Previously, we presented the following ridge augmentation with a brief description of the surgical procedure. When a dramatic increase in the alveolar ridge is required, it is difficult to create volume without the incision lines opening. Attached gingiva is a very passive tissue. Attached gingiva is designed to give way for erupting teeth and moving teeth. This feature also makes the tissue very susceptible to sutures pulling through and incision lines opening. Contrary to common belief, there is no periosteum under the attached gingiva.
On the other hand, the periosteum is a very aggressive tissue that will not give way and will aggressively resist sutures pulling through the tissue. For significant ridge augmentation surgery, it does not make sense to expect the keratinized gingiva to resist suture pull which can result in opening of the incision lines and compromising the graft.
Today we will discuss a method that allows us to use the periosteum to predictably maintain surgical wound closure.
Successful 3D Ridge Augmentation with Implant Placement
Pre Op (Buccal)
2-Month Post Op (Buccal)
Pre Op (Crestal)
2-Month Post Op (Crestal)
At two months, the majority of the 3D-printed ridge is resorbed. The remaining printed ridge is fully integrated into bone growing on the crest:
Blue: gingiva
Yellow: membrane
Green: 3D-printed ridge
The membrane is intact with approximately 3mm of gingiva covering the membrane. The coronal portion of the implants are covered with 2 – 3mm of ossifying tissue. Bone growth in the sinus has reached the apex of the distal implant. Timing of the healing abutments will be between 3 and 4 months post-op. In order to make access to the implants easy, the healing abutments will be placed before the tissue over the implants fully mineralizes. The membrane is exposed mesial to the molar, however, it was still firmly attached to the underlying mineralizing tissue and left in place to be removed at the healing abutment appointment. When using SteinerBio graft materials, bone binds to the d-PTFE membrane via an osteoid layer.
Early exposure of the membrane needs to be avoided to protect the graft. The following case reviews the surgical method used to significantly increase alveolar ridge dimensions without early opening of the flap.
This patient experienced an extraction, graft placement, and failed implant. As a result, a minimal ridge remained. The plan is to graft and place the implant in one appointment:
The initial incision is a split thickness into the mucosa with vertical releasing incisions up into the attached gingiva, across the papilla and around the lingual of the incisions.
The second incision is made approximately 4mm apical to the mucosal incision through the periosteum. The initial mucosal incision purposely does not expose the periosteum, but leaves some connective tissue over the periosteum so it can be located and handled with a easily visible flap.
After the periosteum is incised, the tissue coronal to the periosteal incision is reflected and positioned lingual to the incisors.
The apical periosteal flap is dissected allowing for an easily visualized flap.
The cortical bone is perforated and the surgical stent is in place.
Side cutting burs are used to remove a portion of the lingual wall to prevent the implant from being displaced to the buccal. In order to ensure the full body of the implant integrates, BioDensification is applied to the osteotomy prior to placing the implant in order to bridge any gaps between bone and implant.
The graft site is bedded with Socket Graft Injectable.
The 3D-printed ridge is set in place and another layer of Socket Graft Injectable is placed over the 3D-printed ridge.
The d-PTFE membrane is in place.
The periosteum that is joined to the attached gingiva at the mucogingival junction is sutured to the apical periosteal flap.
The mucosa is closed and also sealed with Oral Bond, creating a hermetically sealed site. With this surgical design, all of the tension is on the periosteum and the mucosa is closed, tension-free.
Combining tissue engineering (the 3D printed graft) and regenerative medicine (Socket Graft Injectable) allows the body to replace missing or compromised tissue with healthy tissue of normal form and function.
MEMBER:
American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)