We previously presented Simple Ridge Augmentation to show the predictability of ridge augmentation using science-based regenerative materials. The cases were presented not as a step by step surgical procedure, but merely to illustrate the effectiveness of the procedure. Below are the pre-op and post-op results achieved with the technique using our Ridge Graft Kit.
Simple Ridge Augmentation:Step By Step
As a result of presenting the cases, many clinicians came forward and requested more detailed information on the surgical procedure. The following case outlines the step by step procedure that produces predictable ridge augmentation.
Pre-op
Initial incision.
The incision is made in the buccal mucosa approximately 3mm apical to the mucogingival junction. The incision is through the mucosa and periosteum. The incision crosses the retromolar pad moving forward through the mucosa and periosteum one tooth forward of the most distal tooth. At this point, the incision is carried coronally through the keratinized gingiva then distal across the papilla. From here, a sulcular incision is made around the buccal of the distal tooth wrapping around the lingual and carried on the lingual across the lingual papilla. Depending on the patient, on occasion, a lingual vertical incision is needed at the same position of the buccal vertical incision to gain adequate flap reflection. This photograph shows the opening of the tissue without any dissection of the buccal mucosa.
A buccal full thickness flap is raised.
The gingiva is elevated off the bone and pushed to the lingual. Cortical perforations are performed. The purpose of the cortical perforation when using science based regenerative materials is to gain access to the cancellous bone and the regenerative cells that populate this tissue. The cortical plate must be completely perforated. However in this photo, note that three of the perforations (blue arrows) do not completely perforate the cortical plate, which may compromise the regenerative potential of the surgical procedure.
The reason for placing the incision in the buccal mucosa is to involve the periosteum in maintaining flap closure. The attached keratinized gingiva is a very passive tissue that provides very little resistance to sutures pulling through the tissue, which allows the flap to open. The periosteum is a very aggressive tissue, possibly the most aggressive tissue in the body, and the periosteum will resist suture pull. Irrespective of what periodontists believe, there is no periosteum under the attached gingiva. In order to engage the periosteum in maintaining flap closure, the periosteum under the buccal flap needs to be apposed to the edge of the periosteum attached to the keratinized gingiva. In this photo, the coronal position of the buccal flap periosteum is grasped, and it is obvious that the periosteum will not cover the graft site and reach the opposing flap.
The site is grafted with Ridge Graft Kit, which is composed of 1cc of putty containing our osteogenic compound and 1cc of our OsseoConduct beta tricalcium phosphate granules.
After grafting with Ridge Graft Kit, it appeared that the graft volume might be inadequate. Therefore, 1cc of Socket Graft Plus was placed over the Ridge Graft to provide adequate graft volume.
In this photo, the buccal flap periosteum is grasped preparing it for a releasing incision at the base of the flap.
The periosteum is incised at the base of the flap and the mental nerve is dissected. In this case, the mental nerve exhibited 3 branches (yellow arrow). Incision line is identified by the white arrows.
The membrane is folded over the graft material.
The edge of the released periosteum is sutured to the edge of the periosteum remaining on the edge of the keratinized gingiva. Closure of the periosteum does not need to be perfect. The edges of the periosteum need to be approximated so the tissue recognizes its orientation. In regenerative medicine, it is not enough to just put cells in the area. The cells must be able to recognize the environment they are in so they know what needs to be regenerated. The incised ends of the periosteum will quickly grow together preventing the flap from opening. The edges of the periosteum are closed with resorbable 40 Look sutures.
The mucosa is closed with 40 Vicryl suture.
Oral Bond is applied to the incisions to set the sutures, correct any anatomical distortion of the flaps, and seal the surgical site from the oral cavity.
The predictability of the surgical procedure is a result of the regenerative potential of the graft material. However, equally important is that the material is a modern, science-based, FDA-cleared graft material and as such does not elicit an immune response by the host. By eliminating the host immune response, the material can be expected to perform consistently in each of your patients. By comparison, cadaver material interacts directly with the host’s immune system to produce calcification. Because there is no tissue matching or anti-rejection medication, it is not possible to predict success or failure when using transplanted materials. When evaluating histology of cadaver bone grafts, authors routinely state that little or no inflammation was found. They conclude that the cadaver material does not cause an inflammatory response. This is quite humorous. We all have patients struggling with autoimmune diseases where the patient’s own immune system is attacking itself. Do the authors expect us to believe that someone else’s bone will not elicit an immune response? The reason our profession thinks that cadaver bone does not elicit an immune response in our patients is because they are always looking at fully calcified histology and they have never seen histology of a cadaver graft prior to calcification.
To emphasize this point, histology from the same animal at the same time frame makes this point clear. The following freeze-dried bone allograft histology shows a complete population of the graft site with chronic inflammatory lymphocytes. The histology of our putty mixed with our beta tricalcium phosphate granules shows no inflammatory response. The purpose of the body calcifying cadaver bone graft is to isolate it from the immune system and when this occurs the inflammation is reduced. Because no effort is made to predict how the host will respond to the cadaver tissue, there is no way to predict the outcome of the surgery when using those materials.
The predictability of ridge augmentation will continue to improve as we develop a more complete understanding of the regenerative process in conjunction with continued improvements in science-based bone graft materials.
MEMBER:
American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)