Oral Surgery Procedures

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Dental Implants - Bone Grafting - Wisdom Teeth - Obstructive Sleep Apnea - Impacted Canines
Facial Trauma - Jaw Surgery - Oral Pathology - TMJ Disorders - Cleft Lip & Palate - Platelet Rich Plasma

Bone Grafting Charlotte NC

Major and Minor bone grafting

Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants.

Today, we have the ability to grow bone where needed. This not only gives us the opportunity to place dental implants of proper length and width, it also gives us a chance to restore functionality and esthetic appearance. If you think you may be a candidate for bone grafting in Charlotte NC, please call us at 704-358-8898 for a consultation.

Major Bone Grafting

Bone grafting can repair dental implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone is either obtained from a tissue bank or your own bone is taken from the jaw, hip or tibia (below the knee.) Sinus bone grafts are also performed to replace bone in the posterior upper jaw. In addition, special membranes may be utilized that dissolve under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration.

Major bone grafts are typically performed to repair defects of the jaws. These defects may arise as a result of traumatic injuries, tumor surgery, or congenital defects. Large defects are repaired using the patient’s own bone. This bone is harvested from a number of different sites depending on the size of the defect. The skull (cranium), hip (iliac crest), and lateral knee (tibia), are common donor sites. These procedures are routinely performed in an operating room and require a hospital stay.

Sinus lift procedure

The maxillary sinuses are behind your cheeks and on top of the upper teeth. Sinuses are like empty rooms that have nothing in them. Some of the roots of the natural upper teeth extend up into the maxillary sinuses. When these upper teeth are removed, there is often just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place. When the sinus wall is very thin, it is impossible to place dental implants in this bone.

There is a solution and it’s called a sinus graft or sinus lift graft. The dental implant surgeon enters the sinus from where the upper teeth used to be. The sinus membrane is then lifted upward and donor bone is inserted into the floor of the sinus. Keep in mind that the floor of the sinus is the roof of the upper jaw. After several months of healing, the bone becomes part of the patient’s jaw and dental implants can be inserted and stabilized in this new sinus bone.

The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option other than wearing loose dentures.

If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the Sinus Augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the dental implants can be placed.

Ridge Expansion

In severe cases, the ridge has been reabsorbed and a bone graft is placed to increase ridge height and/or width. This is a technique used to restore the lost bone dimension when the jaw ridge gets too thin to place conventional dental implants. In this procedure, the bony ridge of the jaw is literally expanded by mechanical means. Bone graft material can be placed and matured for a few months before placing the dental implant.

Nerve- repositioning

The inferior alveolar nerve, which gives feeling to the lower lip and chin, may need to be moved in order to make room for placement of dental implants to the lower jaw. This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molars and/or and 2nd premolar, with the above-mentioned secondary condition. Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates only very slowly, if ever), usually other, less aggressive options are considered first (placement of blade implants, etc.)

Typically, we remove an outer section of the cheek side of the lower jawbone in order to expose the nerve and vessel canal. Then we isolate the nerve and vessel bundle in that area, and slightly pull it out to the side. At the same time, we will place the implants. Then the bundle is released and placed back over the implants. The surgical access is refilled with bone graft material of the surgeon’s choice and the area is closed.

These procedures may be performed separately or together, depending upon the individual's condition. As stated earlier, there are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patient’s own bone for repairs, we generally get the best results.

In many cases, we can use allograft material to implement bone grafting for dental implants. This bone is prepared from cadavers and used to promote the patients own bone to grow into the repair site. It is quite effective and very safe. Synthetic materials can also be used to stimulate bone formation. We even use factors from your own blood to accelerate and promote bone formation in graft areas.

These surgeries are performed in the out-office surgical suite under IV sedation or general anesthesia. After discharge, bed rest is recommended for one day and limited physical activity for one week.

Bone Grafting Options

Maxillary (ie: Upper Jaw) and Mandibular (ie: Lower Jaw) Bone Grafting is the replacement or augmentation of the portion of the jaw bone that anchors the teeth, utilizing one or more variety of surgical techniques. These techniques and procedures are often performed in order to reverse the loss (or resorption) of bone that may have occurred due to tooth loss, trauma, disease or ill-fitting dentures, and to rebuild the bone structure beneath the gums in preparation for the placement of dental implants or other tooth replacements. “Sinus Lifts”, “alveolar bone grafting”, and “socket grafts” are procedures which are commonly performed by Oral & Maxillofacial Surgeons in their daily practice.

Techniques used to correct bone deficiencies vary, and are applied to different types of bone defects (alveolar and socket defects are generally categorized as being either “vertical” bone defects, “transverse” bony defects, or some combination thereof- and may often refer to the number of “walls” involved in the defect)- ie: alveolar bone will commonly resorb in either the vertical or transverse dimension (or some combination thereof) following removal of teeth. Understand that some types of grafting or surgical techniques are better suited for correcting vertical defects (ie: such as “distraction” or “sinus lift grafting”), while some other techniques are better suited for correcting transverse defects in the bone (ie: “ridge splitting”, or “onlay” bone grafting).

Socket grafting is sometimes performed after a tooth has been removed in order to more reliably allow the bony socket to infill with bone (this is most commonly indicated when the anterior (or front) wall of the socket is damaged or missing- either as a result of infection, or as a result of the extraction procedure). If sockets with these defects are not grafted, then a bony defect will result; the ensuing defect commonly prevents straightforward implant placement after healing has taken place- thereby requiring subsequent reconstructive bone grafting before an implant can be placed.

In cases where there is no bony defect that exists after tooth removal, normal bone healing typically results in early bone infill into the area in a 4-6 month time frame (hence, grafting is not typically indicated in these situations). In these cases however, dental implants are generally recommended to be placed within this 4-6 month interval because delayed placement beyond this time frame may allow the bone volume to contract or shrink, resulting in a bony defect (this is why your surgeon may recommend placement of a dental implant either immediately following tooth extraction, or within the 4-6 month interval following extraction). Waiting beyond this time interval for implant placement is commonly detrimental, as bone contraction and shrinkage occurs, altering normal anatomy and sometimes preventing subsequent uncomplicated implant placement. Alveolar bone shrinkage following tooth extraction is progressive, and, if not addressed, will continue for the entire lifespan of the patient.

As opposed to bone grafting (where there is an attempt to add volume to bone that is present), the techniques of Alveolar Distraction and Alveolar Ridge Splitting attempt to make use of residual bone that is present, by either expanding this bone (as with Ridge Splitting), or growing more bone (as with Distraction Osteogenesis).

When bone graft material (of any type) is implanted in the jaw, it doesn't just simply fill a void in the bone; it may also help promote new bone growth in that location. When successful, bone grafting can restore both the height and width of your jaw bone.

You have multiple options/ alternatives for the specific materials or technique used in your bone replacement surgery. Each of these options has certain pros and cons, and they differ not only in how they help promote bone formation, but also in costs and potential risks and benefits. The following discussion is designed to help educate you regarding your options, however, more specific details regarding your specific clinical need and information related to the techniques listed below can be obtained from your doctor:

:Bone Grafting materials are generally grouped into one of four broad categories

Autogenous Bone Grafts

Also called autografts, these types of grafts are made from the patient's own bone, harvested from elsewhere in the body. Typical harvest sites include the chin, jaw, bone of the lower leg (tibia), hip (iliac crest) or the skull (cranium).

Autogenous bone graft has traditionally been considered the "gold standard" as a graft material because it is "live bone" complete with the living cellular elements that enhance bone growth. These include osteogenesis (bone formation from cells), osteoconduction (bone formation via migration upon a scaffold) and osteoinduction (bone formation by proteins such as BMP [bone morphogenetic proteins], which direct cells to form new bone). When bone is transferred using this technique, commonly only 8-10% of the transferred cells remain viable.

A potential downside of autogenous bone grafting, however, is that it involves a second procedure (and second surgical site) to harvest the bone, which may be painful and not in some patients' best interest, depending on their condition (a second surgical site also carries the risks of harvesting [which may involve complications such as nerve damage or infection] in that location). It also may not be a viable option in instances where the patient's overall bone quality and/or density is poor, or when a large volume of graft material is required. As this material is derived from the same person in whom it is being used, communicable infectious risks (ie: transmitted from another individual) are nonexistent. Grafting within the oral cavity, however, is potentially problematic, as the oral cavity (even in the same individual) is considered a contaminated region, and infection due to contamination may result. Antibiotics are commonly prescribed as a prophylactic measure when this technique is used, however, infection may still ensue.

Unique forms of autogenous bone grafting involves the techniques of Distraction Osteogenesis (DO) and Alveolar Ridge Splitting (as noted above). The technique of DO involves creating a bone cut (osteotomy) over which tension is gradually applied with a distraction device (after an initial period of immobilization). The tensile force induced by the device induces the body to lay down (or form) new bone. DO is commonly used to grow bone in large (discontinuity) defects of the jaw, in repositioning of major jaw segments, or in isolated vertical defects of the upper or lower alveolar jaw bone (transverse alveolar defects are not as easily dealt with using DO, as this is where alveolar ridge splitting is commonly applied). DO requires placement of a distraction device, and this device has to be removed after a period of approximately 8-9 weeks. Costs for this technique are generally higher, due to the costs of the device, surgical procedure, and device removal. In ridge splitting, a transversely narrowed ridge is carefully split (while carefully preserving blood supply to both sides of the bone) and wedged apart, and dental implants are placed immediately into the intervening gap to maintain the expanded state. Bone then fills the gap over the course of the ensuing six month period.

Allogeneic Bone

Allogeneic bone, also called allograft, is bone derived from a genetically unrelated member of the same species. It's typically non-vital (dead) bone harvested from a cadaver, then processed using a freeze-drying method that extracts all the water via a vacuum.

Allogeneic bone cannot produce new bone on its own – it's neither osteogenic (like autograft) nor osteoinductive (like BMP). Rather, its primary mechanism of action is that it is osteoconductive, and serves as a framework or scaffold over which bone from the surrounding bony walls can grow to fill the defect or void. Also, as this material is harvested from a cadaver source, there is always theoretical (albeit minimal) risk of infection or communicable disease transmission. These materials are generally purchased from reliable vendors who adhere to standards for procurement and processing according to the American Association of Tissue Banks.

Xenogenic Bone

Similar to allogeneic bone, xenogenic bone is non-vital bone derived from another species, usually a cow. Because the potential for immune rejection and contamination by viral proteins is higher in bovine bone than in human cadaver bone, xenograft material is processed at very high temperatures (600-1,000 degrees Celsius). Xenograft's mechanism of action is similar to that of allograft – it serves as an osteoconductive framework on which bone from the surrounding area can grow to fill the void. While no recorded case has originated from xenogenic bone grafting, bovine spongiform encephalopathy (BSE)- similar to “mad-cow” disease, is a prion disease linked to bovine sources.

The above grafting options are preferred by many patients and dental professionals alike because they eliminate the potentially painful second harvesting procedure. However, because both allografts and xenografts lack autograft's bone forming properties, bone regeneration may take somewhat longer than it does when using the patient's own bone and the outcome may be less predictable or reliable. Transmission of disease from the donor to the recipient is a theoretical risk with the use of allografts and xenografts.

Bone Morphogenetic Proteins

Bone morphogenetic proteins (BMPs) are proteins naturally produced in the body that regulate bone formation and healing. A commercially available recombinant BMP is INFUSE® Bone Graft (rhBMP-2/ACS). The active ingredient in INFUSE® Bone Graft – rhBMP-2 – is a manufactured version of a protein already present in the body that promotes new bone growth.

Commercially Available Bone Graft Substitutes

Bone graft substitutes are commercially produced synthetic products that have many of the same bone forming properties as human bone, and are a safe and proven alternative to autograft and allograft.

One of the advantages of using a bone graft substitute instead of autogenous bone is that it eliminates the need to harvest the patient's own bone, thus potentially reducing the risk and pain associated with the harvest procedure.

Some bone graft alternatives include:

Demineralized Bone Matrix (DBM)/ Demineralized Freeze-Dried Bone Allograft (DFDBA)/ Mineralized Bone Allograft/ “Banked Bone” — a product of processed allograft bone, DBM/DFDBA contains collagen, proteins and growth factors that are extracted from the allograft bone. It is available in the form of a powder, crushed granules, putty, chips or as a gel that can be injected through a syringe. These materials are typically resorbed by your body after placement, and generally work to form a latticework for your body’s own osteoprogenitor cells to adhere to. As these materials are essentially allograft materials, the same risks of allografts as noted above apply to these materials. Puros is a commercially available preparation of mineralized allograft.

Bone Ceramics—Ceramics are also used as a substitute for bone grafts, and are available in many forms such as porous and mesh. Although ceramics may provide a framework for bone growth (ie: are osteoconductive), they contain none of the natural proteins that influence bone growth and may be associated with inflammation in some patients (they are not osteoinductive or osteogenic). Since these materials are man-made, there is minimal, if any, infectious risks with the use of these materials. These materials are generally resorbed by the body over time, hopefully replaced by normal bone. Cerasorb (Beta Tri-Calcium Phosphate), Perioglass, and Hydroxylapetite are examples of bone ceramics.

Graft Composites—Graft composites use combinations of other bone grafting materials and/or bone growth factors to gain the benefits of a variety of substances. Typical combinations in use today include: a collagen/ceramic composite, which closely reproduces the composition of natural bone; DBM combined with bone marrow cells, which aid in the growth of new bone and a collagen/ceramic/autograft composite.

Some of these materials may resorb gradually; if they do not resorb quickly enough, drilling through this material (at the time of implant placement) may be problematic. BioOss is an example of a xenogenic graft composite material.

Bone morphogenetic proteins, or BMPs, have been studied for decades because of their remarkable ability to heal bone and eliminate the need for bone graft harvesting from other parts of the body. Approximately 20 BMPs have been discovered, but only six appear capable of initiating bone growth. Of these, rhBMP-2 has been studied more than any other BMP and is FDA approved for use in certain spinal, tibial (leg) and oral and maxillofacial surgeries.

Naturally occurring BMP is found within the bone itself, but only in small amounts. To provide clinically useful and reproducible amounts of isolated, human BMP, it must be manufactured in a special facility.

Scientists isolated the gene for one protein (BMP-2) from bone tissue and used well-established molecular biology techniques to create genetically engineered cells. These cells then produce large quantities of rhBMP-2. A similar process is used to manufacture other proteins, such as insulin. The recombinant form of rhBMP-2 is identical to the natural form in both its chemistry and its ability to grow new bone.

During surgery, rhBMP-2 is soaked onto and binds with an absorbable collagen sponge (ACS) that is designed to resorb, or disappear, over time. As the sponge dissolves, the rhBMP-2 stimulates the cells to produce new bone. The rhBMP-2 also goes away once it has completed its task of initiating the normal bone healing process.

rhBMP-2 may be used to promote bone growth in several areas of the body. In the spine, the rhBMP-2 grows bone in the disc space to join or fuse the vertebrae to reduce back pain and stabilize the spine. In certain tibial fractures, rhBMP-2 has been shown to help heal broken bones. In instances of jaw bone resorption, rhBMP-2 may be placed in the section or sections of the jaw bone that need to be built back up in preparation for dental implants.

What Are The Benefits of INFUSE® Bone Graft?

One of the primary advantages of INFUSE® rhBMP-2 Bone Graft is that it is an alternative to autograft – the use of autogenous bone (from the hip, rib, leg, jaw or chin) for implantation into a void or defect elsewhere in the body, such as the bones of the jaw.

Prior to INFUSE® Bone Graft, autogenous bone traditionally provided patients with the best grafting results in oral surgeries such as a sinus or socket augmentation. INFUSE® Bone Graft eliminates the need for the bone-harvest surgery that autograft requires, an additional procedure that, depending on the location, may be painful for some patients and lengthen the overall healing process. As this material is derived via a recombinant method, there is essentially no infectious risk associated with use of this product, as seen with allografts and xenografts.

INFUSE® Bone Graft also may be used for oral procedures in which autogenous bone is not typically used, such as a localized alveolar ridge augmentation. INFUSE® Bone Graft may restore bone in the extraction socket of a tooth that has been removed, allowing for future dental restoration such as the placement of dental implants.

INFUSE® Bone Graft:

Provides proven, predictable bone formation.
Offers safety benefits by eliminating the need for bone to be harvested from the patient.
Is supported by extensive research and clinical results.
Has an active ingredient called rhBMP-2, a manufactured version of a protein found naturally in the body, and offers the potential for both bone growth and improved patient healing.

INFUSE® Bone Graft's unique mechanism of action promotes new bone formation:

The application of INFUSE® Bone Graft results in the induction of normal bone at the site of implantation.
The process includes the attraction of the patient's own bone-generating cells into the site.
The bone induced by INFUSE® Bone Graft is normal physiologic bone.

How Is INFUSE® Bone Graft Used?

During your procedure, the rhBMP-2 protein, which is in powder form, is mixed with sterile water. The solution is then soaked into the ACS. Your surgeon will then place the protein-soaked ACS into the space he or she has prepared and then follow the normal surgical care protocol for your procedure.

The specific details of your particular oral surgery will vary, depending on the condition to be treated. Please discuss your treatment plan and the use of INFUSE® Bone Graft thoroughly with your dental surgeon.

Disadvantages of INFUSE® Bone Graft Material

While research on INFUSE® rhBMP-2 has taken place over the past 10-20 years, widespread use in the public is just now beginning. As with any new medical technology, INFUSE® rhBMP-2 is currently an expensive treatment alternative. As with all new medical technologies, costs are a factor, with current minimum costs of approximately $2500 (for an extraction socket)- and upwards of $4000-5000 for use in bilateral sinus lifts (some medical insurance plans may provide coverage for use of this product, but this is difficult to predict). Please ask your doctor for an estimate of the volume of INFUSE® rhBMP-2 required for your specific planned procedure.

INFUSE® rhBMP-2 should not be utilized in pregnant women, or in those women anticipating pregnancy within the next year. Use of this product in persons less than 18 years of age has not been studied. If you are hypersensitive to bovine (cow) Type I collagen or recombinant human Bone Morphogenetic Protein-2, you should not receive this product. Those persons with active cancer are not candidates for use of INFUSE® rhBMP-2, as are those with active infections close to the area of planned placement of this product.

This product has not been tested for the following:

To determine if there are side effects if it is used more than once in the same patient.
In the lower jaw (mandible) or in molar sites.
In people who are experiencing problems with their liver or kidneys - organs involved in the removal of any graft material by-products.
In people who have bone-weakening diseases.
In people with autoimmune or immunosuppressive disease, such as lupus or HIV/AIDS.
In people with immune deficiency due to other treatments, such as radiation therapy, chemotherapy or steroid therapy.
Persons less than 18 years of age.

Although not seen in studies performed by the manufacturer, there is a remote possibility that too much bone may form at the implantation site (exuberant bone formation) or bone may form at a location away from the implant site (ectopic bone formation).

Please discuss with your doctor any questions you have related to the above material, or questions related to your unique and specific procedure.