of xenografts with a much slower resorption rate demonstrated significantly better preservation of the
socket walls than the nongrafted sites.
In large crestal defects for which the aim is both horizontal and vertical bone augmentation, the use of
autogenous block grafts is recommended.

Ridge Augmentation Procedures

1.
2.
3.
4.
5.

ridge preservation,
bone regeneration in fresh extraction sockets,
horizontal bone augmentation,
ridge splitting/expansion,
vertical ridge augmentation

Ridge preservation
Any therapeutic approach carried out immediately after tooth extraction aimed to preserve the
alveolar socket architecture and to provide the maximum bone availability for implant
. placement (Vignoletti et al. 2012)
These ridge preservation approaches have utilized GBR principles using the following regenerative
Resorbable and non resorbable barrier membranes alone
Resorbable barrier membranes in combination with bone substitutes
Bone substitutes alone
:Bone substitutes in combination with soft tissue grafts technologies

hard and soft tissue changes occurring 6 months after tooth extraction in humans and demonstrated a
horizontal bone loss 2963%
vertical bone loss 1122%
).Tan et al. 2012(

Bone regeneration in fresh extraction sockets

immediate and early implant placement (type 1 and 2) protocols have been indicated as the
.most suitable for implant placement following tooth extraction

Horizontal ridge augmentation

Horizontal ridge augmentation can be performed using particulate or block grafts with or without barrier membranes

Ridge splitting/expansion
Another technique used in the maxilla to augment bone width through bone condensation
.is ridge splitting or ridge expansion osteotomy
Ridge splitting and/or expansion are frequently described together because of their common treatment outcome: increase in
lateral bone width. Ridge splitting is essentially the fracture of the buccal cortical plate and its displacement laterally to
.accommodate implant placement

Vertical ridge augmentation

:augmentation techniques
GBR) 1(
onlay boneblock grafting) 2(
distraction osteogenesis) 3(

Class 3 defect (Seibert). Implant placement and vertical GBR with an ePTFE membrane and autologous bone. (d) Re entry 1Y. (Courtesy .) (

Emerging technologies
growth factors- 1
to increase bone volume have significantly advanced
the field of periodontal regenerative medicine. like PDGF and BMPs
2-Cell therapy
Cell delivery approaches are used to accelerate edentulous ridge regeneration through two primary
mechanisms:
(1) use of cells as carriers to deliver growth or cellular signals
(2) provision of cells which are able to differentiate into multiple cell types to promote regeneration

Scaffolding matrices to deliver cells and genes -3

Scaffolding matrices are used in tissue engineering
to provide an environment where space is created and maintained
.over a period of time for cellular growth and tissue ingrowth

Computerbased applications in scaffold design and fabrication -4

Conclusion
. In general, ridge augmentation procedures have become increasingly predictable
The correct selection and application of the available techniques and biomaterials are key
. determinants of implant survival/success rates
Currently, research in the field of advanced bone grafting is directed at overcoming the technical
.and biologic limitations that continue to challenge implant dentistry