Bone grafting. Cost of bone tissue augmentation

The essence of bone tissue augmentation is to restore bone at the site of atrophy. When implanting teeth, there is often a need for a similar procedure: in the absence of a tooth, the bone does not receive normal load, gradually dies and after some time becomes so thin that there is literally nowhere to put the pin. To make implantation possible, the bone tissue must be restored. Bone augmentation during dental implantation

Why does bone die?

There are five main causes of bone atrophy:

no load on the bone after tooth extraction. The tooth root creates a load on the jaw bone, keeping it “toned.” To greatly simplify the situation, we can say that after the loss of a tooth root, the bone has nothing to hold, and the need to maintain a certain volume of tissue simply disappears;
infectious diseases. Osteitis (inflammation of the bone) and periostitis (inflammation of the periosteum) often cause tissue atrophy;
age-related changes;
jaw injuries;
low-quality dentures. Bone atrophy is often caused by improper load distribution on prostheses, especially removable ones.

Edentia(lack of teeth) is always accompanied by a decrease in bone tissue, which, in turn, leads to a displacement of existing teeth towards the resulting void and malocclusion.

Bone atrophy is a serious problem, fraught with extremely unpleasant consequences, such as:

violation of chewing function;
changes in the shape of the face (for example, the characteristic contour of the lower jaw and “sunken” lips in people with complete edentia in one or both jaws);
difficult articulation.

Fortunately, today doctors have many ways to restore lost bone tissue.

Methods of bone augmentation for dental implantation

Bone grafting is primarily for successful tooth implantation. For reliable fixation of the pin, at least 1 mm of bone tissue is required. Installing an implant into an insufficiently thick and dense bone layer threatens to further accelerate the process of tissue atrophy. Restoration procedures are also indicated for jaw injuries and loss of large amounts of bone tissue as a result of inflammation.

Currently, there are several technologies for restoring lost tissue - so-called osteoplasty:

bone block transplantation;
guided bone regeneration;
sinus lift.

Each method has its own pros and cons, features and contraindications.

Bone block transplantation

This method was the very first to be developed. Its essence is to transplant a piece of bone into the area of atrophy; Previously, animal bones or donor tissues were used for this purpose, but due to the low survival rate, the use of foreign biological material has now been abandoned.

Today for transplantation is taken patient's own bone material(usually directly from the jaw; in rare cases - from the thigh); This technique ensures easy and almost one hundred percent engraftment. This process is called autotransplantation.

Bone block transplantation

Recently, artificial bone substitutes – alloplasts – have been increasingly used during transplantation. They take root almost without problems, are reliable, and their use does not cause complications.

The operation is carried out according to the following scheme:

First, the gums on the “donor” jaw are cut and lifted, from where a piece of bone is removed;
the future transplant is given the desired shape;
through a hole in the jaw, the graft is placed in the area of the lost bone and attached with special biocompatible screws;
the gaps are filled with bone chips, the transplant area itself is covered with a special membrane, after which the gum is sutured.

The advantages of such an operation are reliability and predictability of the result– the layer of bone tissue is quite thick, the survival rate of autotransplantation is very high, and there is practically no risk of rejection.

Among the shortcomings - The transplanted material takes a long time to take root, on average from 6 to 8 months; the possibility of simultaneous installation of an implant is excluded, as this increases the risk of rejection of both the implant itself and the bone block; if there is insufficient integration of the transplanted block with the bone tissue, the side may be torn off from the jaw - the risk of such a complication is small, but still exists.

Contraindications to bone block transplantation

acute infectious diseases;
blood diseases;
oncological diseases;
diabetes;
period of pregnancy and lactation.

Guided bone regeneration

The method of guided bone regeneration is used in situations where very little time has passed after tooth extraction. It consists of covering the socket of the extracted tooth with a special protective membrane made of biocompatible material.

The point of this procedure is to protect the tooth socket from the growth of soft gum tissue into it, which grows very quickly and penetrates the bone tissue, preventing it from recovering. Under the protection of the membrane, the bone regenerates naturally. Often to speed up the process additional bone tissue is implanted into the socket or allograft.

Guided bone regeneration

The advantages of this operation are: low morbidity and low stress on the body. Unfortunately, it has many more disadvantages:

high risk of membrane rejection;
risk of rejection of the transplanted bone tissue;
low effectiveness of the procedure due to the structural features of the extended tissue. The fact is that such tissue does not have its own cortical plate and is much worse supplied with blood than “natural” bone, which is why it tends to partially decrease. Restoring your own atrophied tissue in this way is not always meaningful; in addition, the extension will have to be carried out “with a reserve”.

Contraindications to the operation are exactly the same as for bone block transplantation - acute infections, blood diseases, cancer, immunodeficiency conditions, diabetes.

Sinus lift

Sinus lifting is a low-traumatic technology for bone tissue restoration. However, it can only be used on the upper jaw, since it involves manipulation of the maxillary sinuses.

With atrophy of the bone tissue of the upper jaw, the space of the nasal sinuses (sinuses) expands due to the decreasing bone. The essence of the sinus lift method is raising the wall of the nasal sinus and the growth of new bone tissue underneath.

The sinus lift operation can be open, in which a hole is made in the wall of the maxillary sinus, or closed, in which the bone bed itself is prepared. Closed surgery is performed more often, is less traumatic and carries a lower risk of complications. An open sinus lift is performed in extremely rare cases.

In both cases, the technology itself is almost the same. The main stages of the operation are as follows:

the bone tissue is perforated and the membrane covering the sinuses from the inside is carefully peeled off with a special tool;
the space between the membrane and the bone expands and osteoplastic material is introduced into it;
The bone window is closed, and during a closed-type operation the mucous membrane is sutured.

After insertion under the membrane, the osteoplastic material must integrate into the bone tissue. If the integration proceeded without problems, a pin is installed in the resulting bone layer.

Sinus lift

The advantages of this operation are: low morbidity(with closed sinus lift), reliable engraftment of osteoplastics, low risks of rejection, high quality of the grafted tissue.

The main disadvantages are inability to grow a layer of tissue more than 2 mm. Also, this method is not suitable for restoring a large volume of bone - if two or more teeth are missing (and the corresponding degree of atrophy), sinus lifting is useless.

Contraindications to sinus lifting are the same as for other bone restoration operations, however, there are several specific ones - chronic diseases of the nasopharynx, curvatures and abnormalities of the nasal septum, polyps in the maxillary sinus and frequent runny nose. Smoking habit can also become a serious limitation to the procedure.

Transplant materials

As you can see, all three techniques use grafts that replace bone tissue - filling voids, as in a bone graft or sinus lift, or stimulating the growth of your own bone, as in augmentation. There are five types of grafts used in dentistry:

autogenous - represent bone material taken from the patient himself;
allogeneic – donor material that has undergone pre-treatment;
xenogeneic - based on animal material (namely bovine bones);
combined - a combination of autogenous and xenogenous materials in a 1:1 ratio; an effective and safe way to quickly build bone;
alloplasty – artificial bone substitutes.

The most effective is the use of pure autograft and a combination of auto- and xenografts. These materials show the best results in terms of speed and quality of engraftment.

Conclusion

Bone atrophy is an unpleasant and unsafe consequence of tooth extraction, fraught with serious complications. It is better to prevent it immediately by installing implants. However, this possibility is not always available. Fortunately, even if bone resorption has already begun, there are technologies for reliable restoration of lost tissue.

The need to build up bone tissue during implantation results in the failure of this method of tooth restoration for many patients. Why this happens is not difficult to guess, because osteoplastic surgery is almost always associated with additional expenses, quite complex rehabilitation, possible risks and loss of precious time, and the inability to get the smile of your dreams right away. In addition, sometimes doctors also give a “stop” - if there are not a large number of teeth, they simply refuse implantation due to the fact that bone grafting along the entire row is too difficult and expensive. This is how patients return to removable dentures.

Fortunately, today there are implantation methods that make it possible to do without bone tissue augmentation or are carried out in conjunction with this procedure. It is with them that professional dentists see the future, and patients choose such methods of dental restoration with increasing confidence. But there are still a number of questions that a person far from medicine would like answers to. We will help you understand all the nuances of this topic in detail.

Why does the jaw bone atrophy?

As you know, the anatomical features of the structure of the maxillofacial apparatus suggest that each of us has two jaws - upper and lower. On each of them, 14 (or 16 with “eights”) teeth erupt in the permanent dentition. Ideally, a person manages to avoid their loss for the rest of his life, but in most cases, many still have to face the loss of one or more elements of the dentition. Moreover, there is an alarming trend - already people 30-40 years old are faced with partial, multiple and even complete adentia, not to mention those patients whose age is over 60 years.

Interesting! The WHO European Office emphasizes that it strives to minimize the situation regarding edentulism throughout the world. The plans are to increase the level of dental health by 2020 so that the number of toothless people on the planet does not exceed 1%, and about 90% of people have full (natural or restored with prosthetic structures) dentition.

So, with the loss of at least one unit of the dentition, the bone tissue located in this area ceases to be involved and loaded with teeth that “work” and take part in biting, gnawing, and grinding food. It remains “not our destiny” and gradually begins to atrophy and thin out. The same thing happens in cases where a person wears removable dentures or fixed bridge structures for a long time. Moreover, even with teeth, atrophy of the tissues surrounding them can occur - this situation occurs with periodontal inflammation, periodontitis and periodontal disease.

When you can’t do without bone tissue augmentation

It's simple: the longer you don't solve the problem after tooth extraction, the more likely it is that you will have to go through a bone augmentation procedure for implantation in the future. But here it is not only the time factor that matters, but also the method of treatment and restoration of teeth that was shown to you.

For example, the classic protocol for implantation in almost all cases, without exception, places very high demands on the quality of bone tissue, and if it is not enough, then you will have to resort to surgery, then recover for up to six months before the doctor implants the implants directly. You will also have to wait if you have been advised to have a tooth removed - an implant cannot be implanted in its place until the hole has healed.

Important! Externally, the changes that occur to bone tissue are invisible to humans and do not directly cause problems. But until recently, when deciding to finally restore teeth through implantation, many encountered difficulties: the classic two-stage approach could not be carried out until the bone did not have the required volume and height for reliable fixation of implants in it. If there was a lack of bone tissue with this approach, they would simply fall out, become loose at best. In the worst case, when installing them, the doctor could injure the nasal sinuses on the upper jaw or touch the ternary nerve on the lower jaw. After all, there are few bones and these anatomically important elements are now very close.

That is why, when turning to the standard, classical method of implantation, patients have no other choice but to first turn to dental bone augmentation procedures for implantation. This saves the situation and eliminates some problems, for example, wearing removable dentures in the future. But the path to a beautiful and perfect smile is quite thorny: you have to wait a long time and pay a lot. In this case, the patient does not receive a permanent fixed prosthesis at all - 8 or even more months after the initial visit to the doctor. Also, despite the fact that this protocol can restore any number of teeth, it is still more rational to use it if there are 1-2 defects due to the financial component.

What to do for those who do not want to wait or have more serious problems (inflammatory process, chronic diseases), a history of multiple adentia, or no teeth at all in the mouth? Today, such patients have the opportunity to get results in a matter of days and hours thanks to fundamentally different innovative implantation methods, but we will discuss them a little later.

Bone grafting: what's the catch?

Bone augmentation before implantation becomes a stumbling block for many patients, because most of them do not want to deal with several inconvenient moments:

time and money: the procedures will need to be paid separately from the implantation itself. With the classical approach, a prerequisite for further implantation of implants is a rehabilitation period - a period of 3 to 6 months, allotted for the healing of bone structures after the intervention and for recovery,

possible complications: most often complications frighten patients who need to restore teeth in the upper jaw. The fact is that the maxillary sinuses are located here in close proximity, which can be injured during the sinus lift, which will lead to the appearance of a chronic inflammatory process in this area, the occurrence of sinusitis or even meningitis.

However, if the doctor is competent, then the procedure is quite simple for him - the patient can only trust and strictly follow all the recommendations.

Factors that made implantation possible without jawbone augmentation

It is worth noting that the active development of advanced technologies, 3D modeling, the creation of surgical templates, and computed tomography have brought enormous benefits to the development of implantology in general. Thanks to them, today doctors can offer their patients methods of one-stage dental implantation with immediate installation of a prosthesis, which in most cases make it possible to do without bone tissue augmentation altogether.

This unpleasant procedure can be avoided even when the patient has a pronounced degree of atrophy of bone structures, inflammatory processes and other circumstances in the anamnesis that can complicate treatment and achievement of the most positive result: smoking, old age, osteoporosis, HIV, chemotherapy in the past.

On a note! Implantation with immediate loading of the prosthesis and without bone augmentation is possible even when you have just had a tooth removed. The procedure is carried out simultaneously: an artificial root is immediately installed in the hole of the extracted tooth or next to it, and you go home with a prosthesis.

It is worth noting that in general, immediate loading methods are most successfully practiced when patients need to restore a large number of teeth or solve the problem of complete edentia. The most important thing is that with these implantation methods, people actually get new teeth, literally without interrupting work and socializing. The entire treatment process takes from 3 to 7 days. Now let's find out why with one-stage protocols there is no need for bone grafting.

1. Use of certain implant models

Experienced implantologists emphasize that not every implant is suitable for use in one-stage dental restoration protocols. Only certain models that have strictly verified characteristics are specifically suitable for these purposes:

rapid survival in bone tissue: for this, different manufacturers use special coatings. For example, the famous ones have TiUnite, they have a hydrophilic surface that promotes the rapid production of protective cells in bone tissue and its growth,
active thread type for strong bone adhesion to the implant,
the ability to be installed at an angle: this is necessary precisely so that during implantation you do not have to resort to bone augmentation and do not touch the areas of the maxillary sinuses and nerves. The dental implant in the lateral sections is fixed in such a way as to maximize the use of bone structures that are not subject to inflammation and atrophy. Due to the increase in the contact area, it is held tightly in the bone, does not fall out or become loose,
the ability to solve the most difficult cases: a striking example of this is the artificial roots of the brand, which are used for periodontitis and periodontal disease. They are coated with antibacterial coating and also have one design feature - they are one-piece, their body is immersed in the socket of the extracted tooth, and the smooth neck is in contact with the mucous membrane. Thanks to these properties, a patient with inflamed gums does not have to worry about rejection of structures or irritation of the inflamed mucosa, or the accumulation of plaque on the neck of the implant.

2. Careful treatment planning in advance

If the doctor tells you that he is ready to carry out the procedure, bypassing the stages of preparation for dental implantation, then you should think about changing the specialist. You may have fallen into the hands of a non-professional, because an experienced specialist who has the necessary knowledge about the anatomy of the maxillofacial system and knows the techniques of one-stage protocols will never allow this to happen. Whether the procedure is carried out together with bone tissue augmentation or without it, the doctor must necessarily require a computed tomography scan of the jaw (or it will be done directly in dentistry) and a general blood test. Also, if you have chronic diseases, the maxillofacial surgeon or implantologist has no right to begin treatment without the recommendations of highly specialized specialists and their conclusions about your health status.

The doctor needs this data to work out the treatment process on computer equipment, using 3D technologies, to select the optimal implant models for you, to determine the location of their installation, to create surgical templates that allow you to reduce all possible risks from the procedure to a minimum.

3. Fastening the prosthesis immediately

This is a prerequisite for implementing one-stage implantation methods. The doctor can carry out immediate loading with the prosthesis within a period of 4-6 hours to 3-5 days after the installation of artificial roots. It all depends on individual indicators. The prosthesis acts as a guarantee against the implants becoming loose or falling out; it unites the entire system into a single whole.

And one more thing: no matter how long the prosthesis is installed, there is one important condition - this is the need to begin the process of chewing food with new teeth without delaying a single day. There is no need to be afraid, since the design contains a metal base that will not allow the implants to move even under loads. In addition, this way you will help launch metabolic processes in bone tissue, provide it with work and nutrition, due to which the engraftment process will take place quickly and almost unnoticeably.

Implantation options that can be performed without bone grafting

As mentioned above, one-stage protocols are a chance to get new teeth quickly, economically, without bone grafting. In some cases, bone tissue augmentation can be directly carried out during dental implantation, i.e. together with it, this does not change the result when choosing one of the one-stage treatment methods:

or a solution with three implants: this solution was developed by Nobel specifically for patients who are missing teeth in the lower jaw. And the secret of success is simple - these are three two-part Trefoil implants (read as “Trefoil”), installed in the frontal part of the mandibular bone, and a template beam made on high-precision Procera equipment, taking into account the anatomy of the lower jaw and reducing the time for acquiring new teeth,

solving the problem with four implants: there are several options. The first one is higher than the previous technology, but also has more indications for treatment. The protocol was also developed by Nobel using artificial roots of this brand. The second is from Straumann using the Roxolid model. Also in clinics you may be offered other models that are more budget-friendly and less tested by clinical studies, for example, the Korean Osstem, for performing this protocol.
solving the problem with six implants: this is a solution for patients in whom moderate bone resorption was identified at the preparatory stage. allows you to avoid osteoplastic surgery, because six artificial roots in some cases are the optimal number of supports for reliable support of the prosthesis and proper distribution of the chewing load,
solving the problem with the maximum number of supports: the minimum with this approach is 8, and sometimes even 12-14 artificial roots, which an experienced specialist will offer to implant in the patient according to the protocol if he diagnoses severe bone atrophy or an inflammatory process in it. Also, the basal complex will be a real salvation and help for those who have contraindications to all of the above treatment methods or complicating factors,
solving the problem with the help of long ones: let’s immediately say that the method is only suitable for patients with missing teeth. But among its obvious advantages, one can note the indications for use: very severe bone atrophy. The advantage is that such long models (Nobel - Zygoma, Biomed, Noris Medical have them) are fixed not in the jaw, but directly in the vault of the skull and cheekbone. This in itself serves as a guarantor of high primary stability, plus the patient also receives the prosthesis immediately.

Implantation without bone grafting: advantages and disadvantages

The most important advantages: wide range of choices and a real chance to find a technique that suits your situation. This also means financial freedom – the price of the complexes can vary depending on the chosen implant model, of which there are a huge number. So there is plenty to choose from.

Integrated approaches, in principle, are cheaper than classical ones, since they allow you to save on bone grafting and gingival contour plastic procedures (the prosthesis in this case is already equipped with a beautiful gingival edge that covers the imperfections of your mucous membrane). Another advantage is that this approach allows you to calculate all expenses in advance, because clinics that value their reputation offer a turnkey solution to the problem.

Well, the most important advantage is the opportunity to do without waiting and start eating and smiling right away. Here the patient does not need to find free minutes; he avoids unpleasant moments associated with communications. Agree that if the treatment takes only a week, then there is no need to negotiate with colleagues about a replacement at work or ask your boss for a long vacation, constantly asking for time off. You will need to visit the doctor no more than 2-3 times.

As for the shortcomings, there are some here too. Firstly, there is a lack of a large number of specialists in Russia who are truly trained in all the intricacies of working on protocols for immediate loading and implantation without prior bone tissue augmentation. Therefore, the patient, alas, always remains at risk of running into an unprofessional. You need to be very careful when choosing a specialist.

Secondly, this method of treatment requires a high level of self-control and discipline, diligence and from the patient himself. When deciding to restore your teeth in this way, you need to clearly understand that if you do not follow all the doctor’s instructions, violate the rules of the rehabilitation period and are negligent in following the instructions, then you will only have yourself to blame.

Video patient review of the operation

1 Iordanishvili A.K., Gaivoronskaya M.G., Soldatova L.N., Serikov A.A., Podberezkina L.A., Ponomarev A.A. Occlusal-related diseases of the masticatory apparatus. Kursk scientific and practical bulletin “Man and his health”, 2013

From this article you will learn:

how is bone grafting performed in dentistry,
bone grafting methods – price 2019,
Jaw bone augmentation for a dental implant: reviews,

After tooth extraction, bone tissue undergoes gradual atrophy, which leads to a decrease in the width and height of the bone at the site of missing teeth. Bone grafting during dental implantation (synonyms - bone augmentation, bone augmentation) - allows you to increase the volume of bone tissue at the site of implant installation.

Bone tissue augmentation during dental implantation, reviews from implantologists indicate that it is necessary not only for the normal functioning of the implant (from the point of view of bearing the chewing load), but also for aesthetic reasons. The fact is that too thin bone walls around the implant are always subject to resorption, and as a consequence of this, gum recession occurs and the implant neck is exposed.

Optimal bone thickness around the implant –

The most important points (according to Fig. 1) –

1) Firstly– the thickness of the vestibular bone wall (i.e., the one located on the side of the lip/cheek) should be at least 2.0 mm, and 2.5 mm is very good. If the front surface of the implant is covered with bone less than 2 mm thick, this means 100% bone resorption around the implant neck, accompanied by lowering of the gum level and exposure of the implant neck. In this case, the implant will still bear a functional load, however, if it stands in the smile zone, the contour of the gums around the implant will become aesthetically unacceptable over time.

2) Secondly– the thickness of the bone wall between the implant and the root of the adjacent tooth should ideally be 3 mm, but 2.5 mm is tolerable. If this distance is less (for example, 1.5-2.0 mm), then the following problem arises. Even under normal conditions, slight bone resorption is always observed around the neck of the implant. If the bone partition between the implant and the tooth root is too small, then bone resorption will also occur at the surface of the root adjacent to the implant. This means lowering of the gingival level and absence of the interdental gingival papilla (i.e. poor esthetics).

3) Third– the thickness of the bone wall between two adjacent implants should ideally be 3.0 mm. If it is less, then, as in the previous case, this means significant resorption of the bone septum between the implants, and as a consequence of this process - receding gums in this area, absence of the gingival papilla, exposure of the implant (i.e. poor aesthetics).

Causes of bone deficiency:

1) The main reason for the decrease in bone tissue volume is the natural resorption (resorption) of bone in the area of extracted teeth. This happens because the bone loses support in view of the tooth root, and also because chewing pressure ceases to be exerted on the bone tissue. As a consequence, there is a decrease in bone volume, which can occur both in height and in width of the alveolar process of the jaw.

2) The second reason is traumatic injuries caused by dental surgeons. Usually, during removal, the surgeon does not think at all about the safety of the bone walls of the alveoli around the tooth, biting them off with forceps. If you are planning extraction followed by tooth implantation, then it is best to carry out such removal by an implant surgeon, who will try to preserve the bone tissue as much as possible.

There are 3 types of bone resorption –

horizontal resorption (Fig. 2), when the width of the alveolar process decreases,
vertical resorption (Fig. 3), i.e. when there is a decrease in the height of the alveolar process,
+ combined form.

According to the type of resorption in a particular patient, a bone grafting technique is selected, aimed at increasing the width and/or height of the alveolar process of the jaw.

Bone grafting for dental implantation: reviews

There are many different bone grafting techniques, but they can be divided into 2 large groups. Firstly, horizontal bone augmentation techniques aimed at expanding the narrow alveolar process. Secondly, vertical bone augmentation techniques aimed at increasing the height of the alveolar crest.

Most commonly used techniques –

splitting of the alveolar process,
bone block transplantation,
technique of guided bone regeneration (GBR),
sinus lift method (used for insufficient bone height in the lateral parts of the upper jaw).

All these operations are performed under local anesthesia; if necessary (at the patient’s fear), intravenous sedation can be performed. The duration of the operation can be from 1 to 2 hours, which will depend on the technique used, the volume and complexity of the operation. The stitches are removed on the 10th day.

Important : all methods have their pros and cons... Histological studies have shown that after bone augmentation using different methods, a completely different structure of the newly formed bone tissue is observed, which can lead to subsequent resorption of the new bone. In addition, a lot depends on the nature of the bone material being implanted.

1. Splitting of the alveolar process –

Used in horizontal bone resorption to increase the thickness of the alveolar process. Can be performed on both the lower and upper jaws. It must be said that this is the most effective method of expanding the alveolar process today, which also has a low cost (it does not require expensive bone materials and membranes). There are several varieties of such splitting, but we will especially focus on the “Split-Control” technique, which allows for simultaneous expansion and installation of implants.

Contents of the Split-Control technique(Fig.5-10) –
after detachment of the mucoperiosteal flaps (gum), a cut is made in the center of the alveolar ridge with a milling cutter or other special instruments to the height of the future implant (Fig. 6). Next, a pilot drill is used to mark a hole for the implant(s) and spreaders are screwed into the prepared holes (Fig. 7). By using different sizes of spreaders from smaller to larger, you can increase the width of the ridge and immediately install the implant.

There is always a gap left on the sides of the implant, which is filled with bone material, which, if necessary, can be applied in excess to the outside of the alveolar process, covering it all with a special resorbable membrane (Fig. 9). After which the wound is sutured, and we wait for osseointegration of the implant within 3-4 months.

Bone grafting of the lower jaw (splitting method) –

Advantages of the technique –

Firstly– thanks to the splitting of the ridge, we get a bone defect that has bone walls on all sides (except on top). Thanks to this, rapid and high-quality osteogenesis (new bone formation) occurs, because the spongy bone deep in the alveolar process is rich in blood vessels, osteoblasts, mesenchymal cells, growth factors...
Speaking of why it is much worse to increase the width of the bone not through splitting (from within the alveolar process), but to do this through external attachment of bone blocks or bone chips outside the cortical plastic surgery of the alveolar process. The fact is that the outer cortical layer of bone is very dense and there are practically no blood vessels in it. Accordingly, the implanted bone material will take a very long time to grow blood vessels, bone formation will be slower, and there will be a greater risk of failure and complications of such bone grafting.

Secondly– there is no need for expensive bone materials and membranes, again due to the fact that this is a three-wall defect inside the alveolar process, and not outside it. There are enough inexpensive materials here, for example, the bone material "Osteodent-K" and the membrane "Osteodent-Barrier"..

Third– installation of implants with this technique is in most cases possible immediately. If the implants are installed later, then only 3-4 months will have to pass between operations, which is significantly less compared to other bone grafting methods.

Splitting of the alveolar process: animation and video of the operation

Important : There are several types of splitting techniques. With “Split-Control”, the cutter makes only a cut along the crest of the alveolar process + a pair of vertical cuts to the thickness of the cortical plate. But there is a variation of this method, where an additional horizontal cut is made at the level of the tops of future implants, which leads to complete detachment of the bone block (vestibular cortical plate).

Then this block is fixed with screws, which often break it. With this modification of the technique, implants are not installed immediately, but after 3-4 months. In addition, it is quite traumatic and there is a greater risk of complications. This type of technique should only be used for the thinnest alveolar process (2 mm), but some doctors use it even in cases where this is not necessary.

2. Bone block transplantation –

This method can be used both to increase the width of the alveolar process and its height. This technique predominantly uses an autogenous bone block (this means that the bone block is taken from the patient himself in other areas of the jaws). The block can be collected in the area of the tubercle or zygomatic-alveolar ridge of the upper jaw, or in the area of the ramus or mental area of the lower jaw. Bone blocks of allogeneic origin (from another person), as well as xenogeneic origin (bovine bone), are less commonly used, which is associated with their much lower efficiency.

Example of a bone block transplant operation –
In photos 11-16 you can see an example of how bone grafting of the upper jaw (in the area of the central incisor) is performed using two bone blocks. Please note that 2 blocks were used because in this case it was necessary to increase both the width and height of the alveolar process in the area of the extracted tooth.

Bone blocks are first screwed to the bone using special titanium micro-screws (Fig. 12). The block can be additionally covered with bone shavings, after which the blocks and surrounding bone tissue are necessarily covered with a collagen membrane (exactly the same as those used for the guided bone regeneration technique). The membrane is fixed to the bone using special metal pins (Fig. 14), and after this the mucous membrane over the operation site is sutured tightly.

Bone block transplantation: animation and video of the operation

Pros of this method –
This is an excellent method for increasing bone volume with predictable results. The gold standard when using this method is the use of an allograft (a bone block taken from the patient himself). Moreover, it is very important that the graft being transplanted is “cortical-spongy”, i.e. had not only a cortical plate, but also cancellous bone tissue. In this case, you can get a predictable and positive result from a bone block transplant.

Disadvantages of this method –

Additional surgery is required to remove the bone block.

Secondly, with this technique, the possibility of simultaneous installation of implants is most often excluded, because this greatly increases the risk of rejection of both the implant and the bone block itself.

Thirdly, such bone blocks require longer engraftment, i.e. After such an operation, it will be necessary to wait about 6-8 months before installing implants at all. This is because the bone block is screwed to the outside of the jaw. The superficial cortical layer of the jaw bone has very few vessels, and therefore the growth of vessels into the transplanted bone block occurs very slowly.

Fourthly - again due to the slow growth of the bone block by blood vessels (during the subsequent installation of the implant at the second stage) - sometimes the bone block can be separated from the jaw due to its insufficient integration with the bone tissue of the jaw.

3. Guided tissue regeneration (GTR) –

This method can also be used to increase both the width of the alveolar process and its height. In addition, if the lack of bone tissue volume is not critical, then simultaneous installation of implants is possible along with bone grafting. However, the method also has its drawbacks, which we will discuss below.

Directed tissue regeneration (synonymous with directed bone regeneration) involves the use of two components: firstly, implanted bone material, and secondly, a special barrier membrane, the use of which will isolate the bone defect from the effects of adverse factors.

Guided bone regeneration: examples of operations

1) Clinical case No. 1 –
Photo 17 (in the area of planned implantation) shows a significant bone defect, which will be filled using a bioresorbable membrane and Bio-Oss bone material. In photos 21-22, taken 5 months after inert grafting, you can see the installation of the implant in this area...

2) Clinical case No. 2 –
using guided bone regeneration techniques simultaneously with the installation of implants. The materials used were the inert material “Bio-Oss” and the resorbable membrane “Bio-Gaid”...

Importance of Barrier Membrane –
the barrier membrane performs the following functions: it allows you to give the desired shape and volume to the area of bone tissue being built up, protects the grafted bone from being absorbed by osteoclast cells (located in the periosteum), prevents the mechanical impact of the soft tissue of the gums on the grafted bone material and its deformation...

There are different types of membranes, resorbable (Bio-Gaid), non-resorbable (Gore-tex or titanium mesh membranes). The former dissolve on their own over time and do not need to be removed, but they hold their shape much worse compared to mesh titanium membranes or membranes with titanium reinforcement. All these membranes are expensive, but the use of cheap membranes (such as Osteoplast) is not suitable for this technique.

Selection of bone material –
There are many different materials: based on synthetic hydroxyapatite, biopolymers, tricalcium phosphate, bioglass, based on bovine bone, etc. Below we will focus on the most effective types of bone materials (in descending order of their effectiveness).

Use of bone autograft –
Autograft should be understood as bone material that is taken from the patient himself in other parts of the jaws (for example, in the form of bone chips or a bone block). There is only one downside - the need for an additional small intervention to collect bone material.

Combination of autograft + xenograft –
in a 1:1 ratio, bone shavings (taken from the patient) are mixed with material of xenogeneic origin, i.e. based on bovine bone. An example of this is such high-quality and effective material as “Bio-Oss”. This is a very effective combination for increasing bone volume.

Allograft use –
This type of bone material is also very effective, but is used much less frequently. The fact is that the source of bone material in this case is cadaveric material (of other people). These materials are purchased from a special tissue bank; all materials undergo careful processing and are completely safe, but for psychological reasons they are used less frequently.

Use of pure xenograft –
“Bio-Oss” material (based on bovine bone) can be used without mixing it with the patient’s own bone chips, but then the efficiency of bone augmentation will be lower.

Guided bone regeneration with simultaneous implantation: video of the operation

Video 1 – using Bio-gaid resorbable membrane,
video 2 - using a mesh titanium membrane.

Important : It should be noted that this method is not always quite effective. The fact is that the bone material is “planted” outside the cortical plate of the jaw (a very dense surface layer of bone). The newly formed bone differs in structure from the native jaw bone, does not have its own cortical plate on the outside and therefore has a tendency to subsequent partial resorption.

Therefore, it is necessary to carry out bone augmentation using this method “with a reserve” for the planned degree of future resorption, which will be more pronounced the thinner the gum biotype (gingival thickness). This is due to the fact that the surface layers of the bone will receive less oxygen and nutrients due to their less blood supply.

Bone tissue augmentation during dental implantation: price 2019

How much does it cost to build up the jaw bone for a dental implant in 2019? Augmentation of bone tissue for implantation - the cost will differ from the type of technique and the volume of the operation (in the area of how many teeth it is performed), as well as from the type and volume of bone material and membrane used.

Quite often, dentists and their patients have to deal with bone tissue buildup during dental implantation. We will provide the price, reviews and a detailed description of the procedure below.

This happens in cases where a person has spent too much time thinking about whether to install implants. During the absence of dental units, hard tissue atrophies too quickly, which leads to the need for bone grafting.

About the patient's lack of bone tissue

As soon as a tooth falls out or is removed, a natural and irreversible process begins - tissue atrophy. Doctors say that already within a year of the absence of a dental unit, resorption reaches its maximum.

If the patient needs to have an implant implanted to restore the integrity of the row, then the lack of natural bone will become a significant obstacle. It is believed that for high-quality implantation you need at least 10 mm of solid base.

And when it is not enough, you have to use the procedure of bone tissue grafting. In this case, a special operation is performed in which the bone is built up to the required volume. This procedure significantly increases the restoration time of the dentition, but provides high-quality and long-lasting results.

A very important point is that in order to avoid any unpleasant complications, you should choose a good clinic, an experienced doctor and adhere to absolutely all the rules of preparation for the operation.

Why is the procedure necessary?

In the absence of bone tissue, it is necessary to build it up. And this applies not only to cases of subsequent implantation, but is also done to solve other problems:

For sufficiently reliable fastening of the implant if the bone is shorter than the artificial rod.
To prevent tooth displacement, loosening, loss and other dental pathologies.
Prevent distortion of facial expressions and articulation.
Restore chewing function, which inevitably occurs with atrophy.
Prevent facial contours from becoming distorted due to jaw reduction.

Doctors highlight the following advantages of the process when adding artificial bone material or growing it in another way:

Complete restoration of all jaw functions, even if the atrophy has reached a large extent.
Makes high-quality implantation available, in which the rods will stay in place for a long time and reliably.
The attractive appearance of the gums returns, and after prosthetics, the entire dentition.
Following the rehabilitation period, all the inconveniences that accompanied tooth loss and bone atrophy completely disappear.

True, there are also some disadvantages of the procedure, such as the long recovery stage, the operation process itself, and partial restrictions on this time. Building and increasing bone tissue is a complex, long-term and always joint work of the patient and the doctor. Only with coordinated actions can all the positive effects and expected results be achieved.

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Options for bone tissue augmentation during dental implantation

Depending on the condition of the bone, the health of the patient, the expected result and the practical skills of the doctor, various procedures can be performed:

Guided tissue regeneration, otherwise GTR. During the scientific and technological process, the doctor implants a special membrane. It is made of biocompatible material and promotes natural tissue growth. Such a membrane may or may not be absorbable. After its installation, the surface of the wound is sutured and a certain period is waited until the bone grows to the desired size.
Bone block grafting. When grafting a bone block, a piece of the patient’s own bone is most often used. It is usually taken from the chin. This results in two wounds, which is considered a disadvantage of the procedure. But such a transplant takes root better and does not cause rejection. This bone is screwed with special screws into the desired place, compacted with shavings or granules and sutured with a membrane. It is this that will prevent them from being washed out and will contribute to rapid regeneration. Another disadvantage of bone block implantation is the length of time and the procedure being performed several times. After all, initially they make two injuries, and then they perform an additional operation to remove the membrane and implant a pin.

Whichever bone grafting option is chosen, the operation goes through certain stages for which the patient must be mentally prepared:

Mandatory health examination, determination of the degree of atrophy using x-rays. Taking blood tests with advanced interpretation. After all, the operation should be performed only in the absence of any contraindications.
Anesthesia. Most often, local anesthesia is chosen, but in rare cases of increased sensitivity or impressionability of the patient, the doctor may choose light general anesthesia.
A periosteal flap is incised to expose the remainder of the natural bone. In this case, the doctor can additionally diagnose the condition and extent of atrophy. Accordingly, the required material for extension and its adequate quantity are selected.
Next comes the procedure itself, which will differ depending on the chosen plastic surgery method.
After all the manipulations, the doctor is obliged to suture the bone with the installed components and secure the wound. Absorbable sutures are most often used for this procedure, so removing sutures will be unnecessary.

After the operation, the dentist will definitely advise you on what can be done and what should not be allowed. It is very important to follow these recommendations to avoid any consequences.

If the operation is successful, the rehabilitation period will last up to a month. During the first week, you also need to take painkillers and anti-inflammatory drugs.

Sinus lift

This is the most popular procedure, which is carried out in two ways - open and closed. The doctor decides which one is better to choose based on the diagnosis of the condition of the bone tissue.

In this case, mechanical lifting of the maxillary sinus is performed so that the necessary tissue can be built up underneath it. But this method is used only if you need to increase it by 1-2 mm, no more. Also, a limitation for a closed operation is the absence of no more than two teeth in a row.

Otherwise, either an open procedure is performed, or a completely different method of bone grafting is chosen.

Indications for sinus lift are:

Absence of any pathologies at the site of the procedure.
The presence of a certain amount of bone tissue to perform the necessary manipulations.
When diagnosing the patient’s health, nothing was found that could provoke complications after the operation.

It is also important to ensure that the patient does not have the following problems:

The presence of several partitions in the sinuses themselves.
Polyps in the corresponding area.
Constant runny nose for various reasons.
Sinusitis in any form.
Broken or weak bone.
Previous surgical interventions in .
The patient has a bad habit in the form of frequent smoking.

Open

An open sinus lift is a complex operation that is performed only in extreme cases. The following manipulations are carried out:

The doctor drills a hole in the wall of the maxillary sinus, trying not to touch the mucous membrane.
The shell itself is raised to the desired height.
The entire opened space is filled with a special material that will stimulate bone tissue growth.
The wound is closed and sutured, returning everything that was moved during the operation back into place.

Only over time, when the tissue has grown to the desired size, is implantation performed.

Closed

A closed sinus lift is completely different, in which the direct installation of implants becomes possible simultaneously with the implantation of tissue. The procedure is convenient because it is carried out in one go. The following stages are distinguished:

Initially, the bone bed is prepared where the implant rod will be installed. Its size should be 1-2 mm less than the maxillary sinus.
Using a special tool and light tapping, the doctor moves the desired fragment deeper, thereby lifting the mucous membrane to the required height.
Osteoplastic material is introduced through the created hole and at the same time the implant rod is installed.

While tissue healing and gum formation are taking place, the patient may be offered to use plastic temporary structures that will imitate the dentition for the period until permanent implants are created and installed.

Although this procedure is considered simpler, more accessible and less traumatic for the patient, if it is carried out incorrectly, some unpleasant consequences may arise:

Damage to the sinuses, which will lead to chronic runny nose.
Possible sinking of the entire structure, followed by its forced removal.
The occurrence of inflammation in the maxillary area, which will have to be cured and only after that the implantation procedure will be repeated.

To prevent this from happening, the patient must strictly follow all the rules:

Stop smoking.
Restrain yourself when sneezing and coughing, try not to do this, and also do not blow your nose intensely.
Avoid colds, as they will lead to serious complications.
Avoid solid, cold and hot foods during rehabilitation.
Do not visit a bathhouse or sauna, dive under water, or engage in any sports where there is a risk of injury.
Do not travel by air.

What materials are used?

In each of the variants of such plastic surgery, grafts are used. They can be:

Bone tissue of the patient, taken from any healthy part of the body. The rib and ilium are selected, but most often the outgrowths or tubercles of the upper jaw, as well as a small area of the chin, are used.
Allograft - taken from a donor who is another person. Although usually for these purposes they take cadaveric bone, which is further processed. Such a transplant takes longer and is more difficult to take root, but any risks are almost eliminated.
Xenograft – hard tissue of animal origin. This is a more affordable option, but healing may also take longer.
Alloplasts are artificial materials that can completely replace living tissue, take root well and rarely cause rejection. For these purposes, hydroxyapatite and any of its derivatives are used.

Video: about bone tissue building.

How much does the operation cost?

The price for such a complex procedure will largely depend on both the clinic itself and the chosen method of plastic surgery. In addition, the price may also include all the materials used, as well as the implantation procedure, if it is carried out simultaneously with a sinus lift, for example.

Based on the prices of Moscow private clinics, the average cost varies from 150 to 450 dollars for the operation itself. But you can also find various promotions, special offers and discounts. What is more important in this case is not the price, but the quality of the doctor’s work.

Quite often, when planning implantation, a stage of bone tissue augmentation or augmentation. Most people call this stage bone grafting.

Augmentation can be vertical, horizontal and combined. It is performed on both the upper and lower jaws.

Bone grafting for dental implantation

Bones of the upper and lower jaws in their structure have basal and alveolar parts or processes, it is in the alveolar parts that the teeth are located. When teeth are lost, processes are lost in varying amounts.

Augmentation aims to restore lost bone. This is a difficult and crucial moment of the implantation stage. For this, so-called bone grafts are used. They are:

Autogenous: from your own bone tissue.
Allogeneic: cadaveric origin.
Xenogeneic: animal origin.
Alloplastic: synthetic materials.

They are also used in various types resorbable(absorbable) and non-resorbable(non-absorbable) membranes for covering the graft.

Indications

The main reason for osteoplasty is bone deficiency caused by bone atrophy due to tooth loss. With edentia (absence of teeth), gradual atrophy occurs - a decrease in tissue volume as a result of loss of load. Bone loss occurs in both width and height. An important condition for implantation is the presence of bone tissue into which the implant will be installed. The thickness of the bone surrounding it should be not less than 2 mm.

Bone augmentation before implantation

An implant is an artificial root. All products have their own size range in diameter and length. Depending on the group of teeth being restored, one or another size and length of the implant is required.

It is important to take into account presence of anatomical formations in the thickness of bone tissue, such as the inferior alveolar and mental nerves in the lower jaw, the maxillary sinuses, the nasal cavity and the incisive canal.

Therefore, when there is no required bone size corresponding to the implant, operations such as sinus lifting, guided bone regeneration, block transplantation, neighbor augmentation.

How it happens

Depending on where the extension is required, There are several techniques for restoring alveolar bone using bone replacement grafts and membranes:

All types often combined with each other.

How does dental implantation work if there is no bone tissue?

It is not entirely correct to say that there is no bone tissue for implantation. She there is to one degree or another. It is more correct to talk about real conditions for the possibility of implantation.

Thus, with a large loss of alveolar parts in the lower jaw and the difficulty of bone grafting, they can be used basal implants. But they are not a classical method and are not so popular among implantologists.

If there is a deficiency of bone tissue in the upper jaw and it is impossible to carry out classical methods of augmentation, basal implants can also be used. In addition, there is Zygoma zygomatic implantation technique.

Stages

Quite often there are conditions in which bone tissue atrophy is insignificant. In this case, there is a basis for performing bone grafting simultaneously with the placement of the implant. The operation includes several stages:

Carrying out the operation

Several augmentation techniques have already been given above. When pre-forming the conditions for the procedure The same steps are carried out as with implant installation. As a rule, more than one graft is used. Most often, graft mixes are used, one of which must be autobone(bone of the patient himself). Both resorbable and non-resorbable membranes are used as coating; the latter are removed at the stage of implant placement. The membranes are fixed with pins or screws to stabilize the graft.

How long does it take to place implants?

The time of integration (increment) of a material depends on its origin. But the operation of dental implantation on pre-formed bone is performed no earlier than six months later. And in some cases up to nine months.

Photo 3. Jaw before implantation (left) and after surgery (right). Implants are placed after the gums have completely healed.

Gum plastic surgery

We must not forget that in the process of bone tissue atrophy, atrophy of the mucous membrane covering the bone.

Attention! The presence of a certain volume of soft tissue around the implant is an important condition for long-term forecast of product survival.

All biological aspects of implant prosthetics must be observed. And in addition to plastic surgery of bone tissue, it is necessary to perform plastic surgery of soft tissues, follow the principles of “pink aesthetics”.

How to grow gums

As with bone material, grafts are used to compensate for soft tissue deficits. Only in 95% of cases The patient's own tissue is used as grafts. The donor sites are the mucous membrane of the human oral cavity from the area of the palate, maxillary tuberosities, and the retromolar area on the lower jaw.