Istvan Urban Vertical and Horizontal Ridge Augmentation New Perspectives (Y) auintessence PUBLISHING Berlin, Barcelona, Chicago, enh ae zsh: Nin, Mike, New Del Paris, Prague, S80 Paulo, Seoul, Singapore, Tokyo,Abbreviations ABBM —_ anorganic bovine-derived bone mineral AP antecior-posterior ACS absorbable collagen sponge BMP bone morphogenetic protein C&H Cawood and Howell cl confidence interval MX xenogeneic collagen matrix ct ‘computed tomography cTG connective tissue graft DFDBA demineralized freeze-dried bone allograft GPTFE dense polytetrafluoroethylene ePTFE —_ expanded polytetrafluoroethylene FCF free curtain flap FDBA _ freeze-dried bone allograft EGG free gingival graft GBR guided bone regeneration GTR guided tissue regeneration HA hydroxyapatite KT keratinized tissue ‘LSE lingually sliding lap MAPF modified apically positioned flap MCBA ‘mineralized cancellous bone allograft MG] mucogingival junction OSF osteoblast stimulating factor PGA polyglycolic acid PsT papilla shift technique PTFE polytetrafluoroethylene RCT randomized controlled trial rhBMP-2 recombinant human bone morphogenetic protein-2 thPDGF recombinant human platelet-derived growth factor RP retromolar pad sD standard deviation SF safety flap TCP tricalcium phosphate ‘TG transforming growth factor TMC trimethylene carbonate TR titanium-reinforced vas visual analog scale VRA vertical ridge augmentationContents = @@ Chapter 21 Complications of bone ridge augmentation 335 21.1 Complications of healing 336 21.2 Postoperative infection 39 21.3 Nerve injury: 350 214 Complications during implant placement into the newly formed ridge 351 215 Long-term biological complications of implants 355 216 Conclusion 358 217 References 350 Chapter 22 The use of growth factors 361 22.1 Recombinant human platelet-derived growth factor 361 22.2 Bone morphogenetic proteins 365 223 Conclusions 380 224 References 381 Index 383 Permissions from books and journals 389Contents Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 vi Lateralization of the nasopalatine nerve: the palatal flap 15.1 “The palatal flap 15.2. Clinical evaluation 153. References Mucogingival surgery after bone augmentation 161 Representative case 16.2 The adapted soft tissue sungery 163 Representative case 16.4 Long-term results 165 Conclusion 166 References New perspectives in mucogingival surgery after ridge augmentation 17.1 Representative cases and clinical data 17.2 References New perspectives in crestal bone preservation after ridge augmentation 18.1 Case series: long-term results 182 Representative case and lessons learned. 183 Conclusion 184 Reference The development and maintenance of a positive gingival architecture using single implants in multiple missing teeth 19.1 References Reconstruction of the edentulous resorbed maxilla 20.1 Conclusions 20.2 References 203 203 207 209 21 2iz 217 219 230 239 230 241 242 264 265 266 266 276 276 277 292 293 333 334Conteris Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 vil Lateralization of the nasopalatine nerve: the palatal flap 15.1 The palatal flap 15.2 Clinical evaluation 15.3. References Mucogingival surgery after bone augmentation 16.1 Representative case 16.2 The adapted soft tissue surgery 163 Representative case 164 Long-term results 16.5 Conclusion 16.6 References New perspectives in mucogingival surgery after ridge augmentation 17.1 Representative cases and clinical data 17.2 References New perspectives in crestal bone preservation after ridge augmentation 18.1 Case series: long-term results 182. Representative case and lessons learned 183 Conclusion 184 Reference The development and maintenance of a positive gingival architecture using single implants in multiple missing teeth 191 References Reconstruction of the edentulous resorbed maxilla 20.1 Condusions 20.2 References 203 203 207 209 2 m2 a7 219 230 239 239 24 242 264 265 266 276 276 277 292 293 333 334Contents Chapter 1 hapter 2 hapter 3 Chapter 4 Chapter 5 Abbreviations Introduction Acknowledgments Surgical setup and patient preparation 21 Patient selection 22 Patient preparation for surgery 23° Medications 24 The surgical room 25 Postsurgical care and suture removal 26 References Membranes and graft materials 3.1 Scientific documentation of horizontal GBR using different membranes 32 Scientific documentation of vertical GBR using different membranes 33 Grafting materials used for GBR 34 References ‘The intraoral harvesting of autogenous bone 41 Bone harvesting from the mandibular symphysis 42 Bone harvesting from the mandibular ramus 43 — Reference The surgical anatomy of the floor of the mouth 5.1 Musculature of the floor of the mouth and the tongue 52. Arterial supply 53 Anatomical variations of floor of the mouth vascularization 54 Nerves 55 Salivary glands 56 Conclusion 57 References "1 12 17 a a %6 28 29 30 32 36 37 37 37 a7A CIP record for this book is available from the British Library. ISBN: 978-1-78698-000-7 QUINTESSENCE PUBLISHING UNITED KINGDOM Quintessence Publishing Co, Ltd, Grafton Road, New Malden, Surrey KTS 3AB, United Kingdom www.quintpub.co.uk Copyright © 2017 Quintessence Publishing Co. Ltd Allrights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, with- out prior written permission of the publisher. Editing: Avril du Plessis, Quintessence Publishing Co. Ltd, London, UK Layout and Production: Janina Kuhn, Quintessenz Verlags-GmbH, Berlin, Germany Reproduction: Ingo Schmidt, Quintessen2 Verlags-GmbH, Berlin, Germany Printed and bound in Germany by Bosch-Druck GmbH, Landshut/ErgoldingIntroduction When I was asked by Mr Christian Haase of Quintessence Publishing to write a book on ridge augmentation, 1 did not hesitate to say yes. I felt that I had so much to say to my colleagues, and that the best platform to say it would be this book. How- ever, it took me about 2 years to think about what I exactly wanted to say, and to prepare for the actual writing. Now that the book has been published, I think that I still have a lot more to say. Despite that, Tam very satisfied with the book, believe it may save clinicians many headaches, and wish some- body had given me a book like this 15 years ago. If that had happened, I would have better cases today. Thope that through using some of the information provided in this book you will have better cases tomorrow. My goal has always been to achieve the best out come for each patient. Very early on I started to document, organize, and critically analyze the cases Iperformed. For each case, | was careful to select a biologically sound, scientifically proven treatment option. At the same time, I focused on the develop- ment of minimally invasive, simple, and predictable treatment options. A good example of this is the sausage technique", deseribed in Chapter 11 of this book. The scientific documentation and publi- cation of the techniques I have adopted has always been very important to me. ‘The development of new methods as well as the progress regarding the stability and predictability of cases is well repre- sented in this book. Of course, we wonld all like to select better and better cases for a book, yet the educational part of improving our technique is at least equally impor tant. Tagree with the adage that the devil is in the detail; therefore, the details of the cases presented in this book were analyzed from a seli-critical per- spective. 1 think that in regenerative therapy there are three important follow-up dates: 3 weeks, 5 years, and 10 years. It therefore takes a while before we can recognize things that could have been done bet- ter What did I learn from the cases in this book? How would I better solve them today? Which phase could I have improved upon at the time? [think that the answers to these questions might be the most important resource of this book, and am certain that without the “Lessons Learned” sections, which fol- low on from each case, the reader would take much00 | inioduction less out of this book. As you read about the cases, you may find that you like or dislike some aspect of 4 particular case, and may think that you would do it differently. Yet once you have read the lessons thet I learned from each case, it is my hope that your ideas may change, and may change perma- nently “Could you please take another look at this pho- tograph of this case?” or “Can you see that had I made a minor change to this or that aspect of the treatment, I may have had better crestal bone preser~ vation?” These types of questions, suggestions, and observations that run through this book make it more educational, and hopefully will remind the reader of the little things; of the places where the devil hides; of the details that make all the difference. Therefore, this book is not only about how to regenerate lost hard and soft tissue. More impor- tantly, itis also about how to preserve the regener- ated crestal bone and soft tissue contours, often the ‘most demanding part of the treatment. believe that the right education and one’s inter- nal focus are of primary importance. Allow me in this book to share some of my experience, which might be a good example, especially for the very young clinician. When I graduated from dental school I was not completely satisfied. At that time, ‘we learned a lot about repairing and restoring teeth and less about the biological principles governing the potential of maintaining and regenerating lost tissue, which was already then my main interest. I had two choices: quit, or progress further with my education. 1 chose the latter, and today feel that 1 ‘was born to do what I am doing, and enjoy every minute of it. like to keep procedures simple, repeatable, and biologically sound. Overcomplicated treatment strategies have higher complication rates and less predictability in the final outcome. ‘Therefore, I would like to welcome you and thank you for read- ing this book, and to remind you of a quote by Leonardo da Vinci: “Simplicity is the ultimate sophistication” Dr Istvan UrbanAcknowledgments I would like to thank my wife, Judit, for her love and endless support, and our two sons, Isti and Marci, {or their existence, spirit, and positive outlook on life. You make our life complete. As a child (and ever since), my parents never interfered in any of the decisions I made, as they believed in the develop- ‘ment of the individual with only minimal guidance. Ibelieve they were right, and { thank them for that. ‘My teachers were my teachers, continue to be my teachers, and will remain my teachers. Special thanks to Dr Henry Takei for his inspiration and unsur- passed qualities asa humanitarian, both as an eduea- tor and as a periodontist. Special thanks also to Dr Jaime Lozade for his belief in me asa student at Loma Linda University and that I would go on to do vertical ridge augmentation, 1 would also like to thank Dr Sascha Jovanovic for introducing me to guided bone regeneration in a biologically sound way. ‘Thanks also to Dr Joseph Kan, Dr Perry Klok- keyold, Dr Anna Pogany, Dr Lajos Patonay, Dr Paul Gerloczy, and to all my other teachers. Without meeting all of you and being your student, there would be much less to say in this book. Talso thank CDT Nicola Pietrobon for the excel- lent ceramic restorations he made for many of the cases presented in this book I would like to express my appreciation to Quintessence Publishing, specifically to the man~ agement, Horst Wolfgang Haase and Christian Haase, as well as to Johannes Wolters and Avril du Plessis for editing, and to Janina Kuhn for the lay- cout and production of this book. I would like to thank Ms Keisatina Szample for the drawings, and Dr Randy Newby for creating some of the technical drawings for the book. Finally, my thanks go to Ms Jacqueline Kalbach of The Avenues Company, for her support in the preparation of my manuscripts and of this book.ee a — ; a - — ee one Oo 7 OO SS a Be Be Se - ens a a 7 a oe -_._ = - a — oe ie : oe ar ateSurgical setup and patient preparation ‘There are several factors that will lead to success or ilure in the treatment for ridge deficiency. Patient selection, patient preparation for surgery, precise sur- gical techniques, and postoperative management (in- cluding the use of adequate temporary restorations) are the key factors in achieving success. In the au- thor's experience, patient selection and patient prep- aration for surgery are the two most important fac- tors; for example, patient disclosure of smoking habits 1s an important part of the patient selection criteria, This chapter will address patient selection, pa- tient preparation for surgery, medications, patient preparation in the surgical room. and postsurgical care and suture removal. al Patient selection encompasses more than inclusion and exclusion criteria. The clinician has to carefully explore the patient's needs and desires, and deter- Patient selection mine what is realistically achievable for a particular case. Unrealistic patient expectations should be identified and clarified. In the author's practice, a patient presented with an anterior maxillary ridge atrophy and desired “single implants, and a papilla in between them’ (cee Fig 14-9), Although every ef fort is made to satisfy the patient's wishes, this re- quest was considered to be unrealistic. This was made clear to the patient, and confirmed in writing before the treatment began. In addition, every step and time point in the treatment plan must be clari- fied before treatment begins. ‘The general inclusion and exclusion criteria for ridge augmentation are described below. Inclusion criteria: Cases are selected that require vertical and horizontal bone regeneration: 1) to achieve the necessary bone levels in order to place dental implants. 2) to improve the crown/implant ra- tio, or 3) to improve esthetics. In addition, patients, are required to have good oral hygiene prior to treat- ment, Exclusion criteria: Patients with uncontrolled systemic conditions or uncontrolled periodontal disease should not be candidates for this procedure. Other factors for potential exclusion from the pro- cedure include patients who engage in excessive alcohol consumption or are current smokers. Patients who smoke fewer than 10 cigarettes @ day are considered moderate smokers, and those. Suigcal setup and paint preparation who smoke more than 10 cigarettes a day are con- sidered heavy smokers.' It is very difficult to dif- ferentiate between mild and heavy smokers, since individual differences in response to smoking can be expected. If a current smoker is to be treated, the patient should quit smoking prior to the pro- cedure. ‘Wound dehiscence and graft infection occur more frequently in smokers, For complex grafting cases, a complication rate of up to 50% was reported for smokers? ‘The author requires all smokers to quit smok- ing for 3months prior to the procedure, and re- main in a smoking cessation program at least through the initial grait-healing period, which isa minimum of 3 weeks. This is because a postoper- ative infection can occur during the first 9 weeks postsurgery. If the patient starts smoking after this period, it is likely to impair bone formation, but at least detrimental complications will be less likely to occur. The author has found that patients who do not smoke for 3 months also do not start smoking throughout the entire treatment time. 2.2 Patient preparation for surgery Patients should have a professional cleaning within a week of the surgery. They should arrive at the of- fice 60 to 90 minutes before surgery, and should re~ ceive their medications 60 minutes before surgery. ‘They should then be waiting in a relaxed, comfort- able environment, which can be either in the wait- ing area or in a separate room. They should be fully informed and prepared before the date of the sur- gery. The procedural consent form should prefera- bly be signed prior to the surgery date 2.3 Medications There are no differences between medications used for bone regeneration procedures and regular im- plant therapy. The use of antibiotics, chlorhexidine solution, and anti-inflammatory medications are re- viewed in this section. Aniibioties: Penicillin is the most widely used an- tibiotic for bone regeneration. Amoxicillin is the best choice as it is well tolerated by patients, unlike amoxicillin clavulanic acid complex. Two grams of amoxicillin should be taken orally 1 hour before surgery, and 500 mg three times a day (TID) should be administered for 1 week following surgery. After major bone grafting, this period can be extended to 10 days. In the event of a penicillin allergy, clinda: mycin 600 mg is used for premedication, and then 300 mg four times a day (QID) is administered for 1 week following surgery for the same period of time. Oral sedation can also be used for selected pa- tients. Most frequently, this medication is selected for a patient if extensive surgery is needed or if the patient would like to be more relaxed during the surgery. Triazolam is used most frequently at a dose of 0.25 to 0.50 mg, This should be taken 1hour be- fore surgery and, if oral sedation is used, the patient should be professionally supervised after the surgi- cal procedure. Intravenous sedation or general an. esthesia is used for patients having more extensive surgery, such as reconstruction of the edentulous resorbed maxilla, Chlorhexidine solution: A chlorhexidine solution (0.12%, eg, Peridex) is given to the patient to rinse before the surgical procedure. For 24hours after surgery, the patient should not rinse, On the sec- ond day after surgery, the patient should start rins: ing with chlorhexidine twice a day. This is used for lwdays. Anti-inflammatory medications: An anti-inflam- matory medication (50 mg diclofenac potassium or Ibuprofen 200 mg, three times a day) is prescribed for 1 week following the surgery. Since pain is usu- ally not intense, medications containing opioids (such as Vicodin) are usually not necessary, and are not routinely prescribed. Steroids are not used routinely by the author be- cause they can have a negative effect on healing, Clinical experience has shown that giving an anes- thetic to the patient before suturing, and then ap- plying cold packs right after surgery, will result in similar swelling after the first 3 days as if steroidshhad been used, as most of the edema goes away on the third day, and the rest of the swelling remains and may form a hematoma. This can be prevented by using the protocol described above. Therefore, if 4 clinician chooses to use steroids, the length of ac- tion of the particular type should not be more than 20 3 days, The author uses short-acting steroids for patients who have extensive surgery under general anesthesia. Due to the initial stage of edema, some clinicians fear that the swelling will open up the sutures. That is the reason they routinely prescribe steroids post- surgery, The author would like to emphasize that thisis not the case and, by using the techniques that ‘will be described in this book, flap opening should not be an issue. Using remedies such as arnica mon- tana have been reported anecdotally as helpful for some patients, but there is no scientific documenta- tion to support their use. 24 The surgical room ‘The patient should enter the surgical room, which must already be prepared for surgery, about 30 min- ‘utes before surgery. No instrument noise should be made that could make the patient uncomfortable. “The surgical assistant should briefly explain the steps of the procedure. The patient should then rinse with chlorhexidine for Iminute, after which the skin adjacent to the surgical site should be dis- infected. The surgical drape should be professional- ly placed over the patient (Fig2-1), Tnstruments are placed in a surgical tray accord- ing to the order in which they will be used during the surgery (Fig2-2), These instruments are steri- lized in the surgical tray before the surgery. The au- thor uses the instruments out of the tray, and the instruments are kept in order during the entire sur- gical procedure References Fig 2-1. Side view of a sterile surgical drape applied to the patient. 2.5 Postsurgical care and suture removal Medications and doses should be followed as de- scribed above. Chemical plaque control using 0.12% chlothexidine solution should be used from 24 hours postsurgery until the time of suture removal. To avoid postsurgical trauma, a removable appliance should not be placed on the surgical area. Ifthe clin- {cian plans to use an interim removable prosthesis, it should rest on the neighboring dentition with a safety gap of at least 2mm in between the prosthe- sis and the grafted area. A metal-reinforced prosthe- sis with occlusal rests can be used for this purpose. Sutures are also removed in stages: single interrupt- ed sutures are removed at 10 to 14days, whereas mattress sutures are removed at 2 to 3 weeks post- surgery. 2.6 References 1, Levin L, Herzberg R, Dolev E, Schwastz-Arad D, Smoking and complications of onlay bone grafts and sinus lift oper- bons. Int Oral Maxillofac Implants 2004;19:369-373. 2, Barone A, Santini 5, Sbordone L, Crespl R, Covani U, A cinical study of the outcomes and complications asto- ciated with maxillary sinus augmentation. Int J Oral Max~ illofac Implants 2006;21:81-85, cSuigical setup and patient preparation eee NIT Fig 2-2 (1 and 2). Surgical instrument setupMembranes and graft materials Several different types of membranes and bone rafting materials have been used for guided bone regeneration (GBR). In terms of composition of the membranes, synthetic materials have been used, such as nonresorbable polytetrafluoroetinylene (PTFE), and resorbable synthetic materials, such as 4 combination of polyglycolic acid (PGA) and tri- methylene carbonate (TMC). Currently, resorbable materials that are xenogeneic in origin, such as col- lagen, are used most frequently for GBR. One of the first membranes developed specifical- ly for GBR was the nonresorbable, titanium- reinforced (TR) expanded polytetrafluoroethylene (PTFE) membrane. The reinforcement with a tita- nium frame makes the membrane form stable. The Use of these membranes is well documented and considered the gold standard for GBR. More recent- ly, resorbable membranes have been developed that are not form stable, Therefore, membranes can also be classified as form stable and non-form stable, Form stable, nonresorbable TR membranes are con- sidered the gold standard for both vertical and hori- zontal augmentation. Bone grafting materials are used in combination with the membrane for GBR: particulate bone grafts, anorganic bovine-derived bone mineral (ABBM)’, allografts, and synthetic bone graft materials have been used to provide a scaffold to facilitate the growth of bone into the defect space, This chapter will provide an overview of the fol- lowing: * Scientific documentation of horizontal GBR us- ing different membranes. + Scientific documentation of vertical GBR using different membranes. * Grafting materials and representative cases. 3.1 Scientific documentation of horizontal GBR using different membranes GBR for horizontal augmentation has been used to treat multiple types of bone defects, including treat- * Anorganic bavine-derived bone mineral (ABM) is also re ferred to in the literature as deproteinized bovine bone min- eral, deproteinized anorganic bovine bone, and anorganie bovine bone.3 Membranes ad graft mater ment of fenestration defects! and dehiscence de- fects. Ridge augmentation of severely thin ridges using GBR was also introduced using nonresorbable PTFE and, more recently, resorbable collagen membranes"! High rates of implant success and low complication rates have been reported for the Use of GBR for ridge augmentation,! In these ridge augmentation studies, autogenous bone blocks were covered with biomaterials, and membranes were used for GBR." However, bone block grafts are associated with varying morbidity, depending on the harvest site,115 as well a¢ early resorption that tay compromise the clinical out- More recently, particulated graft materials have been used with resorbable membranes for horizon- tal augmentation procedures.!72" Since these mem- branes are non-form stable, it is more technically demanding to use them for ridge augmentation, For horizontal GBR, the “sausage technique” has been developed to overcome this difficulty. This tech: nique will be described in Chapter 11 of this book. One advantage of this technique is that resorbable membranes have shown better soft tissue compati- bility as compared to nonresorbable membranes.2122 However, there are marked differences between different types of resorbable membranes, The fol- lowing sections of this chapter discuss synthetic resorbable membranes and two types of collagen membranes (cross-linked and native collagen). 3.1.1 Synthetic resorbable membranes Traditional synthetic membranes, using traditional polymers like polylactic avid, have demonstrated therapeutic problems due to their inflammatory and foreign body reaction upon degradation.232 Recent experimental results with a newly developed sy thetic resorbable membrane made of PGA and TMC have yielded positive results, and recent studies in an ‘animal model with this membrane have demonstrat- ed no histologic foreign body or inflammatory reac- tion? A prospective clinical study has demonstrated that this membrane can be safely used for horizontal ‘augmentation of severely resorbed ridges"? 3.1.2 Cross-linked collagen membranes Several cross-linking techniques have been used to extend membrane resorption times, including ultra- violet (UY) radiation, chemicals, and enzymatic techniques, Cross-linked collagen membranes re- tain their integrity, and this provides barrier func- tion longer than non-cross-linked membranes.2927 It has also been shown that the resorption time is dependent on the degree of cross-linking ‘However, poor tissue integration, poor vasculari zation, and poor biocompatibility have been demon- strated with cross-linked collagen membranes:725 Differences exist between these type of membranes, which depend on the degree of, and the technology used for, cross-linking, For example, cross-linking, with glutaraldehyde has resulted in decreased bio compatibility.® In addition, periodontal bacteria are able to procice a collagenase enzyme that can de- grade collagen membranes in eases of exposure.” There may be a difference between the re-epithe- lialization of the wound with a cross-linked versus a native collagen membrane.!”27 In a randomized controlled trial (RCT), it was demonstrated that if'a cross-linked collagen membrane becomes exposed, the site will lose about 48.5% of the bone graft. This type of collagen membrane may be more re- sistant to resorption, and wound healing of the ex- posed site takes longer, allowing time for the graft particles to exfoliate:"7"1 3.1.3 Native collagen membranes Rapid biodegradation by the enzymatic activity of macrophages and polymorphonuclear leucocytes occurs when using native collagen membranes. ‘These membranes are well documented and have resulted in excellent long-term clinical outcomes.3? Native collagen membranes have good tissue in- tegration and early vascularization from the peri- osteal side. They are also biocompatible 8 Vascular- ization is a prerequisite for bone formation and may be one of the most important qualities of these membranes. It has been demonstrated that no rem- nants of an exposed native collagen membrane exist after 1 week of healing.”” This is important with re-ard to how much bone gain can be expected in these types of complications. There is « debate about what is more important: resorption time or biecompatibility and vasculariza- tion. Results of nonclinical studies that compared nonresorbable and resorbable membranes,” as well as a case series using natural collagen membrane,!® indicate thata slowly resorbing membrane is not nec- essary for horizontal augmentation. Urban et al have reported on two prospective studies with two mem- branes having different resorption times:!20 one was a synthetic PGA-TMC membrane with 4 to 6 months of wesorption time, and the other was a native colla- gen membrane with about 6 weeks of resorption time, The authors found no difference in the bone gain achieved between the two membranes; however, the collagen membrane was much easier to use. Hence, it appears that the resorption time is not of primary importance for GBR, and the membrane is necessary only for the initial week of healing. 3.2 Scientific documentation of vertical GBR using different membranes GBR for supracrestal regeneration was introduced, the surgical technique was described, and the first animal and human histologic studies using vertical bone augmentation were demonstrated to be suc- cessful 436 Complications reported with vertical bone augmentation invelved membrane exposure and/or subsequent infection, with rates ranging be~ tween 12.5% and 17%.25-97 ‘The long-term results of vertical GBR following 1 tb 5 years of prosthetic loading were examined in a retrospective multicenter study that evaluated 123 implants. Three treatment modalities were studied, being nonresorbable regenerative membranes. in combination with a blood clot only, demineralized freeze-dried bone allograft (DFDBA), and autogenous bone chips. The results from this investigation re vealed that vertical bone regeneration superior to ‘1mm could only be achieved with the use of autoge~ cientfic documentation of vertical GBR using diferent membrane nous bone chips. These authors reported an overall success rate of 97.5%, leading them to conclude that vertically augmented bone using GBR techniques re- sponds to implant placement in a fashion similar to native, non-regenerated bone. All these studies used nontesorbable e-PTFE membranes, which have been associated with a high incidence of soft tissue prob- Jems, such as exposure.2® Other authors have report- ed a similar soft tissue response to e-PTFE mem- branes as compared to resorbable membranes? In a randomized clinical trial for vertical GBR, bone de- fects were treated with either titanium osteosynthe- sis plates covered with a collagen resorbable mem brane, or e-PTFE-TR membranes, There were no statistically significant differences in terms of com- plications between the two techniques” In addition, more sites achieved complete regeneration when the -PTFE-TR membrane was used. The authors report- ed that after 6 years of loading, the regenerated bone functioned like native bone in both treatment groups. with slightly more hone remodeling in the resorbable collagen membrane group. Studies previously reporting on vertical aug- mentation used a non-resorbable, PTFE-TR mem- brane, but this membrane is no longer commercially available. Recently, a new high-density PTFE mem- brane with titanium reinforcement has become commercially available. A prospective clinical and histological study demonstrated that the combina- tion of particulated augmentation material (Le. a combination of autogenous bone and ABBM) and a G-PTFE-TR membrane can be safely and effectively used for vertical augmentation of deficient ridges in the maxilla or mandible.“! Another study compar- ing e-PTFE and U-PTFE membranes found that there 1s no difference between the two materials.® More- over, it appears that in cases with membrane expo- sure, the outcome is more favorable with the d-PT- FE, as e-FTFE exposure to the oral environment resulted in subsequent bacterial colonization in ‘most of the cases:*8 Th general, it can be conchided that a form stable membrane is necessary for vertical GBR. Non-form stable membranes cannot be used predictably un- less they are used for covering a titanium mesh or osteosynthesis plate,© 00 3) Membranes and yattmaterils 3.3 Grafting materials used for GBR Several different types of grafting materials have been used for GBR, including particulated autoge- nous bone grafts, ABM, allografts, and synthetic materials, Each type will be discussed in the sec- tions below, and a representative case will be pre- sented. 3.3.1 Particulated autogenous bone grafts ‘The first particulated bone graft used autogenous bone, ‘This grating material adapts easily to any sur- face irregularities and allows blood vessels to grow rapidly in between the graft particles. Autogenous bone has three major qualities: It is 1) osteocondue- tive (providing a scaffold for bone formation), 2) ‘osteogenic (containing mesenchymal cells), and 3) osteoinductive (containing growth factors). Once autogenous bone is particulated, growth factors and living cells are exposed. Recent research has focused on cortical bone chips. It appears that the paracrine function of cor- tical bone chips has a major impact on bone forma- tion, A study investigated the proteins released from the extracellular matrix of cortical bone chips, and 43 growth factors were identified, including several growth factors that are associated with bone formation Transforming growth factor 81 and 62 (TGFB1 and TGFB2), Osteoblast stimulating factor-1 (OSP-2), Galeetin-1 (and others) were identified to play an important role in the complex process of bone formation, Bone morphogenic protein (BMP) is also present in autogenous bone.!* Research that investigated vertical ridge aug- mentation (VRA) using autogenous particulated bone has had favorable results 806 The use of au- togenous particulated hone in combination with e-PTFE-TR membranes was investigated by Urban et al This study reported on 35 patients with 36 three-dimensional (3D) vertical bone defects who were treated with VRA and had prosthetic loading of 1 t0 6 years, These patients were treated with 82 enhanced, acid-etched, oxidized surface implants. Alter removal of the © PTFETR membrane at im- plant placement, a resorbable collagen membrane was placed over the newly formed crestal bone to protect the graft irom early resorption. There were three treatment groups: Group A had a single miss- ing tooth, Group B had multiple missing teeth, and Group C had vertical defects in the posterior maxil- la only, and were treated simultaneously with sinus graft and vertical augmentation. At membrane re- moval, the mean vertical augmentation was 5.5 mm. (42.29 mm), with a maximum gain of 12 mm. The mean combined crestal remodeling was 1.61. mm (0.57 mm) at 12 months, which remained stable through the 6-year follow-up period, There were no statistically significant differences between the three groups in mean marginal bone remodeling. ‘The overall implant survival rate was 100%, with a cumulative success rate of 94.7% Merli has reported similar findings atter 6 years of loading.*? ‘The overall implant success rates within these studies%*40 are consistent with published long: term results of implants placed in horizontally re- generated bone,!* and results reported for implants placed in native, non-regenerated bone.‘"~% ‘These studies demonstrated that this technique is prediet- able, and that the implants are successful after pros- thetic loading. Autogenous bone chips are a very effective tool in the clinician's hands, They are an integral part of the composition of the current grafts used for verti- cal and horizontal ridge augmentation. This graft material is readily available, and today we have ‘minimally invasive techniques to harvest it 3.3.2 Anorganic bovine-derived bane mineral Even though autogenous bone has long been con- sidered the gold standard for bone regeneration procedures, different bone-filling materials have also been studied to minimize morbidity associated with the second surgical site to harvest bone. ABBM is a deproteinized, sterilized, bovine can- cellous bone that is osteoconductive and provides a favorable scaffold for bone formation. It incorpo- rates into the newly formed bone and, since it isslowly resorbed, keeps the volume of the graft very stable, The good osteoconductivity is due to the pre- served natural structure. The favorable surface to- ography allows good contact with the blood elot, ‘and the interconnected internal channels allow cells and vessels to grow. ‘This graft material when used alone is well doc- umented in sinus augmentation and in GBR of small defects. Research has also focused on vertical and horizontal ridge augmentation using this material 33 Ina RCT investigating the use of ABBM alone ver- sus mixed with o different percentage of autograit, it was shown that after 9 months of healing, ABBM achieved similar bone formation to autogenous bone?! However, a recent RCT found that using less au- togenous bone in the mixture with ABBM resulted in significantly less bone gain, despite the fact that the histology did not reveal any differences.® This study demonstrated that ridge augmentation is dif- ferent fiom augmentation of the sinus or small de fects with OBR. The outer surface of the graft may not become incorporated into the ridge as success- fully as when autogenous bone is mixed into the graft. The extracellular proteins, and the informa- tion in the cells in the autogenous bone chips, may play an active role in the formation of bone far away from the bone walls. The efficacy of a 1:1 mixture of ABBM and au- togenous particulated bone graft using ePTFE membrane was evaluated histologically and histo- ‘moxphometrically in 8 patients (10 ridge defects). 33 Ging nateialsused or GBR 3 @@@e After a healing period of 6 to 9 months, a mean ver- tical gain of 5.15 mm (SD + 1.12 mm) was achieved, ‘The histological analysis demonstrated new bone formation and ongoing remodeling of autogenous articulated bone and the ABBM particles. In subsequent clinical and histological studies, this graft material (1:1 ratio of ABBM mixed with autogenous bone) was investigated for vertical and horizontal augmentations."?2041 In two different studies for horizontal augmentation, a mean bone gain of 5.5mm was achieved. In a vertical augmen- tation study, a mean bone gain of 5.5 mm was achieved, with a maximum of 9 mm, In the histo- logical sections from the VRA study, the grafted autogenous bone demonstrated ongoing bone 1e- modeling, and the ABBM was connected with a dense network of newly formed bone of various degrees of maturation. In addition, the marrow space was well perfuused with blood vessels, and no inflammatory response or foreign body react was noted in any of the specimens. Histomozpho- metric analysis of the VRA results demonstrated a mean bone increase In 366% of the specimens: 19.6% was newly formed bone, and 17% was grafted bone, Grafted autogenous particles demonstrated ongoing remodeling: ABBM was 166% and mar- row space was 46.8%. These results were similar to those reported by Simion et al'? It appears that the ABBM and autograft mixture is an ideal grafting ‘material for vertical and horizontal GBR, as is shown in the representative cases presented in Fig uures3-1 and 3-2.0.00 3 Werbranes ad yltmaterals Figs 3-1 (1 to 4) Representative case ofa histological result after horizontal ridge augmentation using 1:1 ratio of autogenous bone and ABBM mixture and a d-PTFE membrane after 8 months of uneventful healing, (1) Over- view of a histological section taken after 8 months of graft healing. The original maxillery bone can be seen. The augmentation area is connected with newly formed bone to the original maxillary bone (original magnification x 50). (2) Formation of dense trabecular structures composed of newly formed bone with integrated ABBM gran- ules (original magnification x 100). (3 and 4) Mixed deposition of lamellar and woven bone on ABBM by active ‘osteoblasts (original magnification x 200 and x 400, respectively), Connective tissue shows no signs of inflamma- tory reactions33 Grating materials used for GBR 3 @@ Figs 3-2 (1 to 4). Representative case of a histological result after vertical ridge augmentation using 1:1 ratio of uutogenous bone and ABBM mixture and a d-PTFE membrane after 9 months of uneventful healing. (1) Over- view of a histological section taken at 9 months of graft healing (original magnification x 50). (2) Extra- and i lraosseous deposition of new bone on grafted bone particles. (3) Seam of osteoblasts adding osteoid and new bone to bone chips; resorption of autogenous graft particles uninflamed, well-perfused bone marrow (original ‘nagnitication x 200), (4) ABBM and grafted bone primarily embedded in woven bone followed by layers of Jaunellar bone osteon formation; remodeling (original magnification x 200). Connective tissue shows no sigas of inflammatory reactions.coe} Membranes and graft materia 3.3.3. Allografts Allografts are sourced from human cadavers. They can be mineralized or demineralized types, depend- ing on the production process. Mineralized cancel- lous bone allograft (MCBA) is an effective osteocon- ductive material because its highly porous structure maintains volume. Due to its cortical and porous cancellous parts, mineralized cortico-cancellous bone allograft provides better volume maintenance and good osteoconductivity. Mineralized cortical bone allograft is produced for space maintenance. However, the demineralized freeze-dried bone has limited osteoinductivity, and it resorbs rapidly. Allografts are widely used as graft materials for GBR. Simion et al compared DFDBA to autogenous particulated bone grafts clinically and histologically for VRA2” Both groups were considered successtul, both clinically and histologically. The group treated with DFDBA achieved somewhat less vertical bone gain (3.1 mm), whereas autogenous bone gained a mean of 5.02 mm, After 1 to 4 years of follow-up, the 20 implants placed in the DFDBA group demon. strated 1.87 mmm of bone remodeling (ranging from 1 to 4mm), which is somewhat more than results reported with autogenous particulated bone grafts This study demonstrated that DFDBA may not be the best choice for vertical GBR because it is not dimensionally stable. Recenily, a combination of DFDBA and corti- co-eancellous bone chips was compared with au- togenous particulated bone grafts in five patients using @ split mouth study design Both augmenta- tion materials achieved similar vertical bone gains of 4.1 10.4.7 mm, After 6 years of follow-up, favora: ble results were reported for the implants, but the reported data were general, and the results of sub- groups treated with different graft materials were not provided.*5 The evidence of the long-term func tion of allogenic materials in vertical GBR is limited. ‘The results of vertical bone gain, however predicta- ble, were only investigated in moderate vertical de- fects of up to5 mm. A recent split mouth, horizontal ridge augmentation study was reported that inves- tigated a 1:1 ratio of freeze-dried bone allograft (FDBA) mixed with autogenous bone on one side versus FDBA only on the other side.%° ‘The authors were using a tenting screw technique, and the graft was covered with acellular dermal matrix.% Around 3 mm of bone was regenerated on both sides, demonstrating no statistically significant differene- es between the two sites, and similar outcomes without the use of autogenous bone. However, one should bear in mind that both sides had a limited amount of bone gain. The results reported in this study may also be related to technical differences between the tenting screw technique and the sau- sage technique (see Chapter 11). The author believes that using tenting screws for horizontal angmenta- tion with resorbable membranes is more of a disad- vantage than an advantage, as it limits the amount of gain achievable. Throughout this book, specifical- ly in Chapters 11 and 20, horizontal ridge augmen- tation will be described in both partially and com- pletely edentulous patients, where it achieves much more bone gain than was reported by Caldwell et al, and indicates that the use of autogenous bone may be advantageous 9.041652 More research needs to be done on the use of allografts, and dimensional Jong-term stability is one aspect that requires inves tigation, These materials are clearly capable of re~ generating bone, but the question is: How long will the bone gain remain stable? 3.3.4 Synthetic bone graft materials Synthetic bone graft materials clearly have a future in regeneration, Currently, the biggest challenge is ‘that a natural structure has not yet been achieved. ‘The surface contact angle has been flatter than that ‘of natural graft materials, and this usually results in less wettability and less contact with blood, and can lead to less incorporation into the newly formed bone. Arecent RCT performed a clinical and histolog- ical comparison of dehiscence-type defects that were treated with ABBM and beta-tricalcium phos- phate (TCP). The results demonstrated a similar de- fect reduction, and histomorphometric examination found no significant differences between the two groups.5” Dahlin also found similar results compar ing TCP/hydroxyapatite (HA) to ABBM.'® A differ-ent HA/TCP combination was also used suecessful- ly in a variety of indications ranging from sinus floor elevation to ridge preservation.59.° While these results are encouraging, one has to bear in mind thet studies are lacking on vertical and staged horizontal augmentation using these graft materials. 3.3.5 Conclusions about bone grafts By evaluating all these graft materials, one can con- clude that autogenous bone is still the gold standard and the most effective graft material, ABBM is, however, one of the most well-documented biomat- rials, and the mixture ofa 1:1 ratio of autograft and ABBM js the current standard for augmenting, se- verely deficient ridges. ‘This composite graft has been the most widely used in the cases and studies presented in this book. ‘This may change with time and the evolution of sci- ‘ence, However, one should recognize that the bio- logical and surgical principles described herein are generic, and are very likely to remain valid for a long time. These principles are the key to success. 3.4 References 4 Dalilin ©, Andersson L, Linde A. Bone augmeatation at fenestrated implants by an ostsopromotive membrane technique. A controlled clinical study. Clin Oral Implants Res 1991:2:159-168, Dahlin C, Lekbolm U, Linde A. Membrane-induced bone ‘augmentation at titanium implasts. A report on ten fix- tures followed from 1 to 3 years after lo dontice Restorative Dent 1991;11:273-28t 4. Jovanovie $A, Spiekermann H, Richter EJ. Bone regenera tion around titanium dental implants in. dchiseed defect sites a clinical study, Int } Oral Maxillofac Implants 199357:288-245, 4. Mellonig JT, Triplett RG. Guided tisoue regeneration and endesseous implants. Int J Periodontics Restorative Dent 1993:13:109-119, 5, Shanaman RH. A retrospective study of 297 sites treated consecutively with guided tissue regeneratien, lat J Petio- sdontics Resiorative Dent 1995;14:292-301, 6 Dahlin C, Lekholm U, Becker W, st al, Treatment of fenos tration and dehiscence bone defects around oral implants using the guided tissue regeneration technique: a prospec- tive multicenter study. Int J Oral Maxillofac Implants 1995:103312-318, 2, Simion M, Misitano U, Gionso L, Salvato A. Treatment of Aehiscences and fenestrations around dental implants us Ing cesorbable and nonresorbable membranes associated swith bone autografts: a comparative clinical study. Int J Oral Maxillofac Implants 1997:12:158-167 Palmer RM, Smith BJ, Palmer PJ, Floyd PD, Johannson CB, Albrektsson T. Effect of loading on bone regenerated at implant dehiscence sites in humans. Clin Oral Implants Res 1998;9:283-291, Buser D, Brigger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regenera- tion. Clin Oral Implants Res 1990;1:22-32 Buser D, Dula K, Hirt HP, Scherk RK. Lateral ridge aug- mentation using autografts and barrier membranes: a clin- ical study with 40 partially edentulous patients. J Oral Maxillofue Surg 1996354420452 von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res 2006,17:359~3o9. 2. Buser D, Ingimarsion S, Dula K, Lussi A, Hirt HP, Belser UC. Long-term stability of oxseointegrated implants in augmented bone: a 5-year prospective study in partially ‘edentulous patients. Int J Periodontics Restorative Dent 2002;22:109-117, Nkeake E, Schultze Mosgau S, Radespiel-TrOger M, Kloss F, Neuicam FW. Morbidity of harvesting of chin grafts pro- spective study. Clin Oral Implants Res 2091:12:495-502, |. Nkenke E, Weisbach V, Winckler E, et al. Morbidity of harvesting of hone grafts from the iliac crest for prepros- thetic augmentation procedures: a prospective study. Int J Oral Maxillofac Surg 2008;35:197-163, Raghocbar GN, Louwerse C, Kalk WW, Visink M. Mor- bidity of chin bone harvesting, Clin Oral Implants Res 2001;12503-507. Maiorana C, Beretta M, Salina S, Santoro F. Reduction of autogenous bone graft resorption by means of bio-0ss, coverage: a prospective study, Int J Periodenties Restera- tive Dent 200525:19-25. Friedmann A, Strietzel FP. Maretaki B, PtaruS, Bernimou- Jin JP, Observations on a new collagen barsier membrane in 16 consecutively treated patients. Clinical and histolog- ‘cal findings. J Periodontol 2001;72:1616-1623. Hammerle CH, Jung, RE, Yanan D, Lang NP. Ridge aug mentation by applying biorevorkable membranes and de- proteinized bovine bone mineral a report of twelve con- secutive eases. Clin Oral implants Res 2008:19:19-25, Urban 1A, Nagursky H, Lozada JL. Horizontal ridge aug- mentation with a resorbable membrane and particulated autogenous bone with or without unoanic bovine ‘vone-derived mineral: a prospective caze series in 22 pa- tients, Int] Oral Maxillofac Implants 2011:26:404-414 Urban 1A, Nagursky H, Lozada JL, Nagy K. Horizontal ridge augmentation with a collagen membrane and 2 combina- tion of particulated autogenous bone and anerganic bovine bone-detived mineral: » prospective ease series in 25 pa tients Int J Periodontics Restorative Dent 2013/8:280-307 Zitamann NU, Schirer P, Marinello CP. Long-term results of implants treated with guided bone regeneration: a S-year prospective study. Int J Oral Maxillofac Implants 2001;16:395-366,23 24 25, 26, 27. 28 29. 30, 31 2, 2 35, branes and zraft materials Zitzmann NU, Naef R, Schiter P. Resorbable versus non- resorbable membranes in combination with Bro-Oss for guided bone regeneration. tat J Oral Maxillofac hnplants 1997 128-82 Schwarz F, Rothamel D. Herten Met al. Immunohisto- chemical characterization of guided bone regeneration at fa dehiscence-type defect using. different barrier_mem- branes: an experimental study in dogs. Clin Oral Implants Res 2008:19:402-415, AlparB, Leyhausen G, Giinay H, Geurisen W. Compatbil- ity ofresorbable and noaresorbable guided tissue regener- ation membranes in cultures of primary human periodon- tal ligament fibroblasts and human osteoblast-ike cells. Clin Oral Investig 2000:4:219-225, Stavropoulos?, Dahlin C, Ruskin JD, Johansson ©. A com- pparative study of barrier membranes as graft protectors in the treatment of localized bone defects. An experimental study in a canine model Clin Oral Implants Res 200415435142. Pitaru5, Tal H,Soldinger M, Grosskopf A, Noff M. Partial segeneration of periodontal tissues using collagen barsi- fers, Initial observations ia the canine J Periodontal 1988:59:380-586. Paul BF, Mellonig JT, Towle H) 3rd, Gray JL. Use of a col- lagen barrier to enhance healing in human periodontal fureation defects. Int J Periodontics Restorative Dent 1992;12:123-191, Rothamel D, Schwarz F, Seger M, Herten M, Seulean A, Becker J, Biodegradation of differently cross-inked coll gen membranes: an experimental study in the rat. Clin ral Implants Res 2005;16:369-378 Rothamel D, Schwarz F,Sculean A. Herten M, Scherbaum W, Becker J. Biccompatibilty of various collagen mesm- branes in cukures of human PDL fibroblasts and human osteoblast-tike cells. Clin Oral Implants Res 2004:15:443- 449, Sela MN, Kohavi D, Krause 8, Steinberg D, Rosen G. Enzy- matic degradation of collagen-guded tissue regeneration membranes by periodontal bacteria. Clin Oral lmplants Res 2008:14-253-268 Pask SH, Lee KW, Oh Tl, Misch CE, Shotwell, Wang HL. Eflect of absorbable membranes on sundivich bone aug- ‘mentation, Ciin Oral Implants Res 2008:1%:32-41, “Tatakis DN, Fromsuathi A, Wikesjo UM. Devices for per ‘odontal regeneration. Periodontol 2000 1999319:9-73, Jung RE, Fenner N, Hiimmerle CH, Zitzmann NU. Long: term outcome of implants placed with guided bone regen- eration (GBR) using resorbable and nen-resorbable mem- branes after 12-14 years, Clin Oral Implants Res 2018:24:1065-1073, . Jovanovic SA, Schenk RK, Orsini M, Kenney EB. Suprac- restal bone formation around dental implants: an exper ‘mental dog study. Int J Oral Maxillofac Implants 1995;10:23-31. Simon M, TrisiP, Piattelli A. Vertical ridge augmentation using a membrane technique asseciated with osseointe- grated implants. Int J Periodontics Restorative Dent 1994;14:466-511 %. 2m, 3 ». 41. fa . 4 4 46 a, 48 48, ‘inti C, Parma-Benfenati S, Vertical ridge augmentation: surgical protocol and retrospective evaluation of 48 con- secutively inserted implants. Int JPeriodontes Restoraive Dent 1998;18:435-443. Simion M, Jovanovie SA, Test P. Scarano A, Piatti A. Ver- tial ridge augmentation around dental implants using a membrane technique and autogenous bone or allografts in humans Int J Periodontics Restorative Dent 1998:188-23, Mexli M, Migani M, Bernardelli F, Esposito M. Vertical bone augmentation with dental implant placement: effia- cy and complications associated with 2 different tech- niques. A retrospective cohort study. nt Oral Maxillofac Implants 2006;21:600-0, ‘er M, Moscatel M, Mariott G, Rotundo R, Berrardelli F, Nieri M, Bone level variation after vertical ridge aug- mentation: reserbable barriers versus titanium reinforced harriers. A 6-year double-blind randomized clinical tial In J Oral Maxillofac Implants 2014:29:905-913. Urban TA, Lozada JL, Jovanovic SA, Nagursky H, Nagy K. Vertical ridge augmentation with titsnitm-reinforced, dense-PTFE membranes and « combination of particulat~ cf astogenous bore and anorganic hovine bone-dorived rineral:a prospective case series in 19 patients Int} Oral ‘Manele Implants 2014:29:185-193. Rona M, Rebaudi A, Torelli L, Stacchi C. Expanded vs dense polycetrafluoroethylene membranes in vertical rlge augmentation around dental implaats:a prospective randomized controlled linia) trial. Clin Oral Implants Res 2014:25:59-866. Fotek PD, Neiva RF, Wang HI. Comparison of dermal ma- trix and polytetralluoroethylene membrane for socket bone augmentation: a clinical and histologic study. J Pert- dontol 2007, 8:770-785. Caballé-Serrane J, osshardt DD, Buser D, Gruber R. Pro teomic analysis of porcine bose-conditioned medium. Int J Orel Maxillofoc Implants 2014;29:1208-1215. Uist MR. Bore: formation by autoinduction, Science 1965:508895-899, Simion M, Jovanovic SA, Tint C, Benfenati SP. Long-term ‘evaluation of osscointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1-5 year follow-up. Clin Oral Implants Res 2001;1235-85 Urban 1A, Jovanovie SA, Lozada JL Vertical ridge augmen- tation using guided bone regeneration (GBR) in three clin- ical scenarios prior to implant placement retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants 2009;24:502-510, Lekholm U, van Steenterghe D, Herrmann | etal Osseo- Integrated implants inthe treatment of partially etentu- lous jaws: prospective 5-year muleenter study. Int J (ral Maxillofac implants 1994:9:627-695 Adell R,Lekiolm U, Rockler 8, Brinemark PL A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. lt J Oral Surg 1981;10:387-416 ‘Adell K.Clinial results of osseointegrated implants sup: porting fixed prostheses in edentulous jaws. } Prosthet Dent 1983;50:251-254,51 52. 54 ‘Adell R, Eriksson B, Lekhotm UJ, Brinemark PI, Jeost T Long-term follow-up study of osseointegrated implants in tive treatment of totally edentulous jaws. Int J Oral Maxil- Jofac Implants 1990;5:347-359, Hallman M, Sennerby L, Lundgren A clinical and histo- logic evaluation of implant integration in the posterior ‘munilla ater sims loor augmentation with autogenous hone, bovine hydroxyapatite ora 20:80 mixture. int} Oral ‘Maxillofae Implants 2002;17:685-643 ‘Mordenfeld 4, Johansson CB, Albrektsson T, Hallman M. ‘A randomized and controlled ciniea! tral of two diferent ‘compositions of deproteinized bovine bone and autoge nous bone sed for lateral ridge augmentation. Clin Oral Inmplants Res 201425:310-300. Simion M, Fontana F, Rasperini G, Maiocana C. Vertical ridge augmentation by expanded-polytetrafivoroethylene membrane and a combination of intracral auiogenous bone graft and deproteinized anorganie bovine bone (Bio Os), Clin Oral Implants Res 2007;18:620-629, Fontana F, Santoro F, Maiorana C. lez2iG. Piattelli A, rmion M. Clinical and histologic evaluation of allogeneic hone matrix versus autogenous bone chips associated with ttaniu-reinforced ePTFE membrane for vertical Filge nugmentation: a prospective pilot study. tat J Oral Maxillofac trplante 2008;2%1008-1032, Fontana F. Gross GB, Fimand M, Maiorana C. Osseointe- grated implants in vertical ridge augmentation with a noaresorbable membrane: & retrospective study of 75 im- 55 58 Eo 44 References 4 @ plants with 1 to 6-yeare of follow-up. Int J Periodontics Restorative Dent 2015:35:29-39. Caldwell GR, Mills MP, Finlayson R, Mealey BL. Lateral alveolar ridge augmentation using tenting screws, acelu- Jar dermal matrix, and freeze-dried bone allograft alone or with particulate autogenous bone. lat J Periodontics Re- storative Dent 2015;3575-83 . Merli M, Moscatelli M, Mariotti G, et al. Membranes end Bone Substitutes in a One Stage Procedure for Horizontal Bone Augmentation: A Histologic, Double-Blind Faralel Randomized Controlled ‘Trial. Int J Periodontics Restora- tive Dent 201535.463-471 Dahlin C, Obrecht M, Dard M, Denos N. Bone tissue mod. ciling and remodelling following guided bone regenera- tion in combination with biphasic calcium phosphate ma- terials presenting diferent microporosity. Clin Oral Implants Res 2015:26:814-822 ‘Mardas N, Chauha V, Donos N. Alveolar ridge preserra- tion with guided bone segeneration and a synthetic bone substitute or a bovine-derived xenograf: @ randomized, controlled clinical trial. Clin Oral Implants Res 2010:21:688-698, Frenken JW, Bouwman WF, Bravenboer N, Zijderveld SA, Schulten EA, ten Bruggenkate CM. he use of trauma one Ceramic in a mazillary sinus floor elevation proced- ‘ure: a clinical, radiological, histological and histomorpho- metric evaluation with a 6-month healing period, Clin (Oral implants Res 2010;21:201-268,The intraoral harvesting of autogenous bone Autogenous particulated bone is still utilized for vertical and horizontal augmentation using guided bone regeneration (GBR). However, the amount of necessary graft has been reduced by half, since the mixture with hone graf filler materials has proven to be successful, This has also changed the location and methods available for bone harvesting, Less-in- vasive techniques are preferred today for harvest ing autogenous bone. In this chapter, traditional harvesting techniques as well as less-invasive techniques are described. 4.1 Bone harvesting from the mandibular symphysis Until a decade ago, the chin area was the most widely used harvest site. In the author's practice, this site is very rarely used today. Burs, trephines, or a piezo saw can be utilized in the chin area for bone harvesting. Since paresthesia has been associated with this harvest site, the clinician has to be careful about the location and depth of harvesting bone in this sensi- tive area. Before any harvesting is performed, the clinician should visu the symphysis area three dimen- sionally with a cone beam computed tomography (CBCT) scan. It has been recommended to maintain a distance of 5 mm anteriorly from the mental nerve, 5 mm apically from the root tips of the teeth, and 5 mm coronally from the inferior border of the chin.! It is also advisable for the depth of harvesting not to be deeper than 2 to 3 mm into the cancellous bone (Fig 4-1).isbone Pig 4-1 (1 t0 9). Representative case of autogenous bore harvesting from the mandibular symphysis. In this case, a large amount of bone was harvested to treat a severely atrophied edentulous maxilla. For more details, see Tig 20-7, (1 and 2) Five large trephines (8 mm) were initially used in this procedure. (3) Four smaller trephines (6 mm) were then used coronally. 241. Bore harvesting from the mardibular symphysis lle Fig 4-1 cont. (4) Labial view alter removal ofthe bone rings. The depth of the preparation was 3 mm into the ‘cancellous bone. (5) In this ease, ABM was used to fill the defect, since dental implants were to be placed in the anterior mandible. (6) Two collagen membranes were placed to cover the site. Bll The intaoral hanestig of autogenous bone 4-1 cont. (7) The site was sutured first with horizontal internal mattress sutures (5-0 Monocryl, Ethicon). (8) Five internal mattress sutures were used to approximate the flap. (9) Continuous interlocking sling sutures were used for final closure,41. Bone harvesting fc hemandbaarsynpinss L| @ Fig 4-2 (1 to 3) Representative case of bone harvest- ‘ng in the mandibular ramus. (1) Occlusal view of the initial incision that is made parallel to the external ‘oblique line in the mucosa about 3 mm from the mu- cogingival junction. (2) Ocelusal view of overlapping ‘semicircular bone rings prepared with a 6-mm tre- pine, (3) Occlusal view of the site after removal of the semicircular bone rings. Final closure is achieved using continuous interlocking sutures.© 000 [| tre inracaltanestngc avogenous tone preferred technique. (1) Occlusal view of non-overlapping semicircular bone rings prepared with a 6-mm trephin: (2) Occlusal view of the site after the removal of the semicircular bone rings. (3) A large quantity of bone was collected from this site, (4) The harvested bone is particulated in a bone mill (Quétin, Leimen, Germany) (5) Particulated autogenous bone chips. 4.2 Bone harvesting from the mandibular ramus ‘The mandibular ramus has been the most frequently used intraoral harvest site in ridge augmentation. It is very important that the clinician visualizes the location of the mandibular ramus three-dimension- ally using a CBCT scan before any harvesting is performed. The author's preferred technique is demonstrat- ed in the cases in Figures 4-2 and 4-3. With the evo- lution of predictable, non-autogenous graft ma- % terials and the need for less autograft quantities, different bone scrapers have been developed for this purpose. With the use of these instruments, autogenous cortical bone chips can be harvested less invasively (Figs 4-4 to 4-6), Harvesting antogenous intraoral bone has be- come less invasive in the past decade. The clinician reeds to recognize that bone should be harvested in the safest and least invasive way. In most cases, the mixture of autogenous bone with bone filler mater- ials has decreased the necessity for harvesting large ‘quantities. The use of bone scrapers should be con- sidered in most cases.42 Bore hanesirg fom themandtuarramis | @@@e Fig 4-4 Representative case of bone harvesting from the mandibular remus for the reconstruction of an edentu- Jous resorbed maxilla, Refer to Chapter 20 for more information on edentulous maxillary reconstruction. (1 and 2) Multiple cores were harvested fiom the mandibular ramus, Mixing the harvested autogenous bone ‘vith ABBM provided an amount of graft material that was sufficient to reconstruct a severely resorbed maxilla, Fig 4-5 (1 and 2) Representative case of a mini bone scraper (Micross, Meta, Germany) used to harvest bone ‘fom the mandibular ramus using a tunnel preparation. (1) Labial view of a bone scraper that is introduced into the tunnel. (2) Note the amount of bone chips harvested using this mini scraper, a© 00 [| theincarat harvesting of atogenous one Fig 4-6 (1 to 6) Representative case of the use of a larger scraper (Safeseraper, Meta, Italy). The combination of trephines and scrapers is routinely used for large quantities of bone. (1 and 2) Note the large quantity of autoge- rons bone that is collected using this type of scraper. (3) A combination of bone trephine and scraper is used in patients who have advanced ridge atrophy. (4) Autogenous particulated bene after bone milling. (5) Autogenous bone mixed with ABBM. (6) Clinical application of the composite bone graft using a 1:1 mixture of autogenous bone and ABBM. Note the large quantity of graft material applied to this severely resorbed maxilla, 43 Reference L. Huat DR, Jovanovie SA, Autogenous hone harvesting: a chin graft technique for gurtisulate and monocortcal ‘bone blocks. Int J Periodonties Restorative Dent 1999;19: 165-173.The surgical anatomy of the floor of the mouth This chapter describes the surgical anatomy of the described, such as muscles, arterial supply, nerves, and floor of the mouth in a way that is practical and salivary structures, and the surgically driven dinical helpful to the clinician for the safe performance of anatomy is reviewed. A more detailed description can mandibular surgery, Key anatomical landmarks are be found elsewhere! Fig 5-1. Side view of the superficial layer of the musculature of the floor of the mouth. 1. Body of the mandible. 2 Anterior belly of the digastric muscle, 3. Hyoid bone. 4. Mylohyoid muscle. 5, Facial artery. 6. Submental ar- tery. 7, Submandibular gland.5 anatomy of the floor ofthe mouth Thesuric Fig 5-2 Inferior view of the superficial layer of the ‘musculature ofthe floor of the mouth. 1, Body of the mandible. 2, Anterior belly of the digastrie muscle. 3, Mylohyoid muscle. 4 Hyoid bone. 5. Submandibular gland. 6. Facial artery. 5.1 Musculature of the floor of the mouth and the tongue ‘The key muscle of this region is the mylohyoid that creates the diaphragm of the mouth (diaphragma ris) (Figs 5-1 to 5-4). This muscle originates from the mylohyoid line of the inner surface of the man: dible, Its line is oblique, run ng more superiorly at the molar region, and starting deeper in the first premolar and anteriorly (Fig5-5). The muscle in: serts into the body of the hyoid bone and anteriorly into a connective tissue raphe located in the middle (Figs 5-3 and 5-4), ft functions in swallowing as well as moath opening, and creates a separation for the floor of the mouth. Several muscles are involved in the movement of the tongue, including the genioglossus muscle, hyo- slossus and styloglossus muscles, and palatoglossus muscle (Figs5-6 and 5-7). The groove in between the mylohyoid and hyogiossus muscles is called the lat- eral lingual groove (sulcus lateralis linguae) (Figs 5-13 and 5-14). Fig 5-3. Inferior view of a deeper layer of the muscu- lature of the floor of the mouth after removal of the anterior belly of the digastric muscle and resecting the left side of the mylohyoid and the body of the mandi- ble. ‘The submandibular glands have also been re- moved. 1. Mylohyoid muscle. 2. Mylohyoid raphe. 3. Geniohyoid muscle, 4, Hyoid bone. 5. Facial artery. 6, Submental artery. 7, Sublingual branch of the sub- mental artery. Note that it perforates through the mylohyoid muscle, 8. Carotid bifurcation. 9, Stemoby ‘oid muscle, 10. Upper belly of the omohyoid muscle. ‘The digastric muscle has an anterior and a pos- terior belly, which are connected by an intermediate tendon that is attached to the hyoid bone (Figs5-1, 5-2, 5-6, 5-7, 5-9, and 5-12). The stylohyoideus muscle originates from the styloid process. It inserts into the hyoid bone, usually with a lateral and medial tendon that surrounds the posterior belly and the interme diate tendon of the digastric muscle (Figs5-6 and 5-7). The posterior belly arises from the mastoid notch of the temporal bone, and the anterior belly arises from the digastric notch at the mandibular symphysis. The digastric muscle and the body of the mandible form the submandibular triangle. The di- gastric muscle functions in mouth opening and in lowering the mandible. Tt also elevates the hyoid bone when the mandible is stabilized. Some of the muscles of the neck: are noted in the illustrations in this chapter but are not described in detail here because they are not of clinical relevance for mandibular bone graft surgery. They are de- scribed in detail elsewhere!Musculature Fig 5-4 Lateral view of the deeper layer of the musculature of the floor of the mouth after removal of the anter- {or belly of the digastric muscle. The submandibular gland has also been removed. 1. Mylohyoid muscle. 2. Hyoid bone. 3. Facial artery. 4. Submental artery. 5. Sublingual branch of the submental artery. Note that it perforates through the mylohyoid muscle. Fig 5-5 Medial view of the attachment of the mylo- hhyoid muscle into the internal surface of the mandible. 1. High mylohyoid attachment at the molar region. 2.Low mylohyoid attachment in the premolar region. “This is clinically significant when performing posterior mandibular ridge augmentation surgery (see Chap- ter 6) Fig 5-6 Schematic drawing of the suprahyoid muscu- lature. 1. Geniohyoid muscle. 2. Genioglossus muscle 3, Hyoglossus muscle, 4 Posterior belly of the digastric muscle. 5, Intermediate tendon of the digastric muscle. 6 Stylohyoid muscle. 7. Styloglossus muscle. 8 Inferior longitudinal muscle of the tongue. 9, Palatoglossus le the mou andinerongie 5) @@Fig 5-7 Lateral view of the deeper layer of the musculature of the floor of the mouth after the removal of the anterior belly of the digastric muscle and reseeting the left side of the mylohyoid and the body of the mandible ‘The submandibular gland has also been removed. 1. Geniohyeid muscle, 2, Genioglossus muscle. 3. Hyoglossus muscle, 4. Posterior belly of the digastric muscle, 5, Intermediate tendon of the digastric muscle. 6, Stylohyoid muscle, 7, Styloglossus muscle, 8, Inferior longitudinal muscle of the tongue. 8, Lingual artery arising from the medial lingual groove. 10. Hypoglossal nerve, 5.2. Arterial supply Severe bleeding and hematoma have been reported related to implant surgery in the mandible. Ana- tomical knowledge of the vascularization of the floor of the mouth is critical when the clinician is performing regenerative therapy in the posterior and the anterior mandible. ‘The arterial supply is provided by branches of the external carotid artery (Figs5-3 and 5-4). The two main anterior branches of the artery are the lingual and facial arteries, which are the second and third branches arising from the carotid It is not un- common for these arteries to arise from the com- mon linguofacial trunk. 5.2.1 Lingual artery ‘The lingual artery commonly arises from the carotid artery slightly superior to the hyoid bone, as the second anterior branch of the external carotid, It then runs anteriorly in between the space of hyo: glossus and m. constrictor pharyngis medius, and an- terior to the genioglossus muscles. Thisis also called the sulcus medialis linguae (i. medial lingual groove) (Figs 5-8, 5-12, and 5-14). Passing the body of the hyoid bone anteriorly, the lingual artery starts to run superiorly, branch- ing into the hyoid and the dorsal linguae. Running anteriorly, it bifurcates and becomes the deep lin- gual artery and the sublingual artery (Figs5-8,52 tera spy 5 @ Fig5-8 Lateral view after resection of the body of the mandible and partial removal of the digastric, styloglos- sus, medial pterygoid, stylohyoid, and mylohyoid muscles. The hyoglossus muscle was eut through, revealing the ‘medial lingual groove and the path of the lingual artery. 1. Hyoglossus muscle, 2. Genioglossus muscle. 3. Genio- hiyoid muscle 4, External carotid artery. 5. Linguofacial trunk. 6. Lingual artery, 7. Dorsal lingual branches of the lingual artery. 8. Sublingual branch of lingual artery. 9. Facial artery. 10, Hyypoglossal nerve, 5-10 end 5-11). The sublingual artery runs in be- tween the mylohyoid and the genioglossus muscle. Also called the lateral lingual groove (Fig 5-10), it provides branches to the sublingual gland, mus- cles, and gingiva. In most cases, it creates an anas- tomosis with the submental artery anteriorly, Some terminal branches penetrate the cortical bone? 5.2.2 Facial artery ‘The facial artery arises as the third anterior branch of the external carotid. It runs anteriorly and curves superiorly, medial to the digastric and sty- lohyoid muscles, and reaches the base of the man- dible superior to the submandibular gland. Before reaching the mandible, it branches into the sub- mental artery, which runs toward the chin, In 29% of cases, it gives rise to @ branch that perforates the mylohyoid muscle, anastomosing with the sub- lingual artery (Figs 5-1 to 5-4, 5-9, and 5-12). The facial artery then curves up to the face in front of the masseter muscle, running towards the medial corner of the eye It provides branches to the face throughout its course. Bee 5 The surgical anatomy ofthe floce ofthe mouth Fig 5-9 Oblique view of the submandibular region, 1. External carotid artery. 2. Digastrie muscle. 3. Facial artery. 4, Submental artery. 5. Submandibular gland. 6. Masseter muscle. 7. Hypoglossal nerve, Fig 5-10 Lateral view of the lingual artery entering the medial lingual groove. 1. External carotid artery. 2, Linguofacial trank. 9. Lingual artery. 4. Facial artery. 5: Hyoglossus muscle. 6 Hyoid bone. 7. Hypoglossal netye. 8. Hyoid branch of the lingual artery, 9. Poster- ior belly of the digastric muscle, Fig 5-11 Lateral view of the branches of the lingual arlery in the medial lingual groove. 1. External carotid artery. 2. Linguofacial truck. 3. Lingual artery. 4, Dor- sal lingual branch of the lingual artery. 5, Deep lingual artery, 6. Sublingual branch of the lingual artery. This, is a small branch as this specimen had a strong sublin- gual branch from the submental artery. 7, Hypoglossal 34 Fig 5-12. Inferior view of the vascularization of the floor of the mouth. 1, Facial artery. 2. Submental ar- tery, 3, Sublingual branch of the submental artery. Note that it perforates the mylohyoid muscle. 4. Sub- mandibular gland. 5, Mylohyoid musele. 6. Anterior belly of the digastric muscle after detachment of its insertion.52 terial supply 5 eo Fig 5-13 Superior view of the lateral lingual groove after the body of the mandible has been rotated facially. This region is of key interest when posterior mandibular ridge augmentation is performed, In about 30% of cases, the main blood supply to the floor of the mouth comes from the perforating branch of the submental artery, as. seen in this specimen. 1. Mylohyoid muscle. 2, Geniohyoid muscle. 3, Sublingual branch of the submental artery. 4. Sublingual gland, 5. Uncinate process of the submandibular gland, 6. Lingual nerve. 7. Wharton’s duct.-e00e 5 The stigcal anatomy ofthe foor ofthe mouth Fig 5-14. Anterior view of the lateral lingual groove. Sublingual artery arising from the lingual artery is clearly visible. This anatomical variation is the most typical, existing in about 63% of cases. 1. Mylohyoid muse. 2. Gen- loglossus muscle, 3. Lingual artery. gland. 8, Wharton's duct. 5.3 Anatomical variations of floor of the mouth vascularization Studies investigating the anatomical variations of the floor of the mouth have been published recently. In a study investigating 27 cadavers, four different types of variations were found.? The most common anatomical variation (68%) is when the sublingual artery supplies the lingual space (Fig 5-14). In 29.6% of cases, the sublingual artery does not exist, and the sublingual space is supplied by a branch of the submental artery (Figs §-3, 5-4, 5-12, and 5-13). In 36 . Sublingual artery, 5, Deep lingual artery. 6. Lingual nerve. 7. Sublingual this situation, a branch of the submental artery per forates the mylohyoid muscle and enters the lingual space. In these cases, the lingual artery supplies the tongue and the submental artery supplies the floor of the mouth. These are the two main variations. In 5.6% of cases, the sublingual and submental artery anastomoses together, supplying blood to the floor of the mouth, Rarely (ie. in 1.8% of cases), both the sublingual and the deep lingual artery are missing from the lingual artery and the floor of the mouth; also, the tongve is supplied by the submental artery arising from the facial artery.5.4 Nerves ‘here are two major nerves to be aware of when performing these surgeries: the lingual nerve and the hypoglossal nerve. Surgically, the most important nerve is the lin- gual nerve. It is a branch of the mandibular nerve (VII). The lingual nerve starts as a branch just after the mandibular nerve exits the oval hole (foramen ovale) of the skull, Running downwards in between the medial and lateral pterygoid muscles, it reaches the ramus of the mandible. Around the wisdom tooth area, it tums anteriorly and runs into the lat- ‘eral lingual groove. It innervates the anterior two thirds of the tongue, Before entering the lateral lin- gual groove (the chorda tympani), a branch of the facial nerve (VID) connects into the lingual nerve. This is responsible for taste in the anterior two thirds of the tongue and the salivary production of the sublingual and submandibular glands. ‘The hypoglossal nerve (cranial nerve XII) is re sponsible for the motor function of the tongue. Ex- iting the skull, it runs in between the internal carot~ fd artery and the internal juguler vein. Running anteriorly and downward, it enters deep into the lateral lingual groove and reaches the lateral border of the hyoglossus muscle, where it breaks up into its terminal branches. 5.5 Salivary glands There are two salivary glands: the submandibular land and the sublingual gland. The submandibular gland is the main component of the posterior part of the trigonum submandibulare. It protrudes into the sulcus lateralis linguae with its Processus uncina- tus, and occasionally merges with the glandula sub- lingual. ‘The submandibular gland’s excretory duct is the Submandibular duct or Wharton's duct. This runs ‘into the lateral lingual groove; the lingual nerve ‘crosses it inferiorly from outside and opens into the caruncula sublingualis, 57 Reererces 5 @@@ © ‘The sublingual gland is the salivary gland locat- ed in the anterior portion of the lateral lingual groove, Itis covered directly by mucosa and lateral- ly by the lingual frenulum, It protrudes as plica sub- mandibularis in the oral cavity. The posterior lobes open with numerous short duets (ductus sublin- _suales minores) and the anterior lobe opens with the ductus sublingualis major (Bartholin) into the Whar- ton's duct. The anatomy of the mouth is described else~ where in more detail." 5.6 Conclusion In this chapter, the key anatomical landmarks are described. The knowledge of these key anatomical landmarks will help the clinician to safely perform ridge augmentation in the posterior and anterior mandible. 5.7 References 1. Susan Standing (ed). Gray's Anatomy: The Anatomical Basis of Clinical Practice, ed 41. Elsevier, 2015. 2, Katsumi ¥, Tanaka R, Hayashi T, Koga T, Takagi R, Ohshi- ‘ma H, Variation in arterial supply to the floor of the mouth and assessment of relative hemorrhage risk in implant surgery. Clin Oral Implants Res 201524434440, Acknowledgments ‘The author would like to express his gratitude to the Institute of Anatomy, Semmelweis University, Bu- dapest, Hungary, for support in making the speci- mens shown in this chapter, and especially to Vik tor Pankovies for his assistance in the preparation of these specimens. The author would also like to thank Dr Gabor Baksa at the Institute of Anatomy, Semmelweis University, for his invaluable assis- tance and support in preparing this chapter.Principles of vertical and horizontal ridge augmentation in the posterior mandible Since the predictability of supracrestal vertical ridge augmentation (VRA) varies more than horizontal guafting, regandless of material selection or modality, it is necessary to justify this particular treatment for each patient, Alternative treatment options and po- tential compromised outcomes have to be evaluated. aand presented to the patient. Regenerating a defect may not be necessary if it is possible to place im- plants in other adjoining areas by using short im- plants for well-selected eases or pink ceramie restor- ations if longer clinical crowns have to be made. A specific clinical example of these considera- ‘ions for treatment with VRA is a partially edentu- lous patient presenting with a bilateral vertical de- fect in the posterior mandible, with compromised existing teeth in the anterior region. For this type of Patient, instead of bilateral vertical guided hone re- Eeneration (GRR) in the posterior region, a frequent choice of treatment is extraction of all the anterior teeth, and interforaminal implant placement, This freatment is simpler, has less morbidity, and is high- ly suecessful, with a significantly faster overall treatment time,! ‘This chapter will review flap design, preparation of the recipient site, membrane management or ad- aptation, “mobilization” of the lingual flap, buceal flap advancement, and tension-free flap closure in posterior mandibular vertical and horizontal ridge augmentation. It will also review expected healing after posterior mandibular surgery, and the treat- ment of more advanced defects. 6.1. Flap design Management of the soft tissue is a critical aspect of posterior mandibular surgery, The flap design should account for the fact that primary tension-free closure will need to be achieved over an increased dimension after the bone graft has been applied to the defect. In general, a flap that is too small is very difficult to manage and is very often responsible for early mem- brane or graft exposure, The “safety flap” (see Figs 6-1 to 6-4, 6-11-1 and 6-11-2) should be utilized in this procedure, This flap design, described previously as the “remote flap’? consists of both erestal and verti- cal releasing incisions, The rationale behind the de- sign is to have enough soft tissue to accommodate the increased dimension of the grafted ridge. With this design, the clinician can anticipate that primaryeee f Pn of vetial and horizontal ridge augmentation in the posterior mandi Fig 6-1 Lingual view of the pinned membrane. tension-free flap closure will be achievable. A full-thickness, mid-crestal incision is typically used in the keratinized gingiva with a surgical scalpel (No. 15). The distal extension of the crestal incision ends within 2mm of the retromolar pad. For surgical ac- cess, a distal oblique vertical incision is made toward the coronoid process of the mandible. A vertical inc: sion is placed mesiobuccally at least one tooth away, and preferably two teeth away, from the surgical site Mesiolingually, a short, 3 to 4-mm incision is placed at the mesiolingual line angle of the most distal tooth in front of the defect. After the primary incisions, periosteal elevators are used to reflect a full-thickness flap beyond the ‘mucogingival junction (MGJ) and at least 5 mm be- yond the bone defect. The lingual flap is elevated to the mylohyoid line, where the attachment of the fibers of the mylohyoid muscle is identified (Figs6-1 and 6-11-3). Since the mylohyoid attachment is anatomically deeper mesially than the region of the second bicus- ao pid, the depth of flap elevation does not follow the location of the muscle. Instead, itis carefully pre- pared slightly deeper than the elevation of the molar region, corresponding with the muscle attachment. 6.2 Preparation of the recipient site ‘The exposed bone is cleaned of all soft tissue rem- nants with chisels (eg. a back action chisel). The recipient bone bed is prepared with multiple decor- ticalization screw holes using 2 small round bur (Fig6-11-10) If a tenting serew is preferred to pre- cisely determine the desired vertical position, it should be placed at this time. Only specifically de- signed titanium tenting screws should be used, For single tooth defects, the placement of a tenting screw is unnecessary. For long defects involving two teeth, the tenting serew is placed in the middleFig 6-2. Labial view of stabilized membrane. of the defect. With long defects involving three to four tecth, two screws are placed in each third of the defects, However, the author prefers not to com- plicate the surgical procedure with the use of tent- ing screws, as the support of the densely filled graft, in addition to the titanium reinforcement, makes tenting screws unnecessary. 6.3 Membrane adaptation See Figures 6-11-6 to 6-11-14. An appropriately sized membrane is selected and trimmed to totally over the volume of the grat so that the edges are ‘not in contact with the natural teeth. Note that this is critical if a nonresorbable membrane is used, The ‘membrane should rest on at least 2mm of the adja- Cent bone. Membrane fixation is a critical aspect of this procedure, since immobilization of the graft ust be maintained for graft incorporation. The membrane is stabilized first on the lingual/palatal sides using titanium pins or short, 3-mm titanium screws onat least two points. Figures6-1 and 6-11-7 to 6-11-13 clearly depict membrane adaptation. Ifthe placement of the first lingual pin is difficult, “temporary pin” is placed on the crest just behind the last tooth. This fixation makes the positioning of the lingual pins much easier. This temporary pin is, removed after the placement of the three pins. Note that the mylohyoid muscle is not reflected from the mandible (Figs 6-1, 6-4, and 611-7), ‘The autogenous particulated bone graft or com- posite bone graft is placed into the defect, and then the membrane is folded over and stabilized with ad- ditional titanium pins or screws (see Fig 6-11-11 and 6-11-12). The use of different membranes will be discussed in more detail in subsequent chapters for horizontal and vertical augmentation. “There are two ways to position the membranes, ‘The most classic way is to fixate the anterior por- tion in between the two most proximal teeth. Note the extension of the safety flap (Fig6-2). In cases a siopain § @@eeFig 6-3 A variation of the fixation technique where the clinician is running shoct of the device, it fs also acceptable to fixate it just behind the last, tooth. Note that the membrane is cut short of the mental nerve (Fig 63). Note also the position of the now removed temporary pin on the crest behind the last tooth, and how the membrane is not in contact, with the neighboring dentition (Fig 6-4). In this im- age, the design of the flap is clearly visible. 6.4 Mobilization of the lingual flap: the modified lingual flap advancement ‘The modified lingual flap advancement is based on an- atomical considerations of the location of the attach- ment of the mylehyoid muscle, and also on the protec tion of vital anatomical landmarks such as the lingual 2 nerve and the sublingual artery. There are three zones of interest on the lingual side (ie. Zones JU, and Il), and each needs to be approached individually, as is shown in Figure6-5, and discussed in Table 6-1. Zone Tis around the retromolar pad where the lingual nerve runs in close proximity. This has to be handled so that the nerve is protected and the flex- ibility is achieved with blunt management. Zone Il is located in the molar region where the inylohyoid line is attached closer to the crest. In this region it is important that the muscle is not refleet- ed from the mandible. Flap advancement should be achieved with blunt dissection, protecting the key anatomical landmarks, Zone Ill is the premolar region where the muscle is deeply attached and there is a deep periosteal at- tachment of the soft tissue to the lingual side of the mandible. This zone is critical when the premolars are also missing. Membrane exposure occurs most typically in this region, as this is where the clinician6.4 Motiaaton ofthelingual ap the modlfed Ingual fap advancement F) @@O © E : J Hyoid bone Fig 6-5 (1 to 3) (1) Drawing illustrating the anatomy of the typical insertion of the mylohyoid muscle on the internal aspect of the mandibular body and the location of Zones J, Il, and Ill. aca} and hovizortal ridge avgmentate inthe posterior ane Fig 6-5 cont. (2) Modified lingual flap advancement demonstrates significantly more flap advancement than. traditional flap advancement techniques that focused mostly on Zone I. (3) Traditional lingual flap advancement. Note that Zones I ond Ill are not well advanced ‘Table 6-1 Zones on the lingual side and techniques for each zone 1 | Retromolar | ‘Tunneling and lifting of the RP or Zone I. A periosteal instrument such as a Prichard pad (RP) periosteal or Mini Me should be used to gently reflect the retromolar pad from the bone, which is then pulled up in a coronal dizeetion. Since this tissue is elasti, t's easy to perform this step, and the RF will be incorporated into the lingual flap (Fig 612-4). un | “High? Mylotyold separation or Zone Il, Once the mylohyoid muscle is identified, the soft tissue mylohyoid | superiorto the muscle should be gently pushed lingually using blunt instruments. This attachment | way, the flap will be separated fiom the superior fibers of the muscle. Ths should be performed deep at the attachment of the muscle to make sure the clinician will not over- thin the lingual flap, which typically leads to flap necrosis and exposure of the | membrane (Fig 6-11-5 and 6-11-7) m =| “Deep” Horizontal “hockey stick" periosteal incision or Zone IIL From the “mini” lingual vertical mylobyoid | incision to Zone i, a semi-blunt periosteal incision is performed with a No. 15 blade in a attachment | 90-degree rotated angle using the “sweeping” motion technique. Once the periosteum is incised, periosteal instruments are utilized in a motion that pushes coronally. This provides flexibility fo Zone Il and prevents the most common exposures typically located behind the most distal tooth In combination with the “mini” lingual verticel incision, the periosteal incision resembles a hockey stick shape (Fig 6-11-15 to 6-11-17). ‘may easily miss advancing the flap. When this zone is not well advanced, the clinician has to compen- sate for this and advance more buecally, which is the mental nerve region. This could result in more frequent nerve dysfunction (see Seetion 6.5.2). The author strongly recommends that the flap be well advanced in this third, most anterior zone. These 4M three steps are minimally invasive and safely create appropriate lingual flap advancement and a flexible flap that can reach several centimeters because of the complete separation from the rest of the floor of the mouth (Figs 6-11-17, 6-12-5, and 6-13-3). A thor- ough anatomical knowledge is necessary to perform this flap in such a sensitive region.In arandomized controlled split-mouth cadaver study, the author compared this modified lingual flap advancement to previously recommended techniques.*’The results chowed significantly more flap advancement with the modified technique, ‘This seems logical, since previously recommended techniques have focused on Zone II, whereas this study proved that the advancement of all three zones is necessary for advancing the entire lingual flap. 6.5 Buccal flap advancement The periosteal incision does not provide enough elasticity of the flap unless it is performed exten- sively by making either multiple incisions or a sin- gle incision, cutting deeper and deeper. However, these techniques result in potential nerve injury, extensive bleeding, and tissue damage that may im- pair the vascularization of the flap. Therefore, the author has developed the “periosteo-elastic tech- nique” for flap advancement that can be performed in three steps, as outlined below. This technique is mostly bladeless. 65.1 Step 1: Gentle periosteal incision ‘The periosteum should be cut very carefully in the line connecting the two vertical incisions. The cut should only be made through the periosteum and not into the fibers below it. This incision is just a “door opener” into the more flexible elastic fibers that can be further expanded. 65.2 Step 2: Protection of the mental nerve “The strategy of the clinician should be to minimize any nerve injury and even temporary paraesthesia ofthe mental nerve. The management of the lingual flap is an integral part of this. The horizontal “hock- y stick’ incision of Zone I greatly reduces the ‘need for flap advancement around the mental nerve, a8 the location of Zone II on the lingual corre- Sponiis to the location of the mental foramen on the buccal. In strict horizontal augmentation cases, a peri- osteal incision around the mental nerve may not be necessary, However, in most cases itis necessary to advance the flap in this region. In the author’s experience, there are two main categorles of patients: those who have less than 5mm of vertical deficiency, and those who have a more severe defect. In the former category, about 10mm distal to the mental nerve, the periosteal in- cision should be carried mote coronelly, superior to the ramifications of the nerve, and should be curved back to the mesial vertical incision about 10mm an- teriorly. This incision must be made with care in this region, as accidental perforation of the ap is possible ifthe cut is made too deeply (Fig 6-11-17 to 6-11-20). In the latter category (where the vertical defect is more advanced), this incision should be placed more apically. The blade should be used very carefully in a backward motion around the nerve to ensure that no accidental injury oceurs. This inci- sion is superficial, and the clinician should make certain that only the periosteum is cut, and that no incision is made deeper into the tissue (Fig 6-6). 653 Step 3: Cutting the “subperiosteal bundles” and separation of the elastic fibers Since most patients have “periosteal cross bundles,” the flap cannot be advanced as necessary once the periosteal incision has been completed. The elastic ‘Abers are gently cut with “sweeping” incisions, us~ ing the blade first in @ 45-degree angle and then in 4 90-degree angle (Fig 6-11-19), It is important that the blade is no longer utilized for flap advancement. 6.5.4 Step 4: Elastic fiber separation Once this is completed, a blunt periosteal instiu- ‘ment, such as a Prichard periosteal or Mini Me, should be used in a coronal pushing motion to sep- arate the elastic fibers. This will ensure that the flap will be significantly advanced, with less chance of causing injuries to vital anatomical structures, A case with an existing vertical defect of less than 5mm is shown in Figure6-11-20, Note that the en- Bucatlapavvacenent G @@ eeeee 6 Principles of vertical and hortantal ridge augmentation in she posterior mandible Fig 6-6 (lop left) A case with an existing severe vertical deficiency. ‘he periosteal incision had to be per- formed over the ramification of the mental nerve, The superficial incision is made with a backwards motion of the blade. Note that only the periosteum is cut, Fig 6-7 (1 to 3) (1) A periosteal instrument is used in a coronal pulling motion to separate the fibers, (2) Note that after complete advancement, the branches of the mental nerve show through the tissue. I is apparent that there was no injury to the nerve, (3) Occlusal view of the fap advancement distal to the mental nerve, In this re~ ‘gion, more than 30 mm of flap advancement is easly achieved with blunt elastic separation, tire incision and elastic separation is made coronal to the ramification of the nerve (Fig6-7-1 to 6-7-3). ‘Alternatively, scissors can be utilized around the mental nerve in an “opening” motion to initiate the separation. If the clinician prefers this option, it should be used initially about 5mm mesial and dis- tal of the mental nerve, and followed by using a per- iosteal instrument, as described above, Several centimeters of elasticity can be achieved also on the buccal side. Some authors have recom- mended carefully using a surgical blade in a coronal motion to achieve the elastic separation.? However, the author prefers the bladeless technique for elas- tic separation as itis both effective and safer. Utiliz- ing this technique ensures that tension-free prima- ty closure can be achieved regardless of the size of the defect (Figs 6-11-22 and 6-12-3), 46 6.6 Flap closure Once the membrane is completely secured, the flap must be mobilized to permit tension-free primary closure. A periosteal releasing incision needs to connect the two vertical incisions until enough elasticity is achieved. The flap is then sutured in two layers. The first layer is closed with horizontal mat- tress sutures placed Smm from the incision line, and then single interrupted sutures are used to close the edges of the flap. With this technique, the flap margins become everted, effectively abutting the Smm-wide inner connective tissue layers of the buccal and lingual flaps. This intimate contact be- tween the layers of connective tissue provides a barrier preventing exposure of the membrane (see Figs 6-8 to 6-10, 6-11-22, and 6-13-5),56 Fipaosie § @@@o natic drawing the line of the periosteal incision, ‘Schematic drawing representing the labial and occlusal views of the double-layer closure of ayerior mandiole © ©©@ () Princes cf veri and rian ridge augmentation inthe Fig 6-10 Cross-sectional, schematic drawing demonstrating the final double-layer flap closure Preferably, either a dense or expanded polytet- The first mattress suture is placed in the middle rafluoroethylene (-PTFE or e-PTFE) suture is used of the crest, then more mattress sutures are placed for this purpose. The vertical incisions are closed mesially and distally. There should be a distance of ‘with single interrupted sutures, moving from the about 10mm in between the knots. The interrupted apical area to the crestal area (Fig6-8). sutures are placed in between the mattress sutures,6.6 Hap desure 6 eeo" Fig 6-11 (1 to 24) Representative case of surgical steps inthe posterior mandible. (1) Atrophic posterior ‘mandibular area, (2) A safety flap is elevated. (3) Zone I The retromolar pad is gently tunneled and lifted. a© ©. ©.@ ( Princes oferta and horizontal ge augmentation inthe posterior mandible 50Y ke? Fig 6-11 cont. (4) Zone Il The lingual flap is carefully separated from the mylohyoid muscles without disturh- ing any of the ascending fibers, (5) Flexibility of the flap is demonstrated after completing Zones Land Tl, Note that the anterior segment of the flap is preventing it fom being completely flexible. (6) ‘he membrane is secured fist on the mesial aspect with a “temporary pin” behind the most distal tooth. Subsequently, a mesial and distal pin and middle pins are placed. (7 and 8) The Master-pin (Meisinger, Germany) is a modified pin (ack) designed Specifically for this purpose. It has a larger diameter and is made out of a strong titanium allay that does not even in haed bone situations, bend. This makes the process easier, and the clinician can stabilize the membray (9) After the temporary pin is removed, the membrane is stabilized on the lingual side.6.6 Papclosure 6 e 6-11 cont. (10) Buccal view of the composite graft, consisting of 1:1 ratio of autograft mixed with ABBM. ‘The &-PTFE membrane is secured using titanium screws. Self-taping miniscrews (Pro-Fix, Osteogenies Bio- ‘medical) vere utilized, Note that the membrane was stabilized just behind the last tooth. (12) Close-up view of Prosfix mini fixation screw. (13) Complete immobilization of the graft is achieved. (14) The horizontal hockey Stic" incision is carefully performed at Zone II The tip of the blade is used in a 90-degree sweeping motion Care is taken to only sweep through the periosteum (15) After a superficial incision of the periosteum, gentle sepa- tation is performed at Zone Il Once the periosteum is incised, periosteal instruments (e.g. Mini Me) are utilized in a coronal pushing motion. 33~e0e 6 Principles of vertical and hovitontal ige augmentation In he posterior mandible56 Fapdoure () @@@e Fig 6-11 cont, (16) Flexibility of the flap is checked, Note that after finishing the advancement of all three Zones, a completely relaxed lingual flap is achieved. (17 to 20) Protection of the mental nerve is performed using : | periosteal incision. After the periosteal incision, the blade is carefully “swept” through the subperiosteal undies, ané finally the elastic fibers are bluntly separated to achieve enough elasticity of the lap. (21) Elasticity ‘ofthe buccal flap is checked. (22) Tension-free flap closure using the double-layer suturing technique. (23) Labial ‘View of the result of the regenerated bone. (24) Occlusal view of two implants placed into the regenerated bone. 55© @0.0 6 Princes teil and horanal ge augmentin inthe poster mandible Fig 6-13 (1 to9) Representative case of lingual flexibility and its subsequent healing phases. (1) Buccal view of severely atrophic mandibular ridge. (2) Buccal view of composite bone graft in place. (3) Flexbility of the lingual flap after detachment.6.7 Expaced healingafter posterior mancitularsurgery F) @@ @ & 8 Fig 6-13 cont, (4) A d-PTFE membrane was secured to immobilize the graft and a collagen membrane was ‘Used lo cover the mesial gap in between the membrane and the bone graft. (5) Clinical view after 2 weeks of ‘healing. Note the nice tissue readaptation. (6) After 9 months of uneventful healing. (7) Buccal view of the mem- ‘brane in place before its removal. (8) Buccal view of the regenerated bane before implant placement: (9) Buccal ‘View of the regenerated bone after implant placement, Note that this case will be continued in Chapter 8. 596.9 Conclusion It can be concluded that utilizing this surgical ap- proach will safely ensure good graft immobilization and a tension-free primary flap closure, 6.10 References 1, Astrand P, Ahlgvist J. Gunne J, Nilson H. Implant treat ‘ment of patients with edentulous jaws: a 20-year fol- low-up. Clin Implant Dent Relat Res 2008;10207-217. 2. Simion M, Trisi P, iatelli A. Vertical ridge augmentation ‘using a membrane technique associated with osseointe= ‘ated implants Int J Periodontics Restorative Dent 1994; 496-511, (ay © @@ 6) Pincpesofvertcaland horizontal ridge agrentation inthe posterior mandible ‘Tinti C, Parma-Benfenati S. Vertical ridge augmentation surgical protocel and retrospective evaluaticn of 48 con- secutively inserted implants. Int J Periodontics Restorative Dent 1998;18:435—443, Urban 1A, Parkasdi §, Bartee B. Modified lingual fap ad vancement. A randomized controlled human cadaver sty cof two different lingual fap advancement techniques (in press) Pikos MA, Atrophic posterior manilla and mandible: alv solar ridge reconstruction with mandibular block auto grafts, Alpha Omegan 2005:98:34-45, Ronda M, Stacchi C. Management of acoronally advanced lingval fap in regenerative osseous surgery: a case series introducing a nove! technique. Int J Periodontics Restor tive Dent 201151;509-313. Ronda M, Staechi C. A Novel Approach for the Coronal ‘Advancement of the Buccal Flap. Int J Periodontics Re storative Dent 2015°35:795-801Vertical ridge augmentation Supracrestal or vertical bone augmentation presents fone of the greatest challenges of bone regeneration inimplant dentistry. This is primarily due to the dif- ficulty of the surgical procedure and its potential complications. Supracrestal augmentation aims to achieve hone regeneration in a direction without ony walls to support the stability of the bone graft. It is demanding biologically because bone regener- ation and angiogenesis have to reach a distance from the existing bene, In addition, the soft tissue has to be advanced to provide a closed healing en- vironment for the increased dimension of the heal- ing bone graft. Several treatment modalities have been developed for vertical bone growth, including distraction osteogenesis, onlay bone grafting, and vertical guicled bone regeneration (GBR). This chapter will review the different techniques available for vertical bone augmentation, describe techniques and patient selection eriteria for vertical ‘augmentation with GBR, and discuss preliminary esulls with new treatment modalities for vertical augmentation 7.1 Distraction osteogenesis Patients with both adequate horizontal width and inadequate vertical height are candidates for the distraction osteogenesis procedure. lizarov showed that a segment of bone can be distracted in a trans- verse direction to the bone’s normal length axis ‘with subsequent hone formation.!2 Bone healing by distraction osteogenesis occurs by the same process observed during the healing of fractures. There are relatively few articles reporting on bone gein, re sorption, and implant success rates associated with distraction osteogenesis. A study reporting on 28 patients for up to 5 years of loading noted 6.5 mm average vertical and minimal horizontal bone gain. Eighteen patients needed secondary bone grafting, the implant survival rate was 90.4%, and the im- plants demonstrated stable crestal bone levels throughout the follow-up period. A systematic re- view of the literature led to the conclusion that even though a limited number of studies have been re- ported, “distraction osteogenesis can be an effective method to enhance bone volume for implant place~ ment” The major complications reported for this, procedure include lingual/palatal inclination of the] Vertical ridge augmentation regenerated bone, mandibular fracture, and incom- plete bone regeneration. 7.2 Onlay bone grafting Results of studies reporting on onlay bone grafting are heterogeneous, but comparisons between these studies may not be accurate.4 Studies of onlay bone grafting reported 60% to 100% implant survival rates, with a majority of reported survival rates of more than 90749 Implants placed in patients recon structed with iliac bone grafts had a survival rate of 86.5%, those reconstructed with calvarial bone grafts had a survival rate of 94.9%, and those recon- structed with intraoral bone grafts had a survival rate of 97.1%.5 ‘There is a lack of detailed documentation and Iong-term follow-up regarding intraoral onlay grafts. One study demonstrated an overall 1.1 mm of bone resorption after 4 years of function of sev- en implants Relevant differences have been re~ ported regarding bone resorption according to ex- traoral donor sites: resorption rates reported for iliac grafts range from 12% to 60%, whereas resorp- tion rates for calvarial bone grafts range from 0% to 12%.5 7.3. Scientific documentation of vertical GBR with different grafting materials Vertical and horizontal augmentation utilizing GBR has become a major treatment option to pro- vide optimal bone support for osseointegrated dental implants. The application of GBR for hori- zontal augmentation is well documented, includ- ing treatment of fenestration defects? and dchis- cence,°4 with high rates of implant success and low complication rates." The application of OBR for supracrestal regeneration has been intro- duced and the surgical technique described. The first animal and human histologic studies demon strated successful vertical bone augmentation.!?2 Complications reported with vertical augmenta tion involved membrane exposure and/or subse quent infection, with rates ranging between 12.5% and 17%,18.2021 The long-term results of vertical GBR following 1 to 5 years of prosthetic loading were examined in a retrospective multicenter study evaluating 123 implants.22 Three treatment modalities (non-re sorbable regenerative membranes in combination with blood clot only, demineralized freeze-dried bone allograft [DFDBA], and autagenous bone chips) were studied. The results from this investiga tion revealed that vertical bone regeneration super~ ior to ¢ mm could only be achieved with the use of autogenous bone chips, These authors reported an overall success rate of 97.5%, leading them to con- dude that vertically augmented bone using GBR techniques responds to ifmplant placement in a fashion similar to native, non-regenerated bone All of these studies utilized non-resorbable, titan- ium-reinforced, expanded polytetrafluoroethylene (¢-PTFE) membranes. These membranes have been associated with a high incidence of soft tissue prob- ems, such as exposure? Other authors have re- ported a similar soft tissue response of ¢-PTFE membranes when compared to resorbable mem- branes"? Titanium osteosynthesis plates covered with a collagen resorbable membrane were com- pared to e-PTFE membranes in a randomized clin- ical trial for vertical GRR, and there were no statis- significant complications between the two techniques.* The investigators reported that the regenerated bone remained stable at 6 years of implant loading in both groups, and there were no statistically signif- icant differences between bone levels around im- plants. The investigators also reported that more tically differences in terms of sites achieved a complete regeneration when the ©-PTFE membrane was used. Hence, the utilization of PTFE-TR membranes represents the current state of the science in vertical GBR252874 Conclusion Based on the literature, it can be concluded that ver~ tical GBR can be achieved using form-stable, titan- jum-reinforced (TR), ¢-PTFE or d-PTFE membranes. ‘Alternatively, titanium osteosynthesis plates or tita- ‘nium mesh covered with a resorbable membrane can also be utilized. 75 References Ilizarov GA. The tension-stress effect on the genesis and growth of tissues, Part I. The influence of stability of fixa- fion and soft-tissue preservation. Clin Orthop Relat Res 1989,238:249-281, 2 Mizaroy GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of the rate and frequency of distraction, Clin Orthop Relat Res 1989-238: 263-285, 3, Jensen 0, Cockrell R, Kubike L, Reed C. Anterior maxclary alveolar distraction osteogenesis: a prospective 5-year elit ‘eal soy. Int J Oral Masclofae Implants 20023175268, 4 Aghalon TL. Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Im- plants 2007:22(suppl)#9-70. 3. Chlapasco M, Zaniboni M, Boisco M. Augmentation pro eduses for the rchabilitation of deficient edentulous ride fs with oral implante. Clin Oral Implants Res 2006:17(sup- pl 2):136-159. 6 Chiapasco M, Zaniboni M, Rimondini L. Autogenous on lay bone grafis vs. alveolar distraction osteogenesis for the correction of vertically deficient edentulous rides: a 24 year prospective study on humans. Clia Oral Implants Ros 2007;18:432-440, 7. Dahlin C, Andersson L, Linde A. Bone augmentation at fenestrated implents by an osteopromotive membrane technique, A controlled clinical study. Clin Oral Implants Res 1991:2159-165, 5. Dallin C, Lekholm U, Linde A. Membrane-Induced bone Augmentation at titanium implants. A report on ten fix- hres followed from 1 to 3-years after Inading, IntJ Perio- ddontics Restorative Dent 1991511:278~281. 9, Jovanovic SA, Spickermann H, Richter EJ. Bone regeneration ‘round titanium dental implants in dehisced defect sites: a stinical study. int J Oral Maxillofac Implants 1992;7233-243. 40, Mellonig JT, Triplett RG, Guided tissue regeneration and endosseous implants. Int J Periadontice Restorative Dent 1993;13:108-119, 11, Shanaman RH, A retrospective study of 237 sites treated ‘consecutively with guided tissue regeneration. Int J Perio- dontics Restorative Dent 1994;14:282-301, 12, DellinC, Lekdiol U, Becker W, etal. Treatment of fenes- fraion and dehiacence hone defects around oral implants 8 14, 15, 1. 18, 1. 20, Bo 2, 2. 2, 25, 75 Rete using the guided tissue regeneration technique: a prospec tive multicenter study. Int J Oral Maxillofac Implants 1995;10:312-318 Simion M, Misitano U, Gionso L, Salvato A. Treatment of ‘dchiscences and fenestrations around dental implants us- ing resorbable and nonresorbable membrapes associated with bone autografs: comparative elinieal study. Int J Oral Maxillofac Implants 1997;12:159-167. Palmer RM, Smith Ei, Palmer PJ, Floyd PD, Johannson CB, Albrektsson T, Effect of loading on bone regenerated at ‘implant dehiscence sites in humans. Clin Oral Implants Res 1998:9:283-291. Buser D, Bragger U, Lang NP, Nyman, Regeneration and clargement of jaye bone using guided tissue regenera: tion, Clin Oral Implants Res 1990;1:22~32 Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge aug- mentation using autografts and barrier membranes: clin- ical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996;54:420~452. Buser D, Ingimarsson S, Dula K, Lussi A, Hirt 1P, Belser UC. Long-term stability of osseointegrated implants in augmented bone: a 5-year prospective study in partially edentulous patients. Int J Periodontics Restorative Dent 2002;22:109-117. ‘Tinti C, Parma-Bergenati S. Vertical ridge augmentation: surgical protocol and retrospective evaluation of 48 con- secutively inserted implants, Int J Periodontics Restorative ent 1998;18:434-443, Jovanovie SA, Scherle RK, Orsini M, Kenney ER, Supracrest- albone formation around dental implants: an exoerimental dog study. Int J Oral Maxillofac Implants 1995;1023-31. Simion M, TrisiP, Piatelli A. Vertical ridge augmentation using a membrane technique associated with osseointe- ‘grated implants, Int J Periodontics Restorative Dent 1994314:490-511. ‘Simion M, Jovanovie SA, TvsiP, Searano A, Piattelli A. Ver~ tical ridge augmentation around dental implants using a membrane technique and autogenous bone or allografts in ‘humans, Int J Periodontics Restorative Dent 1998;188~23, Simion M, Jovanovic SA, Tinti C, Benfenati SP. Long-term evaluation of osscointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 125 implants with 1.5 year follow-up, Clin Oral Implants Res 2001;12:35-<6. Zitzmann NU, Naef R, Schirer P. Resorbable versus non: resorbable membranes in combination with Bio-Oss for guided bone regeneration, Int J Oral Maxillofac Implants 19972:844-852. ‘Merl: M, Moseatelli M, Mariorti G, Rotundo R, Bernardelli T, Nicsi M. Bone level variation after vertical ridge aug. ‘mentation: rescrbable barriers versus titanium-reinforced barriers. A 6-year double-blind randomized clinical trial. Int J Oral Maxillofac Implants 2014:29:905-913, Urban 1A, Caplanis N, Lozada JL. Simultaneous vertical ‘guided bone regeneration (GBR) and guided tissue regen- ‘eration (GTX) in the posterior maxilla using recombinant human platelet-derived growth factor (rhPDGT): A. case report. J Oral Implantel 2009:35:251-256.] 26, 2, Ci augmentation Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmen- tation using guided bone regeneration (GBR) in three cin- ieal scenarios prior to implant loading: «retrospective study of 35 patients 12 to 72 months after lading. Int} Oral Maxillofac Implants 2009:24502-510, Urban TA Lozada JL, Jovanovie SA, Nagursky H, Nagy K. Vertical ridge augmentation with ttanium-reinforced, dense PTFE membranes and» combination of particu 26 ced autogenous bone and anorganic bovine bone-derived mineral: a prospective case series in 19 patients Int] Oral Maxillofie Implants 2014:29:185-193, Fontana F, Grossi GB, Fimand M, Maiorana C. Osseointe grated implants in vertical ridge augmentation with nnonresorbable membrane: a retrospective study of 75 im- plants with 1 to 6 years of follow-up. lat J Periodontics Restorative Dent 2015:35:29-39,Vertical ridge augmentation in the posterior mandible Vertical ridge augmentation (VRA) in the posterior mandible is considered a difficult procedure to per- form, In addition to the surgery itself, there are cer- tain factors to consider. The clinician should bear in mind that long-term implant function is the ulti- mate goal of treatment. Based on the author's clin~ ical observations, the following considerations should be evaluated before, during, and after treat- ment. 8.1 Important clinical factors for consideration 8.1.1 Biotype and available keratinized tissue before grafting ‘The surgical procedure should be performed as de- seribed previously in Chapter 6, In thin biotype sit~ uations and where keratinized tissue (KT) is mini- mal or completely lacking, many clinicians Fecommend the use of soft tissue grafting before bone graiting. Based on the author's experience, this isnot necessary. In patients with a thin biotype, avery careful flap elevation should be performed to make sure that there is no perforation in the flap. Since the double-layer closure results in thick tissue over the graft, and since the first layer sutures are in the mucosa, adding thickness or KT is not necessary at this point. 8.1.2 Simultaneous versus staged VRA. In general, implants can be placed simultaneously in defects requiring less than 4 mm of vertical aug- mentation with guided bone regeneration (GBR). ‘The staged approach for implant placement should be used in all cases requiring more than 4 mm of regenerated bone. It is technically possible to treat even more severe defects with simultaneous VRA. However, the author prefers staged augmentation procedures, for the following reasons: 8121 Sofeyy If a complication occurs, itis easier to manage. In other words, if there is an exposure of the mem- brane or a low-grade infection, the clinician has the ability to save a major portion of the bone grat, If© vera ige augmentation in the postin mandible an implant has been placed simultaneously, bacteria may adhere to the implant and lead to the loss of the graft and the implant, 81.22 More time for the maturation of the regenerated bone prior to loading the implants In addition to this second reason for preferring a staged approach for implant placement, a preclini- cal study has demonstrated that placing an implant even in an extraction socket might interfere with and slow down new bone formation.! This could also be an important factor in VRA, since this is a biologically demanding defect. 81.23 Problems with kT In simultaneous cases, the usual protocol is that when the membrane is removed, the healing abut- ments are placed prior to the implants. In many of these cases, the amount of KT is minimal. If it is completely lacking, it is very challenging to graft KT to both buccal and lingual aspects of the im- plants, and the long-term function of these implants may be less favorable. 81.3 Crestal bone changes Based on the author's experience, the regenerate posterior mandible is where the patient is most a risk of losing more bone than any other region in thi ‘mouth. One can speculate about the reason for this ‘+ Probably the most important reason is that th: soft tissues are usually thinner then the bio logical width? hence, the biological width cas be formed at the expense of bone loss. ‘+ ‘The distal implant platform is higher than the mesial. This is a typical error in the posterio mandible, which often leads to more bone los: on the distal implant. * Some implant types are difficult to sink into the bone, and the top portion of the implant migh: be above the crest at implant placement. In these cases, the radiographs “look bad,’ as the bone will be located more apically even after re ‘modeling that is considered “normal”8.1 Inporantcnclfacrsioronideatin (J @@@ © Fig 8-1 (1 to 14) Representative case of a long-term result after posterior mandibular VRA. (1) Atrophic pos- terior mandibular area. (2) Particulated chin bone graft is placed on the ridge. Cortical bone was perforated and an e-PTHE-TR membrane was secured on the lingval side before applying the bone graft. (3) e-PTFE-TR mem- brane was secured over the graft with titanium pins. (4 and 5) After 7 months of uneventful healing, the mem- brane was removed and implants were placed, Note that the bone is still immature at 7 months.oe00e 8 erica ridge augmentation inthe posterior mandible Fig 8-1 cont. (6 to 8) Occlusal view of clinical steps for gingival augmentation. Note that the patient had shout 2.5 mm of KT, and a 3-mm steip gingival graft was placed before the implants were uncovered. [Figs 6 $-1-2, £13, 8-1-4, and 8-1-7 are reprinted from Urban ct al, 20092 Fig 81-6 is reprinted from Simion et al, 2001,¢ with permission from Quintessence Publishing and John Wiley and Sons.] (9) Periapical radiograph at implant placement. Note that the bone is not showing good mineralization on the zadiograph, (10 and 11) After an addi- tional 6 months of healing, the three implants were uncovered. Note the well-integrated and matured bone graft (12) Clinical photograph demonstrating healthy peri-implant mucosa. (13) Periapical radiograph at abutment connection, (14) Periapical radiograph at 12-year follow-up with implants in function,8.1 Important clinical factors for consideration § eeecoe 8 Veitical ridge augmertation fn the posterior mandible Lessons learned from this case: 1. Wait for about 9 months before implant place- ment 2. Do not load the implant before 14 months after bone grafting. 3. Gingival grafting is always easier before the implant uncovery procedure. 8.1.4 Mucogingival considerations ‘The need for a minimum amount of KT around teeth and implants to preserve the health and stabil- ity of the gingival and mucosal tissues is still con troversial, Recent clinical studies have concluded that a wider zone of KT may better preserve soft and hard tissue stability around dental implants, as well as their long-term maintenance.5¢ ‘There are three clinical scenarios in the mandi- ble where reconstructing KT is necessary. These scenarios are based on the amount of KT and are discussed in the following paragraphs: 81.4.1 A complete lock of XT (Fig8-3) “The solution in this case is to perform a gingival graft before the uncovery of the implants, as it is not realistic to graft on the lingual side during or after abutment installation. Gingival graiting is es- sential in these situations.’ 4. Mature bone with good bone width and good tissue quality and thickness leads to long-term success.34 81.4.2 Less than 4mm of KT (Figs8-1, 82, 8-4 108-6) “he clinician ean decide whether KT is absolutely necessary. The incision at the uncovery has to bs made at least 2 mm buccal from the lingual mu cogingival junction to ensure that there will be “enough” KT on the lingual side. Also, the cliniciar can decide whether a gingival graft should be per formed on the buccal side at this point, or whethe the mucosa on the buccal side is clinically accep! able? The author's experience is that lingual KT essential, and buccal KT is preferable. In patient who have good oral hygiene, it may not be a re quirement (Fig8-4). A gingival graft can be per formed a few months later if the patient has ditficul ty cleaning the implants. 8143 Atleast4 mm of KT ‘The clinician should distribute the KT evenly during the implant uneovery procedure. Fig 8-2 (1 to 18) This case is an example of a patient with less than 4 mm of KT, It is also a continuation of the case presented in Fig 6-13, and was solved using augmentation of KT and subsequent utilization of the LSF to position the KT around the implants. (1) Labial view of the vertically augmented ridge at implant placement. (2 and 3) Labial and occlusal views of a patient presenting with about 2mm of KT alter VRA. Note that the KT is more labial than the implants (arrow), which demonstrates the problem of where to augment more KT. This can be overcome by using the LSF after a labially augmented KT. (4) Labial view of a strip free gingival eutograft sutured on the facial side of the remaining KT. However, since this patient needed KT on the lingual side, this surgical technique easily increased the amount of KT, which can be repositioned at the uncovery of the implant (5) Labiel view 3 weeks after grafting demonstrating good incorporation of the soft tissue graft 708.1. Impartant clinical factors for consideration, 8 e©} Verticldgeaugnenaion nite poster manclte Fig 8-2 cont, (6 and 7) Labial and occlusal views alter 10 weeks of healing. (8) Occlusal view demonstrating that the KT is more labial than the top of the implants. The following images represent the steps required for the SP. (9) First, a longitudinal incision is made in the middie of the newly formed KT. Care must be taken to end this incision about 3 mm distal to the last implant. The goal of this is to be able to move KT circumferentially be= hhind the last implant. Then, a mesial and distal “mini” (about 2 mm) vertical incision is placed at the end of the first incisions. (10 and 11) A partial-thickness flap is prepared, and the lingual part of the KT is pushed beyond the cover screws of the implants. Note that tie KT is now lingual ef the cover screws. n8.1 Important clinical factors for consideration 8 eon. Fig 8-2 cont. (12) Labial view of the tiseue thickness achieved, This is an important pact of erestal hone stabili- ty, as explained in Section 81.3 (13) Occlusal view of the first two sutures. Suturing should be started on the dis- tal and mesial ends of the flap. The goal of this is to position the KT 360 degrees around the implants. 5-0 or 6-0 ‘sutures can he used for this. In this ease, a 5-0 Monoeryl suture was used. (14) Next, the tissues are approximat- ‘ed using horizontal mattress sutures. The same type of suture was used for this.© @.0 {5 ertial rig augmentation inthe posrcr mandble Fig 8-2 cont, (15 and 16) Labial and occlusal views demonstrate the final interrupted sutures, providing tight closure around the healing abutments. Note that at least 2 mm of KT now exists around all implants, and there is also KT behind the last implants, which is an area where only mucosa commonly exists. (17) Labial view of the final restoration in place. (18) Periapical radiograph after loading. A secondary graft was performed at implant placement using a resorbable membrane and titanium pins on the facial side ofthe last implant. Lessons learned from this case: After VRA, KT is often less than optimal. ‘The existing KT is frequently not located on top of the implants. Augmenting KT, and positioning using the lin- ually sliding flap (LSF) is simpler ifthe soft tis- sue augmentation is performed before uncovery, In this case, it was also possible to produce thick tissue around the healing abutments, which is a prerequisite for crestal bone preser- vation. ‘This technique would be more complicated if a simultaneous vertical augmentation was per- formed with implants, since a full-thickness flap is elevated for membrane removal. This is probably the most precise technique for developing sufficient KT in the correct pos- ition, in combination with adequate tissue thickness, which also seems essential for crest- al bone stability?