reconstruccion de reborde by Hector Norero

ridge reconstruction

alejandro kleinman dds. loma linda university

Tissue Engineering : Long term esthetic & functional stability for Dental Implants is dependant upon

Tissue Engineering

Bone Grafting Contraindications Absolute

High dose irradiation Systemic Hematologic Disorders Recent Myocardial Infarction Psychiatric Problems Disease or drug related immunosuppresion Substance Abuse Uncontrolled Diabetic Pregnancy Smoking

tissue engineering : any attempt to regenerate tissues in the body, whether accomplished in the laboratory or directly in the patient, by adding appropriate biologic mediators and matrices.

ridge reconstruction Matrices For Tissue Regeneration

material to be used for the fabrication of matrices to engineer tissue in vitro, or to facilitate regeneration in vivo, must have the microstructure and chemical composition required for normal cell growth and function. For bone regeneration, a material possessing similar physical, chemical, and mechanical properties is desirable since all of these properties will influence normal bone cell growth and function.

ď&#x192;źScaffold from trauma, pathology and surgery ď&#x192;źRestore from dental desease ď&#x192;źSocket preservation

ridge reconstruction mechanisms of bone regeneration and augmentetion

types of graft material Autogenous Bone organic autologous material, utilizes oseoconduction, Allografts

osteoconduction osteoinduction osteogenesis

Xenografts Alloplasts

osteoinduction and osteogenesis in the formation of new bone may be cortical or trabecular, have osteconductive and possibly osteoinductive properties, but not osteogenic are fabricated from the inorganic portion of bone from animals other than man and are osteoconductive are exclusively synthetic, and the mechanism of action is osteoconduction. They come in a great variety of textures, particle sizes, and shapes

ridge reconstruction

barrier membranes: GTR (guide tissue regeneration) GBR (guide bone regeneration)

barrier membranes techniques are based on criteria that reflect the biologic behavior of different tissues during wound healing. the purpose of barrier membrane procedures is selective cells repopulation to guide proliferation of the different tissues during healing after the therapy

ridge reconstruction

barrier membranes

 prevents undesirables cell migration  mechanical stability of the wound complex  provide a tent-like area creating a space under the surgical flap  maximize the natural potential for functional regeneration  facilitate augmentation of alveolar ridge defects  induce complete bone regeneration, improve bone- grafting results and treat failing implants

materials for barrier membranes

 biocompatibility  cell occlusiveness  space making  tissue integration  clinical manageability

materials for barrier membranes

membranes nonresorbable

resosrbable

e-PTFE

polylactic acid

ti e- PTEF

polyglicolic acid

n-PTEF

laminar bone collagen acellular dermal

nonresorbable membranes

two parts

ti e-PTFE (gore-tex)

open microestructural collar facilitate early clot formation and collagen fiber penetration the occlusive center portion prevents gingival tissue invasion ti e-PTEF were designed to increase the tent-like effect

complications

nonresorbable membranes n-PTFE

socket preservation bone

resorption after a tooth extraction is inevitable, thus it may compromise the future placement of endosseous implant.

membrane GBR

(guided bone regeneration) with a barrier membrane is a well-established therapy (Buser D et al 1990, Dahlin C et al 1981, Schenk RK et al 1994, etc) & this techniques are applied to extraction sockets (Becker W, et al 1994, Lekovic K et al 1998, etc)

exposure is a problem, particularly in extraction socket grafting when non-resorbable membrane (e-PTFE) is exposed, bacteria penetration through the membrane is reported (Simion et al 1994, 1995)

nonresorbable membranes n-PTFE

nonresorbable membranes

The

n-PTFE membrane was well tolerated by the soft tissue without sign of infection Granulation tissue formed under the membrane at removal No loss of graft material was evident Three months later, an implant was able to be placed with simultaneous sinus elevation in the grafted site

n-PTFE

Simion et al.

resorbable membranes Polylactid ac./Polyglycolic ac.

resorption time 3-4 months not stiff enough for ridge augmentation procedures, for small defects only one in vitro study concluded showed enhanced early osteoblast attachment another study compare PGA/PLA with e-PTEF and it showed a significantly greater amount of bone regeneration with e-PTEF

Guide bone regeneration usin a resorbable and nonresorbable membranes: A comparative histologic study in humans. Simion M. et al. IJOMI 1996;11:735-742

resorbable membranes Polylactid ac./Polyglycolic ac.

resorbable membranes laminar bone

•flexible sheets of DFDBA lamunar cortical bone •used in conjunction with particulate graft materials and pin fixation in small to large defects •it resorbs in 5 months •in clinicals studies has showed GBR effects when was compared with ePTFE

resorbable membranes processed bovine type I collagen , origicollagen BioMend BioMend Extended Ossix CollaTape Bio-Gide Pericardium

nating both from tendons and dermal sites chemotaxis (for fibroblasts) and hemostasis scaffold for migration cells low antigenicity high tensil strengtharrier bilayerd membranes compensate for the premature degradation of the external barrier multicenter studies have shown equivalent results of those obtained using e-PTEF

Collagen membranes meet the criteria for membrain barrier techniques: space creation, tissue integration, cell occlusivity, biocompability, and clinical manageability

resorbable membranes Collagen (BioMend)

bovine tendon type I collagen remain intact for 4 weeks, and full resorbsion takes place within 8 weeks for large sinus membrane tears, 3 or 4 wall extraction socket over a graft material, or small ridge deficiencies with or without simultaneous implants

resorbable membranes

bovine tendon type I collagen

Collagen (BioMend Extend)

resorbs within 18 weeks and thus able to maintain a regenerative barrier for a long period thicker than BioMend, more pliable and tear-resistent (0.004 microns) for small or moderate ridge deficiencies with pin fixation and underlying graft material with or without simultaneous implants

resorbable membranes

bovine tendon collagen

Collagen (Ossix)

it resorbs in 6 months In one study showed no differences with e-PTEF in bone formation in a GBR procedures gingival dehisencies disappeared in subsequent weeks with no effect on healing not easy to handling not stiff enough for ridge augmentation procedures

Histological assessment of augmented jaw bone utilizing a new collagen membrane compared to a standard barrier membrane to protect a granular bone substitute material. Friedman A. et al. Clin Oral Implants Res 2002;13:587-94

resorbable membranes Collagen (Ossix)

resorbable membranes collagen

collagen type I minors oral wounds, to close graft sites & to repair sinus membranes control bleeding and stabilizing blood clots provide a matrix for tissue ingrowths associated with GBR is fully resorbs in 7 to 14 days

resorbable membranes collagen

socket preservation #7, 8

resorbable membranes socket preservation #7, 8

collagen

2 weeks 2 months

4 months

resorbable membranes collagen

implant placement #8-9-11-12

resorbable membranes collagen

implant placement #8-9-11-12

resorbable membranes collagen

implant placement #8-9-11-12

resorbable membranes collagen

FCT graft

resorbable membranes collagen

uncovery 1st Provisional

resorbable membranes collagen

bilateral sinus graft

implant on # 3- 14- 19- 30

custom abutment fabrication

Atlantis

•Computer Generated •Patient Specific •Precision Machined from Titanium •Replicates a Natural Prepared Tooth •Use with Cement or Screw Retained Restorations •Most Implant Systems/Any Implant Protocol •Patented Design Process Computer Generated

custom abutment fabrication

Scanning

Surfacing & Feature Detection

3D Model

Atlantis One abutment stays in the mouth.

One abutment goes to the lab

Final Design

Initial Design

custom abutment fabrication

GoldHue™ Abutments excellent for:

Atlantis • • • •

areas with thin tissue in the esthetic zone with an all ceramic crown advantage of Atlantis gold abutments: 80% of the time no additional modifications are made so the gold surface stays in place

custom abutment fabrication

Atlantis abutment in zirconia™

Zirconia: Material of Choice •Strongest & toughest of current advanced ceramic materials - “ceramic steel” •- Strength suitable for dental applications •Near-ideal tooth color in fired state-

Material: yttria-stabilized tetragonal zirconia polycrystals; Y-TZP

• Can be produced in Vita-like shades •Biocompatible

•Technically compatible with Atlantis process

Interfaces Available: Internal hex for Zimmer TSV and ScrewVent external hex for Nobel, etc. *Additional internal Interfaces are planned; 3i Certain and Nobel Replace Material: yttria-stabilized tetragonal zirconia polycrystals; Y-TZP Color: “Natural” (Very white) Zirconia White Strength, Toughness, and Reliability: Highest available

Interfaces Available: Internal hex for Zimmer TSV and ScrewVent implants and external hex for Nobel, etc. *Additional internal Interfaces are planned; 3i Certain and Nobel Replace

implants and

Color: “Natural” (Very white) Zirconia White Strength, Toughness, and Reliability: Highest available

custom abutment fabrication

Atlantis abutment in zirconiaâ&#x201E;˘

courtesy of Julian Osorio, DMD,MScD

custom abutment fabrication

Atlantis

custom abutment try-in

2nd Provisional

custom abutment fabrication

Atlantis

2nd Provisional

custom abutment fabrication

Atlantis

Final Prosthesis

778CANON 779CANON

resorbable membranes collagen

sinus membrane perforation

pouch technique (Loma Linda pouch)

resorbable membranes Collagen (socket repair)

•placement in the area of socket sites

post-tooth extraction to aid in wound healing. •made of Type I Collagen •pre-cut to fit single root sockets; saves valuable chair-time •Contains graft material by capping the socket with the circular portion of the membrane •used in place of the missing post extraction buccal wall to prevent the bone particles from dispersing into the tissue and preventing the migration of the epithelium cells into the site

resorbable membranes collagen

resorbable membranes collagen (Bio-Gide)

bilayer collagen membrane external smooth compact layer covered by a dense film the other side is rough and designed to be placed facing the bone defect to facilitate bone in growth porcine collagen types I and III slow-resorbing (4 months)

resorbable membranes collagen (Bio-Gide) augmentation around simultaneously placed implants GBR in dehiscence defects localized ridge augmentation prior to the placement of implants bone defect filling subsequent to root resection, cystectomy or tooth removal

resorbable membranes collagen (Bio-Gide)

3 months

6 months

resorbable membranes collagen (Bio-Gide)

resorbable membranes collagen (Bio-Gide) Resorbable versus nonresorbable membranes in combination with Bio-Oss for guide bone regeneration. Zitzmann NU, Naef R, Sharer P J Oral Maxillofac Implant 1997; 1997;12:844-852

"results showed an average bone fill of 92% in site covererd by the resorbable membrane. An average bone fill of 78% was observed in sites covered with nonresorbable membrane. Wound dehiscences and/or premature membrane removal ocurred in a large porcentage of sites covered with the nonresorbable membrane compared to those trated the collagen membrane"

resorbable membranes collagen (Pericardium)

• dense, connective tissue surrounding the heart muscle • Pericardium is made up of collagen Type I - it is produced by fibroblasts • a unique, natural biological dressing preserved and sterilized using the Tutoplast® process, which exhibits superior adaptability to surface contours, high strength, & biocompatibility • Puros® Pericardium is used in cases such as Puros® Block coverage and large ridge augmentation procedures as a cell occlusive collagen barrier membrane

resorbable membranes collagen (Pericardium)

ÂŽ â&#x20AC;˘Tutoplast

Pericardium has been utilized in various indications for over 30 years. ~ENT ~Urology ~Herniorrhaphy ~Neurosurgery ~Ophthalmology ~Otolaryngology ~Plastic and Reconstructive Surgery ~Sports Medicine / Orthopedics

resorbable membranes collagen (Pericardium)

• easy to use clinically  contours to ridge; Adaptable  easy to manipulate  no need for secondary surgery ® • sterilized using the Tutoplast process; natural properties remain • strong with multi-directional fibers • good tissue response • accepts all types of fixation devices • biocompatible

• easy to rehydrate • Puros Pericardium has a resorption profile of 4 to 6 • months • uniform remodeling • 5 year shelf life

resorbable membranes collagen (Pericardium)

resorbable membranes acellular dermal allograts (AlloDerm)

•acllular human cadaver skin •deepithelization and decellularization

Advantages of Using Alloderm

•immunologically inert avascullar CT

Time saver No donor site Less postoperative discomfort for patient Less clinician cost (ie, time saved) Fewer complications Simple procedure Safer (no cells involved)

• bioresorbable,remain intact as a barrier for 6 weeks, with complete remodelation in less than 6 months •unlimited supply, •formation of additional attached gingiva

resorbable membranes acellular dermal allograts (AlloDerm)

Dermal/Connective Tissue

Basement Membrane Site

Readily absorbs blood Shinier, more reflective More slippery, smoother

Does not readily absorb blood Duller, nonreflective Rougher by touch

resorbable membranes acellular dermal allograts (AlloDerm)

resorbable membranes acellular dermal allograft (AlloDerm GBR)

resorbable membranes acellular dermal allograt (Puros Dermis)

providing an easy-to-use, steril solution Puros速Dermis is a natural alternative to autogenous soft tissue grafts. it can be used for both horizontal and vertical soft tissue augmentation, increasing volume and leading to a highly cosmetic clinical result. Puros Dermis offers superb soft tissue response and maturation, ideal for aesthetic case requirements. a unique, natural biological dressing preserved and sterilized using the Tutoplast速 process, which exhibits excellent adaptability to surface contours, high strength, & biocompatibility

resorbable membranes acellular dermal allograt (Puros Dermis)

Features •Easy to use clinically

Seconds to re-hydrate (no antibiotic rinsing required) No need for secondary surgery Contours to ridge Accepts all types of fixation devices Excellent soft tissue response •Sterilized using the Tutoplast® process; natural properties remain •Strong with multi-directional fibers

•No refrigeration required •Five-year shelf life •Biocompatible •Composed mainly of Type I Collagen •Puros Dermis has only one thickness = 1.3mm •Sold as a barrier membrane for GBR and TGR •Same thickness as Puros Pericardium

resorbable membranes acellular dermal allograt (Puros Dermis)

remodeling â&#x20AC;˘remodeling starts immediately after

implantation and continues until the implant is completely replaced by host tissue.

Fibroblasts form new collagen fibers Granulocytes & macrophages (white cells) invade

â&#x20AC;˘the process of break-down and build-up goes hand-in-hand, always providing a minimum biomechanical strength that is at the weakest point 50% of the original strength.

Granulocytes & macrophages digest implanted collagen

Granulocytes & macrophages (white cells) invade

resorbable membranes Tutoplast process

A multi-step process

•removes all antigenicity •inactivates all kinds of pathogens •preserves tissue structure and collagen •preserves biomechanics •guarantees sterility •results in graft healing comparable to autografts

•donor selection •osmotic treatment •oxidative treatment •alkaline treatment – Different from Bone •solvent dehydration •low dose gamma irradiation •full documentation

resorbable membranes Tutoplas process

•Donor Selection • Osmotic Treatment • Oxidative Treatment

Donor selection - human method •al donors undergo a full autopsy •serological testing according to FDA and AATB requirements is done •an extensive donor exclusion protocol, far exceeding AATB standards, is followed

•Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

result •tissue from donors with the lowest social and clinical risks

resorbable membranes Tutoplast process

•Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

osmotic treatment method • tissues are treated several times with alternating baths of hyper-osmotic saline and distilled water

result •all cells burst during this treatment and are washed out •antigenicity, mostly located in cell membranes is removed preventing tissue rejection •viruses potentially hidden within the cells are exposed and washed out •bacteria and cells are killed and washed out

resorbable membranes Tutoplast process

oxidative treatment

•Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

method •tissues are treated two times with 3% hydrogen peroxide result •residual soluble proteins are inactivated and washed out •non-enveloped viruses (e.g. HAV, HBV) are inactivated •bacterial spores are inactivated •collagen is preserved

resorbable membranes Tutoplas process

•Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

alkaline treatment

method •tissue is treated for one hour at room temperature with 1N sodium hydroxide that is afterwards neutralized result •this treatment is highly effective against prions •even the brain of a CJD patient in the early clinical stage could be sterilized by this method •genetic material, DNA and RNA, is destroyed • consequently all kinds of viruses are inactivated • biomechanics of collagen are not affected

resorbable membranes Tutoplast process

•Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

solvent dehydration method •tissue is placed several times in pure acetone •at the end of the step acetone is left to evaporate in a vacuum chamber result •dry tissue with a residual water content of less than 5%. Can be stored at room temperature. •tissue is virtually sterile at this point

resorbable membranes Tutoplast process

low dose gamma irradiation •Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

method •tissue is gamma irradiated with a minimum dose of 17.8 kGy and a controlled maximum dose of 23 kGy result •irradiation penetrates the tissue completely •tissue is sterile according to GMP with a Sterility Assurance Level (SAL) of 10-6 •tissue biomechanics are not affected •tissue is free of residues

resorbable membranes

full documentation

guaranteed traceability

Tutoplast process

method •donor protocols, test protocols, inprocess protocols and individual reference samples are stored in Tutogen’s archives for 15 years

method •all documents, inner and outer package and inserted documentation stickers are labeled with a code for harvesting institution, donor and tissue type •shipping documents and bills also carry the code for every individual unit

•Donor Selection • Osmotic Treatment • Oxidative Treatment •Alkaline Treatment •Solvent Dehydration •Low Dose Gamma Irradiation •Full Documentation

result •in case of complaints, protocols can be checked and the reference sample can be retested with potentially more sensitive tests

Method

result •every individual product can be traced to the distributor, doctor or hospital •traceability back to the donor and the processing batch is also guaranteed

resorbable membranes acellular dermal allograt (Puros Dermis)

Dr. Paul Petungaro D

ridge reconstruction mechanisms of bone regeneration and augmentation

osteoconduction osteoinduction osteogenesis

Osteoconduction: bone growth by apposition from the surrounding bone. This process must occur in the presence of bone or differentiated mesenchymal cells. Osteoconductive materials are biocompatibles, and if they are placed in ectopic sites, they do not initiate bone growth.

ridge reconstruction

Osteoconductive Grafting Materials HA Synth :

Calcium phosphate HA Nat

TCP

Calcite Orthmatrix HA Osteogen Osteograft D, LD Bio-Oss Osteograft N Osteomin PepGen P15 Puros Augmen CalciResorb SynthoGraft

Calcium carbonat

Interpore 200 : BioCoral

Bioactive glass Bioglass ceramic : Biogran Perioglass

Biocompatible composite polymer : Bioplant HTR Calcium Sulfate :

CapSet

ridge reconstruction

Bio-Oss anorganic bovine bone that has chemically treated to remove its organic components. It's highly osteoconductive, thereby allowing bone regeneration to occur. Over time, the graft undergoes physiologic remodeling, incorporated into the surrounding bone.

Healing around implants placed in bone defects treated with Bio-Oss. An experimental study in the dog Berglundh T, Lindhe J. Clin Oral Implant Res 1996;8:117-124

"results showed that the Bio-Oss became integrated and was subsequently replaced by new bone, fulfiling the criteria of an osseoconductive material. In addition, a similar qualitative and quantitative degree of osseointegration around endosseous implants were observed in both the large defects grafted with Bio-Oss and the normal bone sites"

ridge reconstruction

Osteoconductive Grafting Materials Histologic evaluation of Bio-Oss in a two-stage sinus floor elevation and implantation procedure. A human case report. Valentini P, Abensur D, Densari D,Granziani JN,Hammerle CHF. Clin Oral Implant Res 1998;9:59-64 "anorganic bone was used as grafting material during sinus elevation , followed by the placement of implants. Microscopic examination revealed direct bone-toimplant contact in the areas of both preexisting bone and the grafted areas,as well as intimate contact between the graft particles and newly formed bone"

ridge reconstruction

Osteoconductive Grafting Materials

Indications: Small reconstructions in defects with high osteogenic potential: maxillary sinus, slightly resorbed ridges alone or with membranes, a few exposed threads on an implant, four-to five wall extraction sockets, ridge augmentation in width. Resorption time: 15-30 months

ridge reconstruction

Osteoconductive Grafting Materials ridge augmentation (horizontal) before implant placement

ridge reconstruction

Osteoconductive Grafting Materials ridge augmentation (horizontal) with implant placement

Osteoconductive Grafting Materials

ridge reconstruction

The TUTOPLAST® Process

PUROS Allograft •The

Tutoplast process is a patented preservation/sterilization process that consists primarily of a series of chemical bathes to ensure the graft material is safe and effective. •Solvent-dehydrated mineralized bone ~Preserves trabecullar pattern and bone porosity ~Preserves collagen (90 – 95% of organic component of bone) ~Free of viral contaminants

•Localized augmentation of the ridge for future implant placement with lower or moderate osteogenic potential •Reconstruction of the ridge for prosthetic therapy •Filling of any kind of osseous defects, such as extractions, apical defects, etc. •Elevation of maxillary sinus floor •Repair of infrabony periodontal defects

ridge reconstruction PUROS Allograft

Osteoconductive Grafting Materials Suggestions For Particulate Use •Small Particles – Smaller defects (periodontal defects, around implants, small tooth extraction sockets) •Large Particles – Larger defects (Large tooth extraction sockets, sinus elevation procedures) •Hydrate prior to use, Mix with saline, blood •Can Press fit particles without fracture •Use of a membrane and primary closure are recommended

Puros Cancellous: Uses/indications •socket preservation • small defects • implants fenestration, dehisencies Puros Cortical: Uses/Indications •used to increase volume and space – •Ssnus grafting; other areas; surgeon preference •can be mixed with Puros Cancellous or used alone •longer resorption than Puros Cancellous (more dense) •as a replacement for BioOss, PepGen, DFDBA’s and other Xenografts and Allografts

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge augmentation before implant placement

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge augmentation before implant placement

ridge reconstruction PUROS Allograft

osteoconductive grafting materials peri-implantitis treatment

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

prophy jet

osteoconductive grafting materials

ridge reconstruction

decorticalization

peri-implantitis treatment

PUROS Allograft

tetracycline puros cortical

ridge reconstruction

osteoconductive grafting materials

2 weeks

peri-implantitis treatment

PUROS Allograft

pericardium

2 months

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

free gingival graft 4 months

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

10 days

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

1 month after FGG

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

2 months after FGG

ridge reconstruction

osteoconductive grafting materials peri-implantitis treatment

PUROS Allograft

FPD repositioning

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge split 2-stage

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge split 2-stage

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge split 2-stage

40 days after

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge split 2-stage

ridge reconstruction PUROS Allograft

osteoconductive grafting materials ridge split 2-stage

ridge reconstruction

PUROS Allograft

osteoconductive grafting materials moderate ridge reconstruction (horizontal)

ridge reconstruction

PUROS Allograft

osteoconductive grafting materials moderate ridge reconstruction (horizontal)

ridge reconstruction

PUROS Allograft

osteoconductive grafting materials moderate ridge reconstruction (width)

ridge reconstruction

PUROS Allograft

osteoconductive grafting materials moderate ridge reconstruction (width)

osteoconductive grafting materials

ridge reconstruction

PUROS Allograft

sinus elevation

Comparative study in sinus floor elevation with anorganic allograft at 6 and 12 months: Histologies and Histomorphometries Kleinman A., Lozada J., Noumbissi S. In prep.

12 sinus in 11 patients Puros cortical and cancellous large particles, mixed half and half was the only graft material 2-stage approach in 6 sinus reentry at 6 months (control group), and in the other 6 at 12 months experimental group) one sinus of the experimental group the sinus membrane was perforated the mean new bone formation in both groups was 33% the lowest new bone formation was in the perforated sinus (15.36%), the highest was one in the control group (46.5%) Conclusion: no differences in the amount of new bone formation in sinus grafted with Puros cortical and cancellous at 6 or 12 months

ridge reconstruction

PUROS Allograft

osteoconductive grafting materials sinus elevation

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

Uses/IndicationsTaken from Iliac crest – •Taken from Iliac crest – both cortical and cancellous •The J-Block Allograft is specifically designed for surgical ridge augmentation of mandible or maxilla in patients where bone volume has been reduced due to atrophy in both vertical and lateral dimensions.

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block) what treatment option is good for the patient? bone graft ? nerve repositioning ? distraction osteogenesis ?

tomography

ridge reconstruction

Puros Block (J-Block) oTreatment options Bone graft? very thin cortical bone at symphysis area and ramus area Nerve repositioning? crown/ root ratio higher chance of neurosensory disturbance Distraction osteogesis?

osteoconductive grafting materials vertical and horizontal defects

stereolithographic model

â&#x20AC;˘what is alternative? Allograft?

xenograft? allograft??

mental foramen is close to alveolar crest!!!

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

X ray postoperative

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

3 months postop

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

implants placement

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

Clinical and histologic evaluation of mineralized block allograft: Results from the development period (20012004) Keith JD. et al Int Journal Periodonto & Restorative Dent. Vol4, 2006 7 of 82 blocks failed 69% didnâ&#x20AC;&#x2122;t loose bone, and 31% lost 1 to 2 mm.

28% new bone

It doesnâ&#x20AC;&#x2122;t mention the amount of new bone created

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

provisionalization Atlantis custom abutments

ridge reconstruction

osteoconductive grafting materials vertical and horizontal defects

Puros Block (J-Block)

provisionalization

one-year postop

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

complications

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

complications

one week

2 weeks

osteoconductive grafting materials

ridge reconstruction

vertical and horizontal defects

Puros Block (J-Block)

3 weeks

complications

4 weeks

5 weeks

osteoconductive grafting materials

ridge reconstruction

vertical and horizontal defects

Puros Block (J-Block)

complications

Bleeding

6 weeks

7 weeks

8 weeks

10 weeks

ridge reconstruction

Puros Block (J-Block)

osteoconductive grafting materials vertical and horizontal defects

complications

3 months-block removal

ridge reconstruction

osteoconductive grafting materials PepGen P15

PepGen P15

ridge reconstruction

PepGen P15

osteoconductive grafting materials

ridge reconstruction

PepGen P15

osteoconductive grafting materials •small to moderate reconstructions in defects with moderate to high osteogenic potencial. • very expensive • generally recommended as a part of a composite graft with other less expensive

ridge reconstruction PepGen P15

osteoconductive grafting materials small ridge reconstruction (horizontal and vertical)

ridge reconstruction PepGen P15

osteoconductive grafting materials small ridge reconstruction (horizontal and vertical)

ridge reconstruction Bioplant HTR polymer Is a microporous composite with a calcium hydroxide graft surface. The polymer resorbs slowly and is replaced by bone after approximately 4 to 5 years.

osteoconductive grafting materials â&#x20AC;˘resorbs too slowly â&#x20AC;˘indicate in an extraction socket that will serve beneath the pontic of a FPD to maintain long term esthetic ridge beneath the pontic

ridge reconstruction

osteoconductive grafting materials

Bioglass (US Biomaterials) Perioglass (Block Drug) Biogran (Orthovita) Are composed of Ca salts and phosphate in similar proportions as found in bone and teeth, as wll as Na salts ans silicon (which are essential for bone to mineralize). BioGlass has two properties that contribute to the successful results observed with its use: 1) a relatively quick rate of reaction with host cells, and 2) its ability to bond with the collagen found in connective tissue. Because the bioactivity index is high, reaction layers develop within minutes of implantation. As a result, osteogenic cells in the implantation site may colonize the surface of the particles and produce collagen on these surfaces. Osteoblasts then lay down bone material on top of the collagen.

bioactive glass ceramics

Bioglass (US Biomaterials) Perioglass (Block Drug) Biogran (Orthovita) PerioGlass is a synthetic, particulate form of Bioglass. In animal studies has demonstrated two favorables characteristics: ease of compactability and the ability to promote hemostasis. Ferner et al. in their animal study reported that the material resulted in osseous and cementum repair superior to those obtained with HA and TCP.

Bioglass (US Biomaterials) Perioglass (Block Drug) Biogran (Orthovita) BioGran is a resorbable bone graft material made of bioactive glass granules (300 to 355 micrones), is hydrophilic and slightly hemostatic. Furusawa and Mizunuma studied the use of BioGran for subantral augmentation after sinus elevation. Histologic and biomechanical analysis revealed new bone formation in all cases; the biomechanical properties of the regenerated bone and native bone tissue were similar.

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osteoconductive grafting materials bioactive glass ceramics

biogran

â&#x20AC;˘recommended for periodontal defects â&#x20AC;˘resorbs too slowly (20-22 months)

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mechanisms of bone regeneration and augmentation

ď&#x192;źosteoconduction ď&#x192;źosteoinduction ď&#x192;źosteogenesis

Osteoinduction: is the process of stimulating osteogenesis, involves new bone formation from osteoprogenitor cells derived from primitive mesenchymal cells under the influence of one or more inducing agents that emanate from the bone matrix, it has been shown to induce bone formation in the ectopic site. Osteoinductive materials can be used to enhance bone regeneration. The most commonly used oateoinductive materials in implant dentistry are autografts and may be some allografts

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osteoinductive grafting materials Bone Allografts: is an osseous transplanted tissue from the same species as the recipient but of different genotype. The tissue is obtained from cadavers, processed, and then stored in various shapes and sizes in bone banks for future use. There are three types of bone allografts: frozen, freeze-dried, and demineralized freeze-dried

Frozen bone : Is rarely used in implant dentistry, because of the risks of rejection and desease transmition FDBAs : Cortical and/or trabecular bone is harvested Washed in in destilled water and ground Inmerse in 100% etanol to remove fat Frozen in Nitrogen and ground to smaller particles Inorganic portion of bone serves as a mineral source and scaffold for bone formation Organic matrix includes BMP within the structure of the HA DFDBAs : An additional step, demineralizing the ground bone powder in 0.6 N hydrochlolic or nitric acid for 6 to 16 hrs. Is irradiated or sterilized in Ethylene Oxide The tissue remaining from this treatment still possesses the organic osteoinductive growth factors necessary for bone formation, including BMPs,which are not soluble in acid The demineralized mineral cortex contains a higher concentration of BMPs than cancellous bone Membranous bone exhibits greater concentrations of BMP than endochondral bone

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osteoinductive grafting materials FDBA or DFDBA controversies? Concerns regarding the possible transmission diseases (1:s.600.000) the demineralization exposes bone collagen and possibly some growth factors (BMP)? FDBA has showed more effective than DFDBA in: •small fenestrations or dehiscences •minor ridge augmentation •socket preservation in the short-term •sinus graft mixed with other materials

Meffert RA. Et al. Denta Implantol Update 1998;9:9-12 no bone in sinus filled with DFDBA in 6 months Brugnami F, et al. J Periodontol 1996;67:821-825 DFDBA particles were found to be sourranding CT Feuille F, et al. Int J Periodontics Restorative Dent 2003;23:29-35 FDBA with e-PTEF barrier can yield predictable results when augmenting alveolar ridges prior to the placement of implants

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osteoinductive grafting materials

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osteoinductive grafting materials tissue engineering

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osteoinductive grafting materials tissue engineering

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osteoinductive grafting materials tissue engineering

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osteoinductive grafting materials tissue engineering influence of abutment disconnection

an unintentional abutment loosening will lead to a disruption of the soft tissue integration and to increased bone remodeling. Hermann et al. (2001)

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osteoinductive grafting materials tissue engineering influence of abutment disconnection

repeated intentional abutment disconnections and reconnections induce an apical repositioning of the soft tissues and marginal bone resorption Abrahamsson et al. (1997)

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osteoinductive grafting materials tissue engineering

platelets rich plasma (prp) AUTOLOGOUS PLATELET-RICH PLASMA (PRP)

Documented evidence, demonstrates the release of a cascade of growth factors through the activation of the platelets with CaCl2 and thrombin.

 Platelet-Derived Growth Factor (PDGF aa-bb-ab)  Transforming Growth Factor-Beta (TGF-B1, B2)

"Platelet-Rich Plasma Growth Factor Enhancement For Bone Grafts Marx RE, Carlson ER, Eichstaed RM, et al. Oral Surg Oral Med Oral Pathol 1998, 85:638-646 Platelet concentrations can be increased 232.000 to 785.000. 88 patients receiving major reconstructive surgery were treated with either iliac crest autograft or mixed with PRP

 Vascular Endothelial Growth Factor: VEGF 

Epithelial Growth factor: EGF

platelet gel. The study demonstrated increases in both the rate of bone formation and bone density.

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platelets rich plasma (prp) Native levels of cell adhesion molecules: Fibronectin Vitronectin Fibrin "These are important in cell migration as a framework, which will support osteoinduction throughout a bone graft, osteoinconduction over a dental implant surface (osseointegration), and epithelial migration over a surface wound"

osteoinductive grafting materials tissue engineering

PDGF's

TGF-b's

Most universal growth factors in wound healing They induce cell replications in cells(mitogens) They will cause replication of mesenquchymal stem cells, osteoblats endothelial cells, and fibroblasts.

Stimulate cell replication Stimulate matrix production Guide differentiation towards cartilage or bone Are also morphogens

"Leads toward revascularization, collagen synthesis, and bone regeneration"

"PDGF and TGF-B1, alone or in combination, increase tissue vascularity, promote fibroblast proliferation, increase the rate of collagen and granulation tissue production, and enhance osteogenesis".

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osteoinductive grafting materials tissue engineering

platelets rich plasma (prp) VEGF

EGF

Limited to its effects on endothelial cells and on recruitment of pericytes to support new blood vessles

Limited to its effects on the basal cells of skin and mucus membrane. It induces a replication of these cells and a stimulation to lay down the specific components of the basement membrane

ridge reconstruction

osteoinductive grafting materials tissue engineering

platelets rich plasma (prp)

1st. Symposium on PRP & its GF Lake Buena Vista, Fl. 2002

The use of platelet rich plasma gel for subantral augmentation. A clinical and histomorphometric study in humans.

Kleinman A., Lozada L.J., Proussaefs P., Loma Linda University

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osteoinductive grafting materials

platelets rich plasma (prp) the purpose of this study is to describe the two processing techniques currently used at LLU for obtaining platelet-rich plasma gel, and the report on the clinical and histological findings using PRP mixed with xenograft and autogenous bone.

tissue engineering

materials & methods Patient Selection. Twelve partially or completely edentulous patients Bilateral Complete Pneumatization

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osteoinductive grafting materials

platelets rich plasma (prp) Group 1: Included patients who received a 2-stage subantral augmentation procedure by using 100% inorganic bovine mineral (Bio-Oss), Osteohealth Co., Shirley, NY).

tissue engineering

Group 2: Included subjects who received a 2-stage subantral augmentation procedure by using PRP and the same type of graft material, i.e. inorganic bovine mineral (Bio-Oss).

Group 3: Comprised patients have the 2-stage sinus grafting performed by using a combination of autogenous intraorally harvested bone graft, Bio-Oss, and PRP.

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

two-stage sinus elevation

6-8 months later

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

Smart PReP Harvest Technologies DIDECO Cell Saving Processing Unit

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

Marx R. 1st. Symposium on PRP & its GF Lake Buena Vista, Fl. 2002

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

Marx R. 1st. Symposium on PRP & its GF Lake Buena Vista, Fl. 2002

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

Marx R. 1st. Symposium on PRP & its GF Lake Buena Vista, Fl. 2002

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osteoinductive grafting materials

platelets rich plasma (prp) autologous graft harvested from the chin

tissue engineering •a healing time of 6-8months •2-mm internal diameter trephine bur at the area where the original bone has the least height. •a minimum of 10mm

in length

of grafted bone was harvested. •HA-coated threaded root form implant was placed.

biopsy procedure

osteoinductive grafting materials

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platelets rich plasma (prp)

tissue engineering 60

e n50 o B 40

w e N30 % 20

Bioss

Bioss+prp

autologous+Bioss=prp 51% new bone

Xen Xen/PRP Auto/Xen/PRP

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osteoinductive grafting materials

platelets rich plasma (prp)

tissue engineering

conclusions our results did not showed difference in platelet concentration between the cell saver unit and the portable unit.

xenograft and PRP alone do not significantly improves new bone formation. autogenous bone is required to trigger new bone formation when xenografts and PRP are used in sinus grafting procedures.

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osteoinductive grafting materials

GROWTH FACTORS MORPHOGENETIC PROTEINS (BMPs) (Urist, 1965) Non collagenous protein Bone differentiation factor (morphogen) Low molecular weight protein At pH 7.4 the osteoinductive activity of BMP is latent in many tissues and organ systems How is delivered by slow release and specificity for target perivascular cells is not know

tissue engineering

BMPs appear to be capable of influencing both types of bone formation. Wozney(1995) Wang (1990) recombinant DNA technology has allowed the production of at least 15 BMPs bone formation in alveolar ridge defects in dogs. Nagao (2002) in sinus elevation using rhBMP-2 in an absorbable collagen sponge carrier all patients experienced induced bone formation , averaging 8.5 mm. in heigth. Boyne (1997) implant were placed from 16 to 30 weeks after ridge augmentation with rhBMP-2/ACS. Cochran(2000)

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osteoinductive grafting materials tissue engineering rh BMP/2

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osteoinductive grafting materials tissue engineering rh BMP/2

preparation in a clean environment

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osteoinductive grafting materials tissue engineering rh BMP/2

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osteoinductive grafting materials tissue engineering rh BMP/2

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osteoinductive grafting materials tissue engineering rh BMP/2

osteogenesis

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mechanisms of bone regeneration and augmentation

osteoconduction osteoinduction osteogenesis

autogenous Bone

osteogenesis: refers to the growth of bone from viable cells transfered within the graft. Autogenous bone is the only graft material available with osteogenic properties. The most effective form is cancellous bone, wich provides bone cells in the greatest concentration. New bone is regenerated from endosteal osteoblasts and marrow stem cells transferred with the graft.

Bone Blood Supply Phase I: Osteogenesis Surviving cell 4 weeks (osteocytes from cancellous bone) = Osteoid Phase II: Osteoinduction BMP release (from cortical bone) 2 weeks to 6 months; peak at 6 w. Phase III: Osteoconduction Inorganic matrix of HA-space filler (sacaffold) Cortical plate, barrier membrane

osteogenesis

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Volume of autologous graft material obtainable for the alveolar defect from various donor sites

intra-oral

Autogenous bone

AUTOGENOUS BONE

<5 cc.

5-30 cc

>30 cc.

Tuberosity Ramus Retromolar area Chin

Tibia Cranial bone

Iliac crest

extra-oral

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osteogenesis Autogenous Bone Intra-oral chin block (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin block (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin block(vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin particulate (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin particulate (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin particulate (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin particulate (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral chin particulate (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral ramus block (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral ramus block (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral ramus block (vertical and/or horizontal defects)

The Use of Ramus Autogenous Block Grafts for Vertical Alveolar Ridge Augmentation and Implant Placement: A Pilot Study

P.Proussaefs, J.Lozada, A.Kleinman, M.Rohrer. IJOMI, 2002;17:238-248

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osteogenesis Autogenous Bone Intra-oral ramus block (vertical and/or horizontal defects)

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osteogenesis Autogenous Bone Intra-oral ramus block(vertical and/or horizontal defects)

CONCLUSIONS •Mandibular block autografts can maintain their vitality •5.12 mm. of vertical ridge augmentation •17% resorption was seen 4 to 6 months after bone grafting. •Late graft exposure may not necessarily result in graft necrosis, while early exposure may result in compromised healing and partial graft necrosis. •Inorganic bovine mineral (Bio-Oss) can be used at the periphery of the block graft when mixed with autogenous bone marrow. The mixture resulted in an average of 34.33% bone formation in this series.

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osteogenesis Autogenous Bone Intra-oral ramus particulate (vertical and/or horizontal defects)

tent technique

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osteogenesis Autogenous Bone Intra-oral ramus particulate (vertical and/or horizontal defects)

tent technique

6 months

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osteogenesis Autogenous Bone Intra-oral ramus particulate (vertical and/or horizontal defects)

tent technique

membrane exposed

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osteogenesis Autogenous Bone Intra-oral ramus particulate (vertical and/or horizontal defects)

tent technique

membrane exposed

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osteogenesis autogenous bone Intra-oral particulate (vertical and/or horizontal defects)

The Use of Titanium Mesh in Conjunction with Autogenous Bone Graft and Inorganic Bivine Bone Mineral (Bio-Oss) for Localized Alveolar Ridge Augmentation: A Human Study Proussaefs P. Lozada J. Kleinman A. Roher M. McMilan P. Perio Rest Dent 2003;23,2:185-193

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osteogenesis autogenous bone Intra-oral particulate (vertical and/or horizontal defects)

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osteogenesis autogenous bone Intra-oral particulate (vertical and/or horizontal defects)

ridge reconstruction

osteogenesis autogenous bone Intra-oral particulate (vertical and/or horizontal defects)

ridge reconstruction

osteogenesis autogenous bone Intra-oral particulate (vertical and/or horizontal defects)

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osteogenesis autogenous bone extra-oral particulate (vertical and/or horizontal defects)

tibia

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osteogenesis autogenous bone extra-oral particulate (vertical and/or horizontal defects)

tibia

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osteogenesis autogenous bone extra-oral particulate (vertical and/or horizontal defects)

hip

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conclusions low osteogenetic potential of graft material

the decision is based on: individual’s systemic healing ability (age, systemic illness affected healing) previous surgeries to the area (scar tissue)

moderate osteogenetic potential of host/site

moderate osteogenetic potential of graft material

local osteogenetic potential of the defect (defect size, # of walls and geometry of the defect) stability of the graft material health of the adjacent periosteum soft tissue closure the surgeon’s skill

low osteogenetic potential of host/site

high osteogenetic potential of graft material

time available for graft maturation

thanks for your attention akleinman@llu.edu