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INTRODUCTION 10 1. BONE BIOLOGICAL PRINCIPLES 13 History 13 Indications and Terminology 13 Bone sources 14 Healing principles and success factors 14 Future aspects 16 2. IMPLANT INTEGRATION IN NORMAL BONE AND BONE GRAFTS 18 Measurements of implant stability 20 Fig 2:1 21 Implant integration in autogenous bone 21 Fig 2:2 23 Stability evaluation for implants integrated in grafted and ungrafted bone, respectively. 23 Fig 2:3 24 Removal torque values for the same implants. 24 3. GRAFTING PROCEDURES 26 Bone graft from the iliac crest 26 3:1 Illustration; 3D Grafting Procedures 26 photos: group 3:2, 3:3, 3:4, 3:5, 3:6, 3:7, 3:8 in one sequence 26 3:2 Soft tissue dissection down to the iliac crest. 26 3:3 The top of the iliac crest is elevated to gain access to the medial surface. 26 3:4 The medial aspect of the iliac bone is exposed. 26 3:5 The size of the bone graft is prepared. 26 3:6 The medial bone block graft is mobilized and removed. 27 3:7 The block graft obtained. 27 3:8 Incision closed with continous intracutaneous suture. 27 Indication 27 Techniques 28 Tibial grafts 29 Photos: group 3:10, 3:11 29 3:10 Bone graft from the tibia. 29 3:11 The grafting site after removal of block graft and spongious bone. 29 Indication 29 Technique 29 Fig 3:12 Illustration 30 Chin grafts 30 Photos: group 3:13, 3:14, 3:15 30 3:13 Surgical exposure of the chin between the mental foramina. Block graft is obtained. 30 3:14 Another design of block graft from the chin region. 30 3:15 Surgical exposure of the chin and graft donor sites after harvesting bone with a trephine drill. 30 Indications 30 Technique 31 Mandibular angle graft 32 Photos: group 3:16, 3:17, 3:18 in one sequence + 3:19 32 3:16 Bone graft from the mandibular angle via a sagittal split approach in soft and hard tissue. 32 3:17 The bone block is split out buccally. 32 3:18 The inferior alveolar nerve is medial to the bone graft region. 32 3:19 Bone graft material from the mandibular angle and trephine material from the chin. 32 Indication 33 Technique 33 Graft from the maxillary tuberosity 34 Photos: group 3:20, 3:21 (in that order) 34 3:20 Bone mill for particulation of the bone graft 34 3:21 Detail of particulated bone graft 34 Indications 34 Technique 34 Bone Collecting Devices 35 Photo: 3:22 35 3:22 BoneTrap® for collection of particulated bone graft when preparing the fixture site 35 4. ONLAY BONE GRAFTING 37 3D Onlay Bone Grafting 37 4:1 Illustration 37 a. Minor bone graft with particulated bone 37 Photos: group 4:2, 4:3, 4:4, 4:5 in sequence + group: 4:6, 4:7, 4:8 in sequence 37 4:2 Extraction site with only the palatal cortex left 37 4:3 Implant with most of the threads exposed buccally. 37 4:4 Particulated bone and bone graft from the BoneTrap® collected during preparation of the implant site and covering the implant. 37 4:5 Bone graft healing after five months. A layer of mature bone is covering the implant. 38 4:6 Fixture exposure after anchorage in the marginal area and the nasal bone. 38 4:7 Exposed threads covered with bone graft from BoneTrap® . 38 4:8 Thin bone lamellae now covering the fixture after four to five months healing. 38 b. Minor bone graft in block form. 39 4:9 Illustration: Minor Bone Graft Block 39 Photos: group 4:10, 4:11, 4:12, 4:13, 4:14, 4:15 in sequence 39 4:10 Bone deficiency in a case of aplasia. 39 4:11 A small circular bone graft is taken from the chin. 39 4:12 The graft is modelled and secured with a plate screw. 40 4:13 Bone material from BoneTrap® is packed around the onlay graft. 40 4:14 Bone healing for five months. The graft is integrated with only minor resorption. 40 4:15 Implant installed in the grafted bone. 40 c. Major onlay bone grafts in block form 41 4:16 Illustration: 3D Onlay Bone Grafting 41 Photos: group 4:17, 4:18, 4:19, 4:20, 4:21, 4:22, 4:23, 4:24, 4:25, 4:26, 4:27, 4:28, 4:29, 4:30, 4:31 41 4:17 Patient with severely resorbed maxilla. 41 4:18 Vestibular incision prior to onlay block grafting of the whole maxilla. 41 4:19 The bony maxilla is exposed and the nasal mucosa lifted carefully. 42 4:20 Horse-shoe shaped graft is obtained from the iliac bone below the iliac crest. 42 4:21 The bone graft is modelled to fit onto the alveolar crest in all directions 42 4:22 Light compression of the soft tissue by the acrylic stent connected to the zygoma. 42 4:23 Acrylic wafer with posterior extension to avoid trauma to the grafted region. 43 4:24 The onlay bone graft is connected to the alveolar crest by simultaneous insertion of the implant screws. 43 4:25 Careful attention is taken to remove all sharp edges of the graft. 43 4:26 Incision is closed with continuous suturing. 43 4:27 Soft tissue healing after ten days. 43 4:28 Implants in place in the upper jaw. 44 4:29 Radiograph of bone graft and implants. 44 4:30 Bone graft and implants after healing six months. 44 4:31 Prosthetic reconstruction after one year. 44 To be mentioned 47 4:32 Illustration: graft with osteosutures 47 Photos: group 4:33, 4:34, 4:35, 4:36, 4:37 in one sequence 47 4:33 A defect in the alveolar process in the right posterior maxilla after trauma. 47 4:34 The clinical situation. 47 4:35 Onlay block graft from the hip connected to the residual bone by means of the implants. 47 4:36 Postoperative radiograph showing demineralized bone graft. The implants seem to be without support. 47 4:37 One year later the bone graft contour is clearly visible. 48 4:38 Illustration 48 5. INLAY BONE GRAFTING 48 Fig 5:1 Illustration: 3D Inlay Bone Grafting 48 5:2 Illustration: Nasal inlays 48 Photos: group 5:3, 5:4, 5:5, 5:6 in this order, one sequence 48 5:3 The nasal mucosa in the nasal aperture is carefully lifted. 48 5:4 Bone graft is pressed into the nasal cavity below the nasal mucosa. 49 5:5 The bony height of the alveolar process increased with 5-6 millimetres. 49 5:6 The nasal inlays combined with onlay grafts on the thin alveolar crest. 49 b. Maxillary sinus grafting (sinus lifting) 49 b. 1. Single implant procedure with local sinus lifting in a one-stage 52 procedure 52 Fig 5:7 Illustration 52 Photos: group 5:8, 5:9, 5:10, 5:11, 5:12 in one sequence + 52 5:13, 5:14, 5:15, 5:16, 5:17, 5:18 in one sequence 52 5:8 Intraoral radiograph showing the available bone height after extraction of 16. 52 5:9 Surgical exposure of the alveolar crest. 52 5:10 Infracture of a bony window with simultaneous lifting of the sinus membrane and insertion of the implant. 52 5:11 Radiograph showing the implant in position. 52 5:12 One year postoperatively. Radiograph showing remodelling of graft material. 53 5:13 Radiograph of extraction site after removal of second premolar. 53 5:14 Elevation of mucoperiosteal flap and removal of bone close to the sinus membrane. 53 5:15 Clinical view of implant touching and lifting the sinus membrane. 53 5:16 Bone material from BoneTrap® is packed around the exposed part of the implant. 53 5:17 Radiograph of implant in place where half of the implant is placed into the sinus cavity. 54 5:18 Exposure for abutment connection four months later shows satisfactory bone healing. 54 b. 2. One-stage procedure with grafting and implant installation at the 55 same time unilateral or bilateral 55 Fig 5:19 Illustration: One-Stage grafting 55 Photos: group 5:20, 5:21, 5:22, 5:23, 5:24, 5:25, 5:26 in sequence 55 5:20 Clinical view of posterior maxilla with elevation of mucoperiosteal flap and osteotomy performed according to the window technique using a round bur. 55 5:21 Elevation of the sinus membrane and infracture of the bony window. 55 5:22 The sinus recess is created for the bone graft by lifting the bone window and sinus mucosa. 56 5:23 Bone graft from iliac crest (cortical and cancellous) is positioned in the sinus recess and implants inserted. 56 5:24 Clinical view of bone graft and implants in relation to the sinus membrane and window. 56 5:25 Suturing of the flap. Note that incision line is positioned palatally of the crest. 56 5:26 Bone healing six months later. 56 b. 3. Two-stage procedure with grafting and implant installation at the staged times unilateral or bilateral 58 Fig 5:27 Illustration: Two-Stage Procedure 58 Photos: group 5:28, 5:29, 5:30, 5:31, 5:32, 5:33, 5:34, 5:35, 5:36, 5:37, 5:38 in sequence 58 5:39, 5:40, 5:41, 5:42, 5:43 in sequence 58 5:44, 5:45, 5:46, 5:47, 5:48, 5:49, 5:50, 5:51, 5:52 in sequence 58 5:53, 5:54, 5:55, 5:56, 5:57 in sequence 58 5:28 Patient with loss of teeth in the left posterior maxilla. 58 5:29 Panoramic X-ray shows inadequate bone volume beneath sinus on the left side. 58 5:30 Sinus lifting with bone graft from the iliac crest. The graft is immobilized with osteosutures. The bone window is used as an onlay graft. 58 5:31 Uncomplicated healing of the soft tissues. 58 5:32 Radiograph showing the bone graft in position. 59 5:33 Tomograph showing the amount of bone augmentation. 59 5:34 Clinical view after four months healing. 59 5:35 Surgical guide for positioning of implants in the grafted bone 59 5:36 Tomography of implants in place in the bone graft. 59 5:37 Radiograph of the implants in the available graft material. 60 5:38 Clinical view of definitive superstructure 60 5:39 Bone window infractured for sinus lifting procedure in the right posterior maxilla. 60 5:40 A space is created inferior to the bone window with the sinus membrane 60 on top of window. 60 5:41 Particulated bone graft is placed below the bony window. 60 5:42 Implants inserted after four months healing. 61 5:43 Bridge connected to implants. 61 5:44 Radiograph of right posterior maxilla showing sinus cavity occupying the alveolar process. 61 5:45 Tomography showing the residual bone volume. 61 5:46 Tomography after bone graft placement and wires. 61 5:47 Panoramic view showing the bone graft reconstruction of the right 62 posterior maxilla. 62 5:48 Bony union of graft material after four months. 62 5:49 Preparation of implant site and guide pins. 62 5:50 Implants placed in grafted bone. 62 5:51 Radiograph showing position of implants 63 5:52 Bridge construction on four implants 63 Ramus Graft 63 5:53 Clinical view of bone window in right posterior maxilla. 63 5:54 Infracture of bone window with elevation of sinus membrane. 63 5:55 Bone graft from the right mandibular angle (cortical) positioned below the bone window and sinus mucosa. Osteosuture is introduced around the graft material. 64 5:56 Space below the cortical graft is filled with particulated bone. 64 5:57 Osteosutures are tightened to keep the bone graft in place. 64 c. Impaction of alveolar bone into the maxillary sinus 65 Fig 5:58 Illustration: Osteotomes 65 d. Maxillary osteotomy with interpositional bone graft 66 Fig 5:59 Illustration: Maxillary Osteotomy 66 Photos: group 5:60, 5:61, 5:62, 5:63, 5:64, 5:65, 5:66, 5:67, 5:68, 5:69, 5:70, 5:71 in sequence and 5:72, 5:73, 5:74, 5:75, 5:76, 5:77, 5:78, 5:79 in sequence 66 5:60 Extreme atrophy of the maxilla. 66 5:61 Vestibular incision marked. 66 5:62 Mucoperiosteal flap elevated and the bony nasal aperture exposed. Note the nasal floor at the level of the crest. 66 5:63 Down-fracture of the resorbed thin maxilla. Sinus cavities and nasal floor exposed 66 5:64 Bone graft from iliac crest is positioned in sinus cavities and nasal floor and secured with osteosutures. 67 5:65 The maxilla is anteriorly and inferiorly repositioned and immobilized with two plates one on each side of the nasal aperture. 67 5:66 Continuous sutures for closure of vestibular incision. 67 5:67 Healing of soft tissues after two weeks. 67 5:68 Lateral radiograph preoperatively. 68 5:69 Lateral radiograph after bone grafting and anterior repositioning. 68 5:70 Bone graft and osteosutures in the down-fractured maxilla. 68 5:71 The grafted maxilla is secured with plates on both side of the nasal cavity. 68 5:72 Panoramic radiograph showing an extremely resorbed upper jaw. 69 5:73 Lateral view further illustrates the lack of bone in the maxilla and the retrognathic position. 69 5:74 Lateral radiograph after maxillary osteotomy le Fort I with interpositional bone graft and anterior repositioning of the maxilla. 69 5:75 Clinical picture of bone graft healing after 4-5 months. 69 5:76 Panoramic radiograph after grafting procedure. 70 5:77 Implants inserted in the grafted maxilla. 70 5:78 Lateral radiograph of the anteriorly repositioned maxilla with implants. 70 5:79 Panoramic view with implants in place. 70 Surgical technique 72 Photos: group 5:80, 5:81, 5:82, 5:83, 5:84, 5:85 in sequence 72 And 5:86, 5:87, 5:88, 5:89, 5:90, 5:91 in sequence 72 5:80 Panoramic radiograph of patient with advanced periodontal and cariogenic disease in his residual dentition of the upper jaw. Traumatic loss of the anterior teeth. 72 5:81 Lateral radiograph showing a retrognathic position of the upper jaw partly due to the traumatic injury. 72 5:82 The situation after maxillary osteotomy with anterior repositioning of the maxilla and interpositional bone graft. 72 5:83 Rehabilitation with implants and bridge. 73 5:84 Panoramic radiograph after implant rehabilitation. 73 5:85 Clinical situation after prosthetic rehabilitation. 73 5:86 The case illustrates an almost total absence of bone in the maxilla. Lateral radiograph shows very retropositioned maxilla. 73 5:87a) andb) Scanora tomography showing absence of bone beneath the sinus cavity.The same projection with bone graft in place 73 5:88 Panoramic view after bone grafting 74 5:89 Lateral radiograph after bone grafting showing a better sagittal relation. 74 5:90 The patient after prosthetic rehabilitation. 74 5:91 Clinical view of bridge reconstruction. 74 6. SEGMENTAL OSTEOTOMY FOR BONE AUGMENTATION PROCEDURE 76 Fig 6:1 Illustration: Segmentell Osteotomy+ Segmentell Osteotomi 76 Indication 76 Photos: group 6:2, 6:3, 6:4, 6:5, 6:6, 6:7, 6:8, 6:9 76 Group 6:10, 6:11, 6:12 76 6:2 Traumatic injury with loss of teeth and alveolar bone in the maxillary 76 anterior region. 76 6:3 Panoramic view of the situation. 76 6:4 Vestibular incision with exposure of the alveolar process and segmental osteotomy of the edentulous portion. 76 6:5 Bone graft from the chin is positioned in the gap after elevation of the segment to increase the alveolar height. 77 6:6 Lateral radiograph visualizing the bone graft site. 77 6:7 Implants inserted in elevated segment. 77 6:8 Bone material from BoneTrap® smoothing the bone surface. 77 6:9 Panoramic radiograph of implants in place. 78 6:10 A patient with fibrous dysplasia where the posterior edentulous 78 maxilla had increased in height and prevents occlusal rehabilitation. 78 6:11 The clinical situation with no space between dentition in the lower jaw and the opposing alveolar crest. 78 6:12 Surgical intrusion of segment and insertion of implants. 78 6:13 Illustration 78 Surgical technique 78 7. DISTRACTION OSTEOGENESIS FOR AUGMENTATION OF THE ALVEOLAR PROCESS 80 Fig 7:1 Illustration: Distraction 80 Indication 80 Photos: group 7:2, 7:3, 7:4, 7:5, 7:6, 7:7, 7:8, 7:9, 7:10, 7:11, 7:12, 7:13 in sequence 80 7:2 Clinical situation in a patient after traumatic loss of teeth and bone. 80 7:3 Vestibular incision and exposure of the alveolar process. 80 7:4 Segmental osteotomy performed with a thin oscillating saw blade. 80 7:5 Thin plates (stop plate and distraction plate) are secured in the bone segment and the alveolar base. The distraction screw is introduced through the segment. 81 7:6 Clinical view after healing period. 81 7:7 After distraction for one week the segment is elevated. 81 7:8 The final situation with distracted segment. 81 7:9 Insertion of implants. 81 7:10 Radiograph showing implants in place. 82 7:11 Rehabilitation with a bridge. 82 7:12 Tomography before the start of distraction. 82 7:13 Tomography showing 7-8 mm distraction osteogenesis. 82 7:14 IllustrationSurgical technique 82 Surgical technique 83 8. COMPLICATIONS 85 Grafting sites 85 Onlay grafting 86 Photos: group 8:1, 8:2 86 8:1 Partial exposure of large onlay graft. Secondary healing with loss of some of the graft material. 86 8:2 Trauma from denture with exposure of cover screws and part of the implants. 86 Inlay grafts 87 Photos: group 8:3, 8:4, 8:5 87 8:3 Wound dehiscences after crestal incision in connection with sinus grafting. 87 8:4 Sinusitis with fistula after sinus lifting procedure. 87 8:5 Sequestration of bone graft in maxillary sinus 87 9. BONE SUBSTITUTES IN MAXILLARY RECONSTRUCTION PROCEDURES 89 Photos: group 9:1, 9:2 89 9:1 Patient with bone deficiency around inserted implant. 89 9:2 Bio-Oss granules are used to improve stability and increase width of alveolar crest. 89 10. SUMMARY 90 Conclusion 92 11. REFERENCES 94
Library of Congress Subject Headings for this publication:
Maxilla -- Surgery.
Implants, Artificial.
Bone-grafting.
Dental Implantation, Endosseous -- methods.
Maxilla -- surgery.