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Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series
Accepted Manuscript Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series George R. Deeb, DDS, MD, Daniel M. Laskin, DDS, MS, Janina Golob Deeb, DDS, MS PII:
S0278-2391(16)31181-8
DOI:
10.1016/j.joms.2016.11.014
Reference:
YJOMS 57547
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 8 September 2016 Revised Date:
16 November 2016
Accepted Date: 16 November 2016
Please cite this article as: Deeb GR, Laskin DM, Deeb JG, Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.11.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series George R. Deeb, DDS, MDa, Daniel M. Laskin, DDS, MSb ,Janina Golob Deeb, DDS, MSc a
AC C
EP
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M AN U
Corresponding Author: Dr. George R. Deeb 521 N. 11th Street PO Box 980566 Richmond VA 23298 [email protected]
SC
RI PT
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA b Professor Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA c Assistant Professor, Department of Periodontology, School of Dentistry, Virginia Commonwealth University, Richmond VA
ACCEPTED MANUSCRIPT
Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series George R. Deeb, DDS, MDa, Daniel M. Laskin, DDS, MSb ,Janina Golob Deeb, DDS, MSc a
SC
RI PT
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA b Professor and Chairman Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA c Assistant Professor, Department of Periodontology, School of Dentistry, Virginia Commonwealth University, Richmond VA
Abstract:
EP
Introduction
TE D
M AN U
Purpose: The purpose of this study was to confirm the efficiency of using a lateral ramus block graft taken at the time of impacted mandibular third molar removal for horizontal ridge augmentation and implant placement. Patients and Methods: Ten patients had grafts obtained from the lateral aspect of the mandible during impacted third molar removal placed in areas of horizontal ridge deficiency. Results: Measurements made on cone beam computerized tomograms after 4 months showed gains of 2.7-3.5 mm and 16 implants were placed successfully. Conclusions: In patients with impacted third molars requiring dental implants, simultaneous harvest of a lateral block bone graft is an efficient way of obtaining bone for horizontal ridge augmentation.
AC C
Inadequate alveolar bone width for dental implant placement is a frequently encountered problem. There are many surgical techniques available to reconstruct these horizontal defects, including an autogenous onlay graft harvested from the ramus of the mandible. In 1999, Misch described a technique in which such a graft could be harvested in conjunction with impacted third molar removal (1). Subsequently, Lee reported on 4 patients in whom a laser was compared to a bur for obtaining the graft, but he did not report the amount of augmentation that occurred or if implants were successfully placed (2). We present a series of cases in which this technique, with some modifications, was used to achieve successful dental implant placement.
Patients and Methods: 1
ACCEPTED MANUSCRIPT
RI PT
Ten consecutive healthy implant patients aged 17 to 38 years, with a total of sixteen alveolar deficiencies, were enrolled in this IRB approved study (Table 1). Inclusion criteria were the need for horizontal alveolar augmentation prior to dental implant placement, skeletal maturation, and the presence of an impacted mandibular third molar requiring extraction.
SC
Preoperatively, patients were administered an IV dose of clindamycin, 900mg, and sedated with Versed and Fentanyl. After obtaining local anesthesia of the edentulous site and the mandibular third molar region, the edentulous site was exposed using a crestal incision with bilateral vertical releases. If there were adjacent teeth, it was helpful to include a papilla of at least one tooth mesially and distally to keep the suture lines distant to the graft (Figure 1). A periosteal release was made on the flap to ensure tension free closure.
TE D
M AN U
Once the recipient site had been prepared, a full thickness buccal envelope flap with a distal buccal or hockey stick release was reflected for access to the impacted third molar (Figure 2). The interdental papilla between the first and second molar was included to improve access and aid in wound closure. The third molar was removed, conserving as much bone as possible. Once the tooth was removed, a fissure bur was used to create proximal and distal osteotomies through the lateral aspect of the ramus. After these cuts were made a round bur was used to create an inferior osteotomy connecting them. The graft was then removed using a dental elevator or osteotome (Figure 2).
AC C
EP
At this point, the graft was trial-fit to the recipient site. In some instances the recipient bed was prepared to accommodate the graft by creating an inlay type of preparation. The cancellous portion of the graft was removed with a rongeur and, if necessary, the graft was trimmed with a surgical handpiece. The goal was to get broad, intimate contact between the graft and the recipient bed, so the graft was tried in several different orientations. Once the graft was adapted to the recipient site, two fixation holes were made (Figure 3). A lag screw technique was used, so the holes were made slightly larger diameter than the fixation screws. Two screws is the preferred number to reduce graft mobility (Figure 4). A round bur was used to create a countersink in the graft so that the fixation screws would be flush with the graft and have less chance of causing wound dehiscence (Figure 3). The next step was to trim a resorbable collagen membrane (BioGuide) to cover the graft. When adjacent grafts were used, cancellous allogeneic bone was placed between the grafts in order to get additional bone formation (Figure 5). The resorbable collagen membrane was placed over the graft and the wound was closed with PTFE sutures in an interrupted fashion (Figure 5). Postoperatively, the patients were placed on clindamycin for 1 week and a chlorhexidine mouth rinse was prescribed. The sutures were removed after 10 days. Figure 6 shows a patient two weeks postoperatively. Approximately 4 months 2
ACCEPTED MANUSCRIPT
postoperatively a cone-beam computed tomogram was taken to evaluate the graft and plan for implant placement (Figure 7).
RI PT
Results: Postoperatively, none of the sites had wound dehiscence or infection, and only one exhibited minimal graft exposure of approximately 5% at a wound margin that was removed with a curette. One patient had transient paresthesia from the third molar removal.
M AN U
SC
Measurements made on the CBCTs showed gains between 2.7-3.5 mm of bone width (Table 1). Although some studies using ramus grafts have shown slightly greater amounts of bone width, this is due to cortical grafts taken higher on the ramus being initially thicker than those taken in approximation to an impacted tooth.
Discussion:
TE D
The implant sites were exposed using the same incisions used for graft placement. Clinically all of the sites had adequate horizontal bone augmentation for successful implant placement.
AC C
EP
A common challenge faced by oral and maxillofacial surgeons is the horizontally deficient alveolar ridge in the location of a desired dental implant. These deficiencies can be due to trauma, tooth loss, pathology, or the congenital absence of teeth. Many options for management of these defects exist, assuming that an implant of appropriate diameter is to be placed and grafting at the time of surgery is not an option. These techniques include particulate bone grafting and guided bone regeneration (GBR) (3-5), tunneling techniques (6, 7) ridge splitting (8), tissue engineering (9), titanium mesh (10) and tenting screws (11). The horizontal gains documented for the various surgical techniques are predictable and result in a high percentage of successful implant placement. A block autograft harvested from the ramus of the mandible is a good, simple alternative in many cases when the GBR technique cannot be used. Such cortical grafts show little loss of volume and become incorporated in a relatively short time. It is an ideal procedure when an unerupted or impacted mandibular third molar is present since it allows tooth removal and graft harvesting through a single incision. The additional use of allogeneic bone and a barrier membrane improve the quantity of augmentation achieved, countersinking the
3
ACCEPTED MANUSCRIPT
fixation holes reduces potential irritation from the screw heads, and periosteal release assures a tension free closure and avoids wound dehiscence.
RI PT
References: 1. Misch, CM, The harvest of ramus bone in conjunction with third molar removal for onlay grafting before placement of dental implants. J Oral Maxillofac Surg 1999; 57:1376-1379.
SC
2. Lee, CYS. Procurement of autogenous bone from the mandibular ramus with simultaneous third-molar removal for bone grafting using the Er, Cr:YSGG laser: A preliminary report. J Oral Implantol 2005;31: 32-38.
M AN U
3. Dahlin C, Gottlow J, Linde A, Nyman S. Healing of maxillary and mandibular bone defects using a membrane technique. An experimental study in monkeys. Scand J Plast Reconstr Surg Hand Surg 1990; 24:13-19. 4. Buser D, Dula K, Belser U, et al. Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29-45.
TE D
5. Buser D, Dula K, Belser UC, et al. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int J Periodontics Restorative Dent 1995; 15:10-29.
EP
6. Block, Michael S, Kelley, B. Horizontal posterior ridge augmentation: The use of a collagen membrane over a bovine particulate graft: Technique note. J Oral Maxillofac Surg 2013; 71: 1513-1519.
AC C
7. Deeb GR, , Wilson GH, Carrico C, Laskin DM, Deeb JG. Is the tunnel technique more effective than open augmentation with a titanium-reinforced PTFE membrane for horizontal ridge augmentation? Journal of Oral and Maxillofacial Surgery, September 2016 (In Press) 8. Elnayef B, Monje A, Lin GH, Gargallo-Albiol J, Chan HL, Wang HL, Hernández-Alfaro F. Alveolar ridge split for horizontal bone augmentation: a systematic review. Int J Oral Maxillofac Implants. 2015; 3:596-606. 9. Mandelaris GA, Spagnoli DB, Rosenfeld AL, McKee J, Lu M. Tissue engineering for lateral ridge augmentation with recombinant human bone morphogenetic protein 2 combination therapy: a case report. Int J Periodontics Restorative Dent. 2015;35:325-33.
4
ACCEPTED MANUSCRIPT
10. Di Stefano DA, Greco GB, Cinci L, Pieri L. Horizontal-guided Bone Regeneration using a Titanium Mesh and an Equine Bone Graft. J Contemp Dent Pract. 2015:1;16(2):154-62.
RI PT
11. Caldwell GR, Mills MP, Finlayson R, Mealey BL. Lateral alveolar ridge augmentation using tenting screws, acellular dermal matrix, and freeze-dried bone allograft alone or with particulate autogenous bone. Int J Periodontics Restorative Dent. 2015; 35:75-83 10. Yates DM, Brockhoff HC 2nd, Finn R, Phillips C. "Comparison of intraoral harvest sites for corticocancellous bone grafts. J Oral Maxillofac Surg 2013; 71: 497-504.
Figure Captions:
TE D
M AN U
SC
11. Sittitavornwong, S, Rajesh G. Bone graft harvesting from regional sites. Oral Maxillofac Surg Clinics N A 2010; 22: 317-30.
EP
Figure 1. Intraoperative view of recipient sites for grafting congenitally missing laterals. It is important to keep vertical releases distant from the proposed graft sites and to release the periosteum for tension free wound closure.
AC C
Figure 2. Intraoperative photo of the incision design for third molar removal and simultaneous lateral ramus harvest.
Figure 3. Two fixation screw holes are drilled in the graft and countersunk to ensure that the screws will be flush with the graft. Figure 4. Intraoperative view of two ramus grafts secured with two fixation screws. Note that sharp edges have been rounded to decrease the chance of wound dehiscence. Figure 5. Intraoperative photo showing the adaptation of collagen membranes to the grafts after placement of allograft around the ramus graft periphery. 5
ACCEPTED MANUSCRIPT
Figure 6. 2 week postoperative view showing excellent soft tissue healing. There are two bracket retained plastic teeth being used as provisionals during graft healing.
AC C
EP
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M AN U
SC
RI PT
Figure 7. Four month postoperative CBCT at the time of implant planning showing the added alveolar width of 3.5mm after the ramus grafting procedure.
6
ACCEPTED MANUSCRIPT
Table 1. Retrospective Evaluation of Results Ag e (yrs )
Site s
Smoki ng History
Barrier Membra ne
1
F
17
7 10
No
Yes Yes
None None
2
F
18
7 10
No
Yes Yes
None None
3
M
19
8 9
No
Yes Yes
None None
4
M
18
9
No
Yes
5
F
20
10
No
Yes
6
M
24
6
No
Yes
7
F
28
11
No
Yes
None
8
F
17
8 10
No
Yes
None None
9
M
18
Yes
None None
Yes Yes
None None
F
38
7 10
No No
Graf t Los s
Horizont al Gain
Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e 5% Non e Non e Non e
3.4mm 3.3mm
Yes Yes
None None
3.5mm 3.2mm
Yes Yes
None None
2.7mm 2.8mm
Yes Yes
Transient Paresthesi a
3.2mm
Yes
None
3.3mm
Yes
None
2.7mm
Yes
None
3.2mm
Yes
None
2.8mm 3.1mm
Yes
None
3.0mm 3.1mm
Yes Yes
None None
2.7mm 2.9mm
Yes Yes
None None
M AN U None
None
None
TE D
EP No
AC C
10
7 10
Postop Infecti on
7
Implan ts Placed
Donor Site Complicatio ns
RI PT
Se x
SC
Patien ts
AC C
EP
TE D
M AN U
SC
RI PT
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TE D
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SC
RI PT
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SC
RI PT
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SC
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S0278-2391(16)31181-8
DOI:
10.1016/j.joms.2016.11.014
Reference:
YJOMS 57547
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 8 September 2016 Revised Date:
16 November 2016
Accepted Date: 16 November 2016
Please cite this article as: Deeb GR, Laskin DM, Deeb JG, Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.11.014. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series George R. Deeb, DDS, MDa, Daniel M. Laskin, DDS, MSb ,Janina Golob Deeb, DDS, MSc a
AC C
EP
TE D
M AN U
Corresponding Author: Dr. George R. Deeb 521 N. 11th Street PO Box 980566 Richmond VA 23298 [email protected]
SC
RI PT
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA b Professor Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA c Assistant Professor, Department of Periodontology, School of Dentistry, Virginia Commonwealth University, Richmond VA
ACCEPTED MANUSCRIPT
Simultaneous Impacted Third Molar Extraction and Lateral Ramus Block Graft Harvest for Horizontal Ridge Augmentation: A Case Series George R. Deeb, DDS, MDa, Daniel M. Laskin, DDS, MSb ,Janina Golob Deeb, DDS, MSc a
SC
RI PT
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA b Professor and Chairman Emeritus, Department of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Richmond VA c Assistant Professor, Department of Periodontology, School of Dentistry, Virginia Commonwealth University, Richmond VA
Abstract:
EP
Introduction
TE D
M AN U
Purpose: The purpose of this study was to confirm the efficiency of using a lateral ramus block graft taken at the time of impacted mandibular third molar removal for horizontal ridge augmentation and implant placement. Patients and Methods: Ten patients had grafts obtained from the lateral aspect of the mandible during impacted third molar removal placed in areas of horizontal ridge deficiency. Results: Measurements made on cone beam computerized tomograms after 4 months showed gains of 2.7-3.5 mm and 16 implants were placed successfully. Conclusions: In patients with impacted third molars requiring dental implants, simultaneous harvest of a lateral block bone graft is an efficient way of obtaining bone for horizontal ridge augmentation.
AC C
Inadequate alveolar bone width for dental implant placement is a frequently encountered problem. There are many surgical techniques available to reconstruct these horizontal defects, including an autogenous onlay graft harvested from the ramus of the mandible. In 1999, Misch described a technique in which such a graft could be harvested in conjunction with impacted third molar removal (1). Subsequently, Lee reported on 4 patients in whom a laser was compared to a bur for obtaining the graft, but he did not report the amount of augmentation that occurred or if implants were successfully placed (2). We present a series of cases in which this technique, with some modifications, was used to achieve successful dental implant placement.
Patients and Methods: 1
ACCEPTED MANUSCRIPT
RI PT
Ten consecutive healthy implant patients aged 17 to 38 years, with a total of sixteen alveolar deficiencies, were enrolled in this IRB approved study (Table 1). Inclusion criteria were the need for horizontal alveolar augmentation prior to dental implant placement, skeletal maturation, and the presence of an impacted mandibular third molar requiring extraction.
SC
Preoperatively, patients were administered an IV dose of clindamycin, 900mg, and sedated with Versed and Fentanyl. After obtaining local anesthesia of the edentulous site and the mandibular third molar region, the edentulous site was exposed using a crestal incision with bilateral vertical releases. If there were adjacent teeth, it was helpful to include a papilla of at least one tooth mesially and distally to keep the suture lines distant to the graft (Figure 1). A periosteal release was made on the flap to ensure tension free closure.
TE D
M AN U
Once the recipient site had been prepared, a full thickness buccal envelope flap with a distal buccal or hockey stick release was reflected for access to the impacted third molar (Figure 2). The interdental papilla between the first and second molar was included to improve access and aid in wound closure. The third molar was removed, conserving as much bone as possible. Once the tooth was removed, a fissure bur was used to create proximal and distal osteotomies through the lateral aspect of the ramus. After these cuts were made a round bur was used to create an inferior osteotomy connecting them. The graft was then removed using a dental elevator or osteotome (Figure 2).
AC C
EP
At this point, the graft was trial-fit to the recipient site. In some instances the recipient bed was prepared to accommodate the graft by creating an inlay type of preparation. The cancellous portion of the graft was removed with a rongeur and, if necessary, the graft was trimmed with a surgical handpiece. The goal was to get broad, intimate contact between the graft and the recipient bed, so the graft was tried in several different orientations. Once the graft was adapted to the recipient site, two fixation holes were made (Figure 3). A lag screw technique was used, so the holes were made slightly larger diameter than the fixation screws. Two screws is the preferred number to reduce graft mobility (Figure 4). A round bur was used to create a countersink in the graft so that the fixation screws would be flush with the graft and have less chance of causing wound dehiscence (Figure 3). The next step was to trim a resorbable collagen membrane (BioGuide) to cover the graft. When adjacent grafts were used, cancellous allogeneic bone was placed between the grafts in order to get additional bone formation (Figure 5). The resorbable collagen membrane was placed over the graft and the wound was closed with PTFE sutures in an interrupted fashion (Figure 5). Postoperatively, the patients were placed on clindamycin for 1 week and a chlorhexidine mouth rinse was prescribed. The sutures were removed after 10 days. Figure 6 shows a patient two weeks postoperatively. Approximately 4 months 2
ACCEPTED MANUSCRIPT
postoperatively a cone-beam computed tomogram was taken to evaluate the graft and plan for implant placement (Figure 7).
RI PT
Results: Postoperatively, none of the sites had wound dehiscence or infection, and only one exhibited minimal graft exposure of approximately 5% at a wound margin that was removed with a curette. One patient had transient paresthesia from the third molar removal.
M AN U
SC
Measurements made on the CBCTs showed gains between 2.7-3.5 mm of bone width (Table 1). Although some studies using ramus grafts have shown slightly greater amounts of bone width, this is due to cortical grafts taken higher on the ramus being initially thicker than those taken in approximation to an impacted tooth.
Discussion:
TE D
The implant sites were exposed using the same incisions used for graft placement. Clinically all of the sites had adequate horizontal bone augmentation for successful implant placement.
AC C
EP
A common challenge faced by oral and maxillofacial surgeons is the horizontally deficient alveolar ridge in the location of a desired dental implant. These deficiencies can be due to trauma, tooth loss, pathology, or the congenital absence of teeth. Many options for management of these defects exist, assuming that an implant of appropriate diameter is to be placed and grafting at the time of surgery is not an option. These techniques include particulate bone grafting and guided bone regeneration (GBR) (3-5), tunneling techniques (6, 7) ridge splitting (8), tissue engineering (9), titanium mesh (10) and tenting screws (11). The horizontal gains documented for the various surgical techniques are predictable and result in a high percentage of successful implant placement. A block autograft harvested from the ramus of the mandible is a good, simple alternative in many cases when the GBR technique cannot be used. Such cortical grafts show little loss of volume and become incorporated in a relatively short time. It is an ideal procedure when an unerupted or impacted mandibular third molar is present since it allows tooth removal and graft harvesting through a single incision. The additional use of allogeneic bone and a barrier membrane improve the quantity of augmentation achieved, countersinking the
3
ACCEPTED MANUSCRIPT
fixation holes reduces potential irritation from the screw heads, and periosteal release assures a tension free closure and avoids wound dehiscence.
RI PT
References: 1. Misch, CM, The harvest of ramus bone in conjunction with third molar removal for onlay grafting before placement of dental implants. J Oral Maxillofac Surg 1999; 57:1376-1379.
SC
2. Lee, CYS. Procurement of autogenous bone from the mandibular ramus with simultaneous third-molar removal for bone grafting using the Er, Cr:YSGG laser: A preliminary report. J Oral Implantol 2005;31: 32-38.
M AN U
3. Dahlin C, Gottlow J, Linde A, Nyman S. Healing of maxillary and mandibular bone defects using a membrane technique. An experimental study in monkeys. Scand J Plast Reconstr Surg Hand Surg 1990; 24:13-19. 4. Buser D, Dula K, Belser U, et al. Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29-45.
TE D
5. Buser D, Dula K, Belser UC, et al. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int J Periodontics Restorative Dent 1995; 15:10-29.
EP
6. Block, Michael S, Kelley, B. Horizontal posterior ridge augmentation: The use of a collagen membrane over a bovine particulate graft: Technique note. J Oral Maxillofac Surg 2013; 71: 1513-1519.
AC C
7. Deeb GR, , Wilson GH, Carrico C, Laskin DM, Deeb JG. Is the tunnel technique more effective than open augmentation with a titanium-reinforced PTFE membrane for horizontal ridge augmentation? Journal of Oral and Maxillofacial Surgery, September 2016 (In Press) 8. Elnayef B, Monje A, Lin GH, Gargallo-Albiol J, Chan HL, Wang HL, Hernández-Alfaro F. Alveolar ridge split for horizontal bone augmentation: a systematic review. Int J Oral Maxillofac Implants. 2015; 3:596-606. 9. Mandelaris GA, Spagnoli DB, Rosenfeld AL, McKee J, Lu M. Tissue engineering for lateral ridge augmentation with recombinant human bone morphogenetic protein 2 combination therapy: a case report. Int J Periodontics Restorative Dent. 2015;35:325-33.
4
ACCEPTED MANUSCRIPT
10. Di Stefano DA, Greco GB, Cinci L, Pieri L. Horizontal-guided Bone Regeneration using a Titanium Mesh and an Equine Bone Graft. J Contemp Dent Pract. 2015:1;16(2):154-62.
RI PT
11. Caldwell GR, Mills MP, Finlayson R, Mealey BL. Lateral alveolar ridge augmentation using tenting screws, acellular dermal matrix, and freeze-dried bone allograft alone or with particulate autogenous bone. Int J Periodontics Restorative Dent. 2015; 35:75-83 10. Yates DM, Brockhoff HC 2nd, Finn R, Phillips C. "Comparison of intraoral harvest sites for corticocancellous bone grafts. J Oral Maxillofac Surg 2013; 71: 497-504.
Figure Captions:
TE D
M AN U
SC
11. Sittitavornwong, S, Rajesh G. Bone graft harvesting from regional sites. Oral Maxillofac Surg Clinics N A 2010; 22: 317-30.
EP
Figure 1. Intraoperative view of recipient sites for grafting congenitally missing laterals. It is important to keep vertical releases distant from the proposed graft sites and to release the periosteum for tension free wound closure.
AC C
Figure 2. Intraoperative photo of the incision design for third molar removal and simultaneous lateral ramus harvest.
Figure 3. Two fixation screw holes are drilled in the graft and countersunk to ensure that the screws will be flush with the graft. Figure 4. Intraoperative view of two ramus grafts secured with two fixation screws. Note that sharp edges have been rounded to decrease the chance of wound dehiscence. Figure 5. Intraoperative photo showing the adaptation of collagen membranes to the grafts after placement of allograft around the ramus graft periphery. 5
ACCEPTED MANUSCRIPT
Figure 6. 2 week postoperative view showing excellent soft tissue healing. There are two bracket retained plastic teeth being used as provisionals during graft healing.
AC C
EP
TE D
M AN U
SC
RI PT
Figure 7. Four month postoperative CBCT at the time of implant planning showing the added alveolar width of 3.5mm after the ramus grafting procedure.
6
ACCEPTED MANUSCRIPT
Table 1. Retrospective Evaluation of Results Ag e (yrs )
Site s
Smoki ng History
Barrier Membra ne
1
F
17
7 10
No
Yes Yes
None None
2
F
18
7 10
No
Yes Yes
None None
3
M
19
8 9
No
Yes Yes
None None
4
M
18
9
No
Yes
5
F
20
10
No
Yes
6
M
24
6
No
Yes
7
F
28
11
No
Yes
None
8
F
17
8 10
No
Yes
None None
9
M
18
Yes
None None
Yes Yes
None None
F
38
7 10
No No
Graf t Los s
Horizont al Gain
Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e Non e 5% Non e Non e Non e
3.4mm 3.3mm
Yes Yes
None None
3.5mm 3.2mm
Yes Yes
None None
2.7mm 2.8mm
Yes Yes
Transient Paresthesi a
3.2mm
Yes
None
3.3mm
Yes
None
2.7mm
Yes
None
3.2mm
Yes
None
2.8mm 3.1mm
Yes
None
3.0mm 3.1mm
Yes Yes
None None
2.7mm 2.9mm
Yes Yes
None None
M AN U None
None
None
TE D
EP No
AC C
10
7 10
Postop Infecti on
7
Implan ts Placed
Donor Site Complicatio ns
RI PT
Se x
SC
Patien ts
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
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SC
RI PT
ACCEPTED MANUSCRIPT
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SC
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ACCEPTED MANUSCRIPT
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SC
RI PT
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