Bone and Soft Tissue Augmentation in Implantology

With the use of the SBB technique, it is possible to harvest sufficient bone, allowing for the grafting of multiple horizontal and vertical bony defects. Since with this technique every harvested bone block is split into two or three blocks, one can multiply the number of blocks available for the grafting procedure. In some situations, with a well-pronounced external oblique line, and when following the SBB technique, block harvesting from one retromolar area can be sufficient to graft large areas ( Fig 2-24ato d). If there is a need for more bone blocks, the harvesting procedure can be performed from both the right and left mandibular retromolar areas ( Fig 2-25ato e). For a complete oral rehabilitation with multiple bone grafting in the maxilla and mandible, bone grafts can also be harvested from the chin and molar areas in addition to the mandibular retromolar areas ( Fig 2-26ato h).

Fig 2-25aTwo donor sites in the retromolar area of the right and left mandible for two augmentation procedures in the right and left maxilla.

Fig 2-25bRadiographic control 14 years postoperatively.

Fig 2-25cTwo donor sites in the retromolar area of the right and left mandible for multiple augmentation areas in the maxilla and mandible.

Fig 2-25dRecall radiograph 2 years postoperatively with implants that show good osseointegration.

Fig 2-25eControl radiograph 12 years postoperatively.

Fig 2-26aSevere periodontal disease with many mobile teeth.

Fig 2-26bMultiple bone grafting in various areas of the maxilla and mandible after periodontal rehabilitation with extraction of the hopeless teeth and a fixed temporary restoration using provisional implants. The bone grafts were harvested from the retromolar area on the right and left mandible as well as from the chin area.

Fig 2-26cClinical situation of the vertical grafted bone in the right maxilla (3D reconstruction) 4 months postoperatively.

Fig 2-26dControl radiograph 7 years postoperatively.

Fig 2-26eClinical situation 7 years postoperatively.

Fig 2-26fThe long upper lip covers the pink ceramic and the cleaning canals.

Fig 2-26gClinical appearance 17 years postoperatively with poor oral hygiene: patients must stay in a regular recall program to help them to maintain good oral hygiene.

Fig 2-26hControl radiograph 17 years postoperatively.

Only in exceptional cases, such as extensive vertical bone defects with severely scarred soft tissue and a history of uncontrollable smoking, is it advisable to use a cortico-spongy iliac crest graft due to its high regeneration potential. In addition, if there is insufficient bone in the mandible for harvesting in the case of extensive defects, a sufficient donor area is always available in the iliac crest to enable the reconstruction of difficult defect geometries ( Fig 2-27ato f).

The selection of the appropriate method is thus determined by the various parameters and depends on the individual patient findings.

Targeted implant therapy requires a precise survey of the treatment-relevant, individual patient findings, especially when severe bone loss is present. Due to the exact knowledge of the anamnesis and the anatomical structures, patients can be provided with a sufficient alveolar crest for the intended implant placement to achieve an appropriate prosthetic restoration. Different grafting procedures are available, their use depending on the soft tissue situation, the defect configuration, and the desires of the patient. In the atrophied edentulous maxilla, the surgical part of hard and soft tissue augmentation can be less invasive in case of a removable definitive restoration compared with a fixed restoration. In this situation, the goal of the bone grafting procedure is to provide enough bone volume for the insertion of implants. In case of a planned fixed restoration, there are additional goals apart from the aim of inserting the implant, which include having a significant volume of bone and soft tissue to guarantee an esthetic restoration with definitive crowns of a normal length and adequate soft tissue volume, margins, and papillae.

It is important to pay special attention in cases of reconstructions in the esthetic area. In some situations, there is a need for preoperative orthodontic treatment to create sufficient space for a symmetric restoration without injury to the neighboring teeth, something which is not always easy. In such a situation, where the orthodontic treatment was not able to fulfill the expected result, alternatives need to be discussed with the patient ( Fig 2-28ato k).

Precise preoperative diagnostics allow for the exact positioning of implants even under difficult anatomical conditions. Especially in the situation with looseness of the vertical dimension, e.g. in the case of hypodontia, the planning as well as the surgical guide must be the result of teamwork between the surgeon, prosthodontist, and dental technician ( Fig 2-29ato y). In routine cases, the use of tooth-borne orientation guides on the basis of a 2D radiologic diagnosis is sufficient.