Oral implantology :: Surgical Techniques for Creating Conditions for Intra-Bone Implantation when missing

In order to carry out bone implantation, we need the bone to have height, thickness, proper configuration and bone density. We can influence, through various surgical techniques, the first three requirements when they are not available, and for the fourth, we will tailor the type of implant we will place.

As I mentioned in the section "Multi-type implant concept", the "concept" does not conflict with the possibility, if necessary, to make bone grafts in certain sections of the jaws in order to place a certain type of implants, which in this case would be in the interest of the patient, as well as the possibility, under certain anatomophysiological features, of treating the case with the same type of implants.

The advantage of this concept is that the treatment is faster, at times cheaper and 100% successful.

I will show you diagrams of different techniques for bone enlargement with a view to bone implantation. The photos and diagrams are from my lectures in the theoretical and practical courses I have done.

Bone autografting



Donor sections of the upper and lower jaw, from which it is safe to obtain high quality and in sufficient quantity bone, compact and spongiosa for auto graft.


Donor sections of the roof of the skull, from which we can take more bone, compact and spongiosis, with the largest area.

The X-ray shows how thick the bone is here (about 1 cm), and the red line shows till where the bone is taken - absolutely safe, since the lower plate of the so-called "diploe" is not violated.


Bone from "crista iliaca"/ flank / from which we can take quality bone, compact and spongiosis in the greatest quantity.



Big shin - we can take compact bone safely from it.
The other donor area is the ribs, but we can take insignificant  volume and area bone from them, but not safely, which is why it is no longer practiced. There is a risk of pneumothorax.



The left diagram shows a bone graft with compact and spongiosa in asymmetrical bone atrophy and on the right a bone graft with bilaterally compacted and spongiosa in the middle, with symmetric bone atrophy. We can fix the graft till the healing with special osteosynthetic screws or ligature wire / see my clinical case in Multimedia /

Regeneration osseous guide – ROG / guided bone regeneration /


A left / from the textbook / diagram shows guided bone regeneration and the right one that is mine is the same, but the wound is not yet sutured. It is used in cases where there is no bone but bone is that much preserved so that the implant can be wound in 4 - 5 turns to give initial stability. We put substitute bone  around the implant, which is covered with a special membrane. After surgery, there is, so to speak, a competition between the tissues. The gum is ahead of the bone. The membrane impedes mechanical invasion of the mucous membrane. After all, the body forms a bone at this point.

I will bring to your attention a clinical case, one of the few survivors of numerous hacking attacks on my site, as well as cabinet robberies that have left too many and valuable databases missing.



Sector X-ray showing a periodontal lesion of 15 teeth, apparently caused by nothing. My colleagues referred this case for surgery. I scheduled the operation for ROG.



To my surprise, during the surgery I found that the tooth is split in two, but in the anterior-posterior direction, so the x-ray could not show the fracture. Naturally, extraction was required. You see the two root fragments.



At the site of the extracted tooth, we see a bone wound that was superficially too wide and irregular in shape, which did not allow immediate implantation without ROG. On the right picture is an extirpated periodontal cyst.


I implanted immediately, using a special bone substitute - gel and granules that are mixed as "putty".


The implant


The substitute bone


These 4 pictures show the sequence of insertion of the membrane and the suturing of the wound.

Sinus lifting
Very often implantation is required in the area below the sinus. Unfortunately, there is usually a lack of bone height in most cases, which requires a specific kind of surgery called sinus lifting. We distinguish:
• Closed sinus lifting
• Lateral sinus lifting



The blue lines indicate the areas in which it can be implanted unimpeded and the red ones below the sinus area where bone height too often not enough.


In the relevant situation, seen on an orthopantomography or scanner, we undertake one or the other type of sinus lift.


Closed sinus lift / intralift /


Schematic section of a sinus with inserted pictures from a clinical case. Incision, lambo to bare the bone. Initial opening in the bone. The step-by-step operation. 



Next Steps… Forming the bone bed for the implant and entering the sinus without breaking the sinus mucosa.


Next steps… Putting a bone replacement in the bone bed.


Next steps… Stuffing up the bone substitute into the sinus. We can see from the diagram and the X-ray that it unstick and pushes the mucosa of the sinus.


Next steps… We increase the bone height as we need it to implant a long enough implant. On the last scheme is the plased implant. If it is possible the implant to screw up into the bone 4 - 5 turns so as to obtain initial stability, it is implanted immediately, ie. in the same operation. If not - after 4 - 6 months, during which time the body will form new bone. The diagram shows the operation the old way, with an osteotome. Now it's done with piezo surgery.



Last steps… Implants placed - one in the existing bone and two in the newly created one. The stitched wound.




Intralift creates sinus elevation in a restricted area. When we need to create a bone in a larger area, we resort to…

Lateral sinus lifting


At it creates a bone window of different sizes, depending on how much we want to lift.



The step - by - step operation ... We make a bone window, remove it or push it into the sinus, so that it becomes a "ceiling" for the newly created cavity and "under" the rest of the sinus cavity. We peel off and push the sinus mucosa, and in the cavity thus formed, adjacent to the sinus, we place a bone substitute.



This is how we push out the bone window - scheme.



This is how we push out the bone window – into the operation.



Next steps ... We either place the implant immediately or delayed (see explanation above).
We do the bone window with a bone cutter / see the movie with my clinical case in Multimedia or with piezo surgery.

Here is a sinus lift of a training model during a workshop, at one of my lectures.
 

The incision of the silicone mucosa and its reparation. We mark with a chemical, the ridge of the gum, and we do the incision very inward to the palate, so that the wound to seal more securely.


We make a bone window and push it in the direction of the sinus cavity.


Here, cotton plays the role of bone substitute, and part of the needle packaging - of the membrane.


We suture the "wound".



My clinical case with lateral sinus lifting (SL) at which of 5 mm. I have achieved a total of 20 mm.



Another clinical case where I can implant in the area of 14 tooth a normal 6 mm implant. Such a short implant in this place does not work (see next photo). In the posterior I cant implant at all without SL.


Here is the sizing analysis. The figures speak eloquently.



I performed a lateral sinus lift, such as the bone window
becam the new sinus floor. I immediately placed 2
11.5 mm implants. and bone substitute / Biostit /

A relatively modern trend in bone replacement is the addition of platelet-rich plasma to the bone substitute, as it contains many growth factors that stimulate the formation and maturation of new bone. Platelet-rich plasma we obtain from venous blood taken from the patient himself, in a special way, by a centrifuge.

During one of my implantology specialties in Munich, Germany, I learned an original sinus lift technique called "balloon technique".
Ballon Lift Control – Ballon assisted sinus lift elevation



As you have seen, very precise but sophisticated and expensive technique, very expensive consumables / a single use balloon costs 200 Euro / and although the operation is very effective, I did not put it into my practice.
In the practical course we did it on frozen heads of pigs / pig organs are too close to human's /.
I learned it easily, but I figured out that this technique is simply not for sale in Bulgaria. At this point, I introduced piezo intralift in my practice.
Today, there is a variety of simplified methods with dedicated rotary instruments, both indoor and lateral SL. Here is one of them.





You can see my clinical case in the classic old way with lateral SL in Multimedia.

Nerve transposition
 


From the slide, you can see in what situation what technique I do.
I will show schematics of the surgical technique "nerve transposition".



Similar to the sub-sinus region, in the upper jaw, and in the lower most often atrophies the body.   This is why the nerve transposition / displacement/ we do at this place. Then we place the implants unobstructed, as you will see below.


On the left - classic incision of the gum, if there are teeth, or if there are not any. On the right - we do the first perforation to unmark the window is 3 mm. behind and under the foramen.





We may not put the window back in place, but we will place the substitute bone and a membrane.
A different look at the schematically presented operation, in sections for more clarity.


1 - Preparation of the bone window
2 - Removing it from outside the jaw
3-  Removing the nerve outside the jaw
4 - Preparing the implant bed
5 - Return the nerve and bone window back
6 - Complete operation
7 - Top view

Here is the operation of a training model during a workshop after my lecture.






1 - A section of the mucosa
2 - Preparation of bone window
3 - Separation of bone window from jaw
4 - Preparing an additional bone window and separating it
5 - Marking the implant site
6 - Initial opening for implant placement
7 - The next step in preparing the implant bed
8 - Final preparation of the implant bed
9 - Initial turning of the implant by hand
10 - Screwing the implant with a ratchet
11 - The finally wrapped implant and nerve attached to it
12 - Adaptation of the bone window to the implant
13 - Replace the bone windows
14 - A suture of the mucosa is forthcoming

Contact pfhristov@yahoo.com for more details
 

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