Horizontal and vertical bone augmentation (using Urbán’s method)
Following the removal of focally infected, pus-ridden teeth 3 to 6 months’ healing must ensue before implant surgery can take place. By such time it will become apparent whether enough bone has formed and a “plain” implant surgery is in order or bone graft will be necessary, based on the 3 dimensional radiograph or CT (CBCT Cone beam computed tomography) taken. In the present instance neither the width nor the height of the ridge was up to par, which indicated a horizontal and vertical ridge augmentation.
Inadequate bone height is clearly visible in this panoramic radiograph
Panoramic radiograph following horizontal and vertical ridge augmentation and the mounting of implants
Bone graft is essentially guided bone formation and regeneration (GBR, for short) with a view to rendering the jawbone suitable for receiving implants.
Complete edentulism. Mounting the implants on the mandible is only possible by means of bone graft surgery
In the course of bone graft surgery both the patient’s own bone (autogenous bone) and bone graft material is used. Natural bone is derived from the lower jawbone and morselized by a bone grill (Ustomed).
The removal of bone blocks from the lower jawbone
The site of the bone blocks in the lower jawbone. The bone regenerates and heals in 2 to 3 months
A mixture of the patient’s natural bone and bone graft material is used during the intervention.
The maxillary sinus is exposed for Sinus lift surgery
The finished sinus window and the lifting of the maxillary sinus membrane (Schneiderian membrane)
The sinus lift window is filled with the mixture of the patient’s natural bone and bone graft material once the sinus membrane has been lifted. In the first instance, it is always height which is increased. Then only can the widening of bone follow.
The fastening of the membrane with pins
Following the augmentation of the height and width of the bone, the bone grafted area is covered with a non-resorbable membrane, fastened by means of titanium pins (Master Pin Meisinger). These pins and the non-resorbable membrane are removed during the following surgery.
Close-up image of the membrane fastened with pins
All surgical procedures are performed using the PRF technique. The PRF technique is one of the most effective and cutting-edge ways of promoting wound healing, exerting its effect, among others, through white blood cells, growth factors, and cytokines found in the blood.
Since the procedure also involves taking the patient’s own bone, the surgery is not performed solely in the bone-deficient area but also in other areas of the oral cavity (whence the bone is taken). This is stressful for the patient, so in the event of multilateral bone-deficiencies, we recommend that the intervention be performed on one side at a time. Between two interventions a minimum of 1 month’s healing time is recommended for the patient to recover and brace for the next surgery.
All interventions should be preceded by tartar removal, to prevent tartar and bacteria from compromising the success of the surgery.
On completion of the bone graft, 6 months’ healing time is required before the implants can be installed. As a matter of course a CBCT scan is taken again prior to the installation of the implant to examine the healed bone graft and measure bone mass.
Panoramic radiograph of the bone grafted site clearly displaying the pins used for fastening the membrane
Bone grafts greatly extend the treatment window. The time between the removal of teeth and finished restoration may span from 1.5 to 2 years. This is a long time and compliance with the minimum healing times is essential, the shortening of which is ill-advised as it risks the success of the procedure with the patient having to incur money loss and face unnecessary ordeals. Make sure you comply with the treatment specialist’s instructions to enjoy the returns of the costs and energy invested in the shape of an aesthetic and fully operable tooth restoration.
The table below summarises the necessary treatments and their estimated associated healing times:
|
Treatment |
Post-treatment healing time |
|
Tooth extraction |
3 months |
|
Horizontal and vertical bone augmentation |
8 months |
|
Implant surgery |
6 months |
|
Fabrication of permanent tooth restoration |
regular annual check-ups |
CBCT scan in which the width and the height of the bone grafted area is clearly visible
There are factors that need to be thoroughly examined and discussed with the patient prior to an intervention.
Factors compromising the success of the bone graft:
-
Smoking
-
Untreated periodontal disease
-
The presence of focally infected teeth in the mouth
-
Inadequate oral hygiene
-
The use of removable tooth restorations
Factors compromising the success of bone graft must be eliminated prior to the intervention. Often such preparations may take months, and the interventions require the thorough weighing up of the pros and cons, a lot of patience a good deal of resolve.
Bibliography
Gy. Szabó: Oral and maxillofacial surgery, Semmelweis Kiadó, Budapest 2004.
I. Gera: Periodontology. Semmelweis Kiadó, Budapest, 2009
I. Urbán: Vertical and Horizontal Ridge Augmentation: New Perspectives. Quintessence Publishing, 2017.