Bone grafting. Cost of bone augmentation

The essence of bone tissue augmentation is to restore the 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 a normal load, gradually dies off and after a while becomes thinner so that the pin literally has nowhere to put it. In order for implantation to become possible, bone tissue must be restored. Bone augmentation during dental implants

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 jawbone, keeping it “in good shape”. To greatly simplify the situation, we can say that after the loss of the tooth root, there is nothing to hold the bone, and the need to maintain a certain amount of tissue simply disappears;
infectious diseases. Ostitis (inflammation of the bone) and periostitis (inflammation of the periosteum) often cause tissue atrophy;
age-related changes;
jaw trauma;
poor quality dentures. Bone atrophy often leads to improper distribution of the load on prostheses, especially removable ones.

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

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

violation of chewing function;
a change in the shape of the face (for example, a characteristic contour of the lower jaw and "sunken" lips in people with complete edentulousness of one or both jaws);
difficult articulation.

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

Methods of bone augmentation for dental implants

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

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

transplantation of bone blocks;
guided bone regeneration;
sinus lift.

Each technique has its pros and cons, features and contraindications.

Bone block transplant

This method was developed very first. Its essence lies in the transplantation of a piece of bone in 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 provides easy and almost one hundred percent engraftment. This process is called autotransplantation.

Bone block transplant

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

The operation is carried out according to the following scheme:

first, the gum is cut and raised on the "donor" jaw, from where a piece of bone is removed;
the future transplant is given the desired shape;
through the 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 closed 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 turns out to be quite thick, the survival rate during autotransplantation is very high, there is practically no risk of rejection.

Of the shortcomings - transplanted material takes root for a long time, on average 6 to 8 months; the possibility of simultaneous installation of the implant is excluded, as this increases the risk of rejection of both the implant itself and the bone block; with insufficient integration of the transplanted block with the bone tissue, the flank can be detached from the jaw - the risk of such a complication is small, but still there.

Contraindications for 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 a situation where very little time has passed after tooth extraction. It consists in covering the socket of the extracted tooth with a special protective membrane made of a biocompatible material.

The meaning of this procedure is to protect the tooth socket from the growth of soft tissues of the gums into it, which grow very quickly and penetrate into 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 hole or allograft.

Guided bone regeneration

The advantages of this operation are low trauma and a low degree of stress for the body. Unfortunately, it has many more disadvantages:

high risk of membrane rejection;
risk of rejection of transplanted bone tissue;
low efficiency 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 the “natural” bone, which is why it tends to partially decrease. It is not always meaningful to restore one's own atrophied tissues in this way, in addition, the extension will have to be carried out “with a margin”.

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

Sinus lift

Sinus lifting is a low-traumatic bone tissue restoration technology. However, it can only be used on the upper jaw, as it includes 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 elevation of the sinus wall and the growth of new bone tissue under it.

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

In both cases, the technology itself is almost the same. The main steps 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, during the operation of the closed type, the mucous membrane is sutured.

After insertion under the membrane, the osteoplastic material should be integrated into the bone tissue. If the integration went without problems, a pin is inserted into the resulting bone layer.

Sinus lift

The advantages of this operation are low trauma(with closed sinus lift), reliable engraftment of osteoplasts, low risks of rejection, high quality of augmented tissue.

The main disadvantages are inability to build up a layer of tissue more than 2 mm. Also, this method is not suitable for restoring a large volume of bone - in the absence of two or more teeth (and a 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, curvature and anomalies of the nasal septum, polyps in the maxillary sinus and frequent colds. Also, a serious limitation to the procedure can be the habit of smoking.

Materials for transplantation

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 one's 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 preliminary processing;
xenogenic - based on animal material (namely, bovine bones);
combined - a combination of autogenous and xenogenic materials in a ratio of 1: 1; an effective and safe method of rapid bone growth;
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 to reliably restore lost tissue.

The need to increase bone tissue during implantation turns for many patients into a failure of this method of restoring teeth. Why this happens is easy to guess, because osteoplastic surgery is almost always associated with additional expenses, with rather complicated rehabilitation, possible risks and loss of precious time, with the inability to get a dream smile 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. So patients return to removable dentures again.

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

Why does jaw bone atrophy?

As you know, the anatomical features of the structure of the maxillofacial apparatus suggest that each of us has two jaws - the upper and lower. On each of them, 14 (or 16 with “eights”) teeth erupt in a permanent bite. Ideally, a person manages to avoid their loss until the end 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 of 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 is committed to minimizing the situation of edentulism around 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 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 “working” teeth that take part in biting, gnawing, grinding food. It remains “not destiny” and gradually begins to atrophy, thin out. The same thing happens when a person wears removable dentures or fixed bridges for a long time. Moreover, even in the presence of teeth, atrophy of the tissues surrounding them can occur - this situation occurs with inflammation of the periodontium, with diseases of periodontitis and periodontal disease.

When you can not do without building up bone tissue

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

For example, the classical implant implantation protocol 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 up to six months before the doctor implants the implants directly. You will also have to wait if you have been shown a tooth extraction - an implant cannot be implanted in its place until the hole heals.

Important! Outwardly, the changes that occur with bone tissue are invisible to humans and do not directly cause problems. But when deciding to finally restore teeth by implantation, until recently, many had difficulties: the classic two-stage approach could not be implemented until the bone had the necessary volume and height to securely fix the implants in it. With a lack of bone tissue with this approach, they would simply fall out, loosen at best. At worst, when installing them, the doctor could injure the sinuses in the upper jaw or touch the trigeminal nerve in the lower. After all, there are few bones and these anatomically important elements are now very close.

That is why, when referring to the standard, classical method of implantation, patients have no other choice but to turn first to the procedures for increasing the dentary bone 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, pay a lot. In this case, the patient does not receive a permanent fixed prosthesis at all soon - after 8 or even more months after the initial visit to the doctor. Also, despite the fact that such a 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 all teeth are missing in the mouth? Today, such patients have the opportunity to get results in a matter of days and hours thanks to fundamentally different innovative methods of implantation, 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 face several uncomfortable moments:

time and money: procedures will need to be paid separately from the implant itself. With the classical approach, a prerequisite for the 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 here in the immediate vicinity are the maxillary sinuses, 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 for him is quite simple - the patient can only trust and strictly follow all the recommendations.

Factors that made possible implantation without augmentation of the jawbone

It should be noted that the active development of advanced technologies, 3D modeling, the creation of surgical templates, and computed tomography have brought great benefits to the development of implantology in general. Thanks to them, today doctors can offer their patients methods of one-stage implantation of teeth with immediate installation of a prosthesis, which in most cases allow you to do without bone tissue growth at all.

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 achieve 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 in one step: 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 adentia. Most importantly, with these methods of implantation, people really get new teeth, literally not looking up from work and communication in society. The entire treatment process takes 3 to 7 days. Now let's find out why there is no need for bone grafting with one-stage protocols.

1. Use of specific implant models

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

fast survival in bone tissue: for this, different manufacturers use special coatings. For example, famous ones have TiUnite, and have a hydrophilic surface that promotes the rapid production of protective cells in bone tissue and its growth,
active type of thread for strong adhesion of the bone to the implant,
the ability to be installed at an angle: this is necessary precisely so that during implantation it is not necessary to resort to bone augmentation and not to touch the areas of the maxillary sinuses and nerves. The tooth 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 and does not loosen,
the ability to solve the most difficult cases: a vivid example of this is the artificial roots of the brand, which are used for periodontitis and periodontal disease. They are covered with antibacterial coating, and also have one design feature - they are one-piece, their body is immersed in the hole of the extracted tooth, and the smooth neck is in contact with the mucosa. Thanks to these properties, a patient with inflamed gums may not worry about the rejection of structures or irritation of the inflamed mucosa, or the accumulation of plaque on the implant neck.

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. Perhaps you fell into the hands of a non-professional, because an experienced specialist who has the necessary knowledge of the anatomy of the maxillofacial system and owns the techniques of one-stage protocols will never allow this. Whether the procedure is carried out jointly with or without bone augmentation, but without fail, the doctor must require a computed tomography 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 start treatment without the recommendations of highly specialized specialists and their opinion on the state of health.

This data is needed by the doctor to work out the treatment process on computer equipment, using 3D technologies, to select the optimal implant models for you, to determine the place of their installation, to create surgical templates that reduce all possible risks from the procedure to a minimum.

3. Fastening the prosthesis immediately

This is a prerequisite for the implementation of one-stage implantation methods. The doctor can immediately load the prosthesis within 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 that the implants will loosen or fall 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 start chewing food with new teeth without delay. You should not be afraid, since the design contains a metal base, which will not allow the implants to move even under loads. In addition, this way, you will help start the metabolic processes in the bone tissue, provide it with work and nutrition, due to which the engraftment process will pass quickly and almost imperceptibly.

Implant 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 growth 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 methods of treatment:

or the solution of the problem with three implants: this solution was developed by Nobel especially for patients who have missing teeth in the lower jaw. And the secret of success is simple - these are three two-piece Trefoil implants (read as "Trefoil"), which are installed in the anterior part of the mandibular bone, and a template bar 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 is which is higher than the previous technology, but there are more indications for treatment. The protocol was also developed by the Nobel company using the artificial roots of this brand. The second is from Straumann using the Roxolid model. Also, in clinics, you may be offered other, more budgetary and less clinically proven models, for example, Korean Osstem, for the implementation of this protocol,
solving the problem with six implants: this is the way out for patients in whom moderate bone resorption was detected at the preparatory stage. allows you to refuse osteoplastic surgery, because six artificial roots in some cases is the optimal number of supports for reliable support of the prosthesis and competent distribution of the masticatory 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 a 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 methods of treatment or complicating factors,
solving the problem with long ones: we immediately make a reservation that the method is only suitable for patients with missing teeth on. But among its obvious advantages, indications for use can be noted: very strong 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 cranial vaults and cheekbones. 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: a wide range of choices and a real chance to find a technique that suits your situation. It is also financial freedom - the price of complexes can vary depending on the chosen implant model, of which there are a huge number. So there is plenty to choose from.

Complex approaches, in principle, are cheaper than the 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 margin that covers the imperfections of your mucosa). Another plus 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 ability to do without waiting and start eating, smiling right away. Here the patient does not need to find free minutes, he avoids unpleasant moments that are associated with communications. Agree that if the treatment takes only a week, then there is no need to negotiate with colleagues about substitution at work or ask the boss for a long vacation, constantly asking for time off. The doctor will need to visit no more than 2-3 times.

As for the shortcomings, then they are here. Firstly, this is the absence in Russia of a large number of specialists who are really trained in all the intricacies of working on protocols for immediate loading and implantation without prior bone augmentation. Therefore, the patient, alas, always has the risk of running into a non-professional. You need to be very careful in choosing a specialist.

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

Video review of the patient about the operation

1 Iordanishvili A.K., Gaivoronskaya M.G., Soldatova L.N., Serikov A.A., Podberezkina L.A., Ponomarev A.A. Occlusion-caused 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 the extraction of teeth, the bone tissue undergoes gradual atrophy, which leads to a decrease in the width and height of the bone in the place of the 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 growth during dental implantation Implantologists' reviews suggest that it is necessary not only for the normal functioning of the implant (in terms of 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 result of this, gum recession and implant neck exposure occur.

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 very well - 2.5 mm. If the front surface of the implant is covered by a bone less than 2 mm thick, then this means 100% bone resorption around the implant neck, accompanied by a lowering of the gum level and exposure of the implant neck. In this case, the implant will still carry a functional load, however, if it stands in the smile zone, the gum contour around the implant will eventually become aesthetically unacceptable.

2) Secondly- the thickness of the bone wall between the implant and the root of the adjacent tooth should ideally be 3 mm, tolerable - 2.5 mm. If this distance is smaller (for example, 1.5-2.0 mm), then the following problem arises. Around the neck of the implant, even in normal conditions, there is always a slight resorption of the bone. If the bone septum between the implant and the tooth root is too small, then bone resorption will also occur at the root surface adjacent to the implant. This means a lowering of the gingival level and the absence of an interproximal gingival papilla (i.e. poor esthetics).

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

Causes of bone deficiency

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

2) The second reason is traumatic dental surgeons. Usually, during the removal, the surgeon absolutely does not think about the safety of the bone walls of the alveoli around the tooth, biting them with forceps. If you are planning an extraction with subsequent implantation of a tooth, then it is best to carry out such an extraction with 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 there is a decrease in the width of the alveolar process,
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 implants: reviews

There are many different methods of bone grafting, but they can be conditionally 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 ridge of the alveolar process.

Most commonly used techniques –

splitting of the alveolar process,
bone block transplantation,
Guided Bone Regeneration (GBR)
sinus lifting method (used with a lack of bone height in the lateral sections of the upper jaw).

All these operations are performed under local anesthesia, if necessary (the fear of the patient) 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 techniques have their pros and cons… Histological studies have shown that after bone augmentation by 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 implanted bone material.

1. Splitting of the alveolar process -

Used for horizontal bone resorption to increase the thickness of the alveolar process. It can be performed both on the lower and on the upper jaw. It must be said that this is the most effective method of expanding the alveolar process today, which, moreover, 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 you to simultaneously carry out both expansion and installation of implants.

The content of the "Split-Control" methodology(Fig.5-10) –
after detachment of the mucoperiosteal flaps (gums), a cut is made in the center of the crest of the alveolar process with a cutter or other special instruments to the height of the future implant (Fig. 6). Next, a hole for the implant(s) is marked with a pilot drill, and spreaders are screwed into the prepared holes (Fig. 7). 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 on the sides of the implant, which is filled with bone material, which, if necessary, can be applied in excess and outside the alveolar process, covering it all with a special resorbable membrane (Fig. 9). After that, the wound is sutured, and we wait for the osseointegration of the implant within 3-4 months.

Bone grafting of the lower jaw (splitting method) –

Advantages of the technique –

Firstly- due to the splitting of the ridge, we get a bone defect that has bone walls on all sides (except on top). Thanks to this, fast and high-quality osteogenesis (the formation of a new bone) occurs, because spongy bone in the depths of the alveolar process is rich in blood vessels, osteoblasts, mesenchymal cells, growth factors ...
By the way, why it is much worse to increase the width of the bone not due to splitting (from inside the alveolar process), but to do this due to the external attachment of bone blocks or bone chips outside the cortical plasty of the alveolar process. The fact is that the outer cortical layer of the bone is very dense and there are practically no vessels in it. Accordingly, the transplanted bone material will take a very long time to grow into vessels, bone formation will proceed more slowly, 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, for example, bone material "Osteodent-K" and the membrane "Osteodent-Barrier".

Thirdly– installation of implants with this technique in most cases is possible immediately. If the implants are installed later, then only 3-4 months will have to pass between the operations, which is much 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 methods. With “Split-Control”, only a cut is made 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 the complete detachment of the bone block (vestibular cortical plate).

Then this block is fixed with screws, which often break it. Implants with this modification of the technique are not installed immediately, but after 3-4 months. In addition, it is very traumatic and more risk of complications. This type of technique should only be used on 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 parts of the jaws). Block sampling can be carried out in the region of the tubercle or zygomatic-alveolar ridge of the upper jaw, or in the region of the branch or chin area of the lower jaw. Less commonly used are bone blocks of allogeneic origin (from another person), as well as xenogenic origin (bovine bone), which is associated with their much lower efficiency.

An example of a bone block transplant operation –
On 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 chips, after which the blocks and the surrounding bone tissue must be closed with a collagen membrane (exactly the same as those used for guided bone regeneration). The membrane is fixed to the bone with the help of special metal pins (Fig. 14), and then the mucous membrane over the operation site is tightly sutured.

Bone block transplantation: animation and video of the operation

Advantages of this method –
this is an excellent method for increasing bone volume with predictable results. The gold standard for this method is the use of an allograft (a bone block taken from the patient himself). Moreover, it is very important that the transplanted graft be "cortical-spongy", i.e. had not only a cortical plate, but also spongy bone tissue. In this case, a predictable and positive result of bone block transplantation can be obtained.

Cons of this method –

An additional operation to take the bone block is required.

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 a longer engraftment, i.e. after such an operation, it will be necessary to wait about 6-8 months before starting the installation of implants at all. This is due to the fact that the bone block is screwed on the outside of the jaw. The superficial cortical layer of the jaw bone has very few vessels, and therefore the germination of vessels into the transplanted bone block is very slow.

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

3. Guided tissue regeneration (GTR) -

This method can also be used to increase the width of the alveolar process, as well as 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.

Guided tissue regeneration (synonymous with guided 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 adverse factors.

Guided bone regeneration: examples of operations

1) Clinical case No. 1 –
Photo 17 (in the area of the 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 bone grafting, you can see the installation of the implant in this area…

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

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

There are different types of membranes, resorbable (Bio-Gaid), non-resorbable (Gore-tex or mesh titanium 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 titanium-reinforced membranes. All these membranes are expensive, but the use of cheap membranes (such as Osteoplast) is not suitable for this technique.

Choice 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 –
an 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 minus here - the need for an additional small intervention for the collection of bone material.

Combination autograft + xenograft –
in a ratio of 1:1, bone chips (taken from the patient himself) are mixed with xenogenic material, i.e. based on bovine bone. Such a high-quality and effective material as "Bio-Oss" can serve as an example of it. 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 the cadaveric material (of other people). These materials are purchased from a special tissue bank, all materials are carefully processed and 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 growth will be lower.

Guided bone regeneration with immediate implantation: operation video

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

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

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

Bone augmentation during dental implantation: price 2019

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

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

This happens when a person has thought too long about whether to install implants. During the absence of dental units, the hard tissue atrophies too quickly, which leads to the need for bone grafting.

About the lack of bone tissue in a patient

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

If the patient needs to implant an implant in order 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, at least 10 mm of a solid base is needed.

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

A very important point is that in order to avoid any unpleasant complications, you should choose a good clinic, an experienced doctor and follow absolutely all the rules for preparing 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 a sufficiently reliable fixation of the implant, if the bone is shorter than the artificial rod.
To prevent the displacement of teeth, their loosening, loss and other pathologies of the dentition.
Prevent distortion of facial expressions and articulation.
Restore chewing function, which will inevitably occur with atrophy.
Prevent facial contours from being distorted due to jaw reduction.

Doctors highlight the following advantages of the process when artificial bone material is added or augmented in another way:

Complete restoration of all jaw functions, even if atrophy has reached a large volume.
Makes affordable high-quality implantation, in which the rods will hold for a long time and reliably.
The attractive appearance of the gums returns, and after prosthetics, the entire dentition.
Following the rehabilitation period, there is a complete disappearance of all the inconveniences that accompanied tooth loss and bone atrophy.

True, there are some disadvantages of the procedure, such as a long recovery stage, the process of the operation 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 the expected result be achieved.

A photo

Bone augmentation options for dental implants

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 NTR. In the process of NTR, 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 resorbable. 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 transplanting a bone block, most often a piece of the patient's own bone is used. Usually it is taken from the chin. It turns out two wounds, which is considered a disadvantage of the procedure. But such a transplant takes root better and rejections do not happen with it. This bone is screwed with special screws to the right place, compacted with chips or granules and sutured with a membrane. It is she who will not allow them to be washed out and will contribute to rapid regeneration. Another disadvantage of bone block implantation is the duration and the procedure several times. After all, initially they make two injuries, and then they also perform an additional operation to remove the membrane and implant the pin.

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

Mandatory health examination, setting the degree of atrophy using x-rays. Taking blood samples with extended interpretation. After all, the operation should be carried out only in the absence of any contraindications.
Anesthesia. Most often, local anesthesia is chosen, but in rare cases of increased sensitivity or susceptibility of the patient, the doctor may choose a light general anesthesia.
An incision is made in the periosteal flap, which exposes the rest of the natural bone. In this case, the doctor can additionally diagnose the condition and size of atrophy. Accordingly, the desired material for building up and its adequate amount are selected.
Then the procedure itself takes place, which will differ depending on the chosen method of plastic surgery.
After all the manipulations, the doctor is obliged to sew up the bone with the installed components and secure the wound. For this procedure, absorbable sutures are most often used, so removing the sutures will be unnecessary.

After the operation, the dentist will definitely advise on what can and cannot be done. It is very important to adhere to these recommendations so that there are no consequences.

If the operation was successful, the rehabilitation period will last up to a month. The first week is also necessary to drink painkillers and anti-inflammatory drugs.

Sinus lift

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

In this case, a mechanical lifting of the maxillary sinus is performed so that the necessary tissue can be built up under 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 a sinus lift are:

The 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 make sure that the patient does not have the following problems:

The presence of several partitions in the sinuses themselves.
Polyps in the corresponding zone.
Constant runny nose for various reasons.
Sinusitis in any form.
Broken or weak bone.
Previous surgical interventions in .
Bad habits in the patient in the form of frequent smoking.

Open

An open sinus lift is a complex operation that is done only in extreme cases. Carry out the following manipulations:

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

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

Closed

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

Initially, the bone bed is prepared, where the rod for the implant will be installed. Its size should not reach the maxillary sinus by 1-2 mm.
With the help of a special tool and light tapping, the doctor moves the desired fragment inward, thereby raising the mucosa to the required height.
The osteoplastic material is introduced through the created hole and at the same time the implant shaft is installed.

While the tissues are healing and the gum is forming, the patient may be offered to use plastic temporary structures that mimic the dentition for that period until permanent implants are created and installed.

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

Damage to the sinus, leading to a chronic runny nose.
Possible sinking of the entire structure deep into, followed by its forced removal.
The occurrence of inflammation in the maxillary region, which will have to be cured and only after that to perform a second implantation procedure.

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

Give up smoking.
Restrain when sneezing and coughing, try not to do this, and also do not blow your nose intensively.
Avoid colds, as they will lead to serious complications.
Refuse for the period of rehabilitation from solid, cold and hot food.
Do not go to the bathhouse or sauna, dive under water or engage in any sports where there is a possibility of injury.
Do not travel by air.

What materials are used?

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

The patient's bone tissue taken from any healthy part of the body. They choose the rib, the ilium, but most often they use outgrowths or tubercles of the upper jaw, as well as a small area of \u200b\u200bthe chin.
Allograft - taken from a donor, which is another person. Although usually for these purposes they take a cadaveric bone, which is additionally processed. Such a transplant takes longer and 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 can also be delayed.
Alloplasts are artificial materials that can completely replace living tissue, while taking root well and rarely cause rejection. For these purposes, hydroxyapatite and any of its derivatives are used.

Video: about bone growth.

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 cost may also include all the materials used, as well as the implantation procedure, if it is carried out simultaneously with the sinus lift, for example.

Focusing 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. 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 refer to this stage as bone grafting.

Augmentation can be vertical, horizontal and combined. It is carried out both on the upper and on the lower jaw.

Bone grafting for dental implants

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. With the loss of teeth, the processes are lost in different volumes.

Augmentation is aimed at restoring the lost bone. This is a difficult and crucial moment of the implantation stage. For it, 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 its atrophy due to loss of teeth. With adentia (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 in which the implant will be installed. The thickness of the bone surrounding it must 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 consider the presence of anatomical formations in the thickness of the bone tissue, such as the lower alveolar and mental nerves on the lower jaw, maxillary sinuses, nasal cavity and incisive canal.

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

How is it happening

Depending on where the extension is required, There are several methods for restoring the alveolar bone. using bone-replacing grafts and membranes:

All types often combined with each other.

How does dental implantation work if the bone is without tissue

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

So, with a large loss of the alveolar parts in the lower jaw and the complexity of bone plasty, can be used basal implants. But they are not a classic method and are not so popular with implantologists.

With a shortage of bone tissue in the upper jaw and the impossibility of performing classical methods of augmentation, basal implants can also be used. In addition, there is Zygoma zygomatic implantation technique.

Stages

Quite often there are conditions under which atrophy of bone tissue is insignificant. In this case, there is a reason to perform bone tissue grafting at the same time as placing an implant. The operation includes several stages:

Operation

Several methods of augmentation have already been given above. In the preliminary formation of conditions for the procedure the same steps are carried out as with the installation of the implant. The graft, as a rule, is not used alone. Most often, graft mixes are used, one of which must be autobone(the patient's own bone). Both resorbable and non-resorbable membranes are used as a coating, the latter are removed at the stage of implant placement. The membranes are fixed with pins or screws for stable retention of the graft.

How long does it take for implants to be placed?

The integration time (increment) of the material depends on its origin. But the operation of implantation of teeth on a pre-formed bone is performed not earlier than six months later. And in some cases and up to nine months.

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

Gingival plastic surgery

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

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

It is necessary to observe all biological aspects of prosthetics on implants. And in addition to plastics of bone tissue, it is necessary to carry out plastics of soft tissues, follow the principles of "pink aesthetics".

How gums grow

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