Running Time: 58 min
Ridge Augmentation: Decision Tree
Release Date: March 31, 2017Subtitle:
[MUSIC PLAYING] Welcome, my colleagues from gIDE. It’s a privilege for me to return here talking to you. I must first, of course, thank Dr. Sascha for the invitation, Beau for setting everything here behind the camera, and of course I have to thank you for taking your time to see my presentation. And today I have a very challenging situation here to be, because the topic of the presentation is ridge augmentation. And talking about ridge augmentation itself is really challenging. But most importantly, talking in the website that was created by Sascha Yovanovic, who is one of the fathers of the gIDE bone regeneration procedure, makes this a little bit more challenging for me. But I’m not going to try to cover the whole package with you. If you want to really understand everything, you should pretty much make the courses from gIDE with Sasha and the other teachers. You’re going to probably learn a lot about this topic. Today, I’m going to provide you a very humble and simple decision tree of how to attack the cases that I see in my private office every day. So how can I manage my patients, knowing some specific aspects and to find the best treatment options for my patient? So this is the topic of my conversation today. So these are some of the patients that you can find in your everyday practice. These are patients, of course, that they don’t have the availability of bone necessary to place the implants in the proper way. So if you want to find excellence in your practice in the face of the presence of the real deformities, you should think considering ridge augmentation. It’s very important to understand that ridge augmentation is not a clinical procedure. This is a clinical objective. And what we mean by that is to understand that when you see a clinical situation such as this one that precludes you from placing the implant in the prosthetically driven position, or at least you don’t have the amount of bone necessary to do so, you should perform some kind of clinical procedure in order to be able to recreate a nice volume in the horizontal and vertical dimensions that allows you to place the implant in the proper three-dimensional position with the formation of living hard enough bone that is capable to be drilled so that you can place your implants that eventually will be also integrated and will be eventually loaded and must resist the test on time. And they shall also support the soft tissues. And that can be life changing for the patients. That can be aesthetically life changing for some patients, such as this patient that lost her front interior teeth. And we are able to recreate the bone and make some implants and finally deliver a nice prosthetic resolution for this patient. That is very nice, as you can see. And it can also be functional life changing for most of the patients, such as this case that the patient came into the office with those teeth remaining. And with suggestion to remove all her teeth, but the patient just doesn’t want it. So is it possible to recreate a good amount of bone to this patient and deliver her a prosthetic nice resolution? Of course it is. So this is what I’m going to talk to you about today. Ridge augmentation can be performed either staged, where you first recreate the bone and several months later you place your implants in a best scenario as possible or you can do that simultaneously to the placement of the implant, which is always very interesting because it has some operational advantages, such as eliminating one surgery, decreasing the overall treatment time, decreasing the morbidity of the patient, and also decreasing the cost of the overall procedure. But when should you do what? And to answer that, you have to address another question. And the question is, is it possible to place the implant in the perfect three-dimensional position despite the bone deficiency? If you answer yes to that question, of course that you can consider going for the simultaneous approach. On the other hand, which is very common in treating those cases, which we say no, it’s not possible to place the implant in the perfect three-dimensional position. So you should probably go for the staged solution. There are of course, many clinical procedures that can be performed. And it pretty much depends on the background of the clinician. If he is a maxillofacial surgeon, if he is implant related, or if he has periodontal background. Some other aspects such as the soft tissue quality has to be addressed at first. Sometimes we have to consider performing some soft tissue augmentation to improve the quality of the soft tissues. But most importantly, what is the defect anatomy? And that will define the course of the treatment to me. So right now, I’m entering to the decision tree that I told you that I would provide. In my understanding, there are two kinds of defects. There are the vertical defects, and there are the horizontal defects. I cannot name another kind of defect. What is a vertical defect? A vertical defect is like this one that you are seeing, clinically and in the CT scan, in which you can appreciate the presence of bone peaks adjacent to the bone defect. They are more coronal to the base of that defect. That means that the connection of one bone peak to another is not a straight line. But it’s like a curved line. And that creates the vertical deficiency or sometimes we call it like a three-dimensional deficiency. Or you can see a horizontal defect, and those are horizontal deficiencies where you can appreciate that the bone peaks adjacent to the defect are in the same line. So when you bridge those adjacent bone peaks, it’s a straight line as opposed to the sloped line that we just saw in the vertical deficiencies. But whenever you see a horizontal defect, you have to further characterize it. And to do that, you must have a cone beam CT to see if there is or not the metal or bone in between the cortical plates. In the middle, you can appreciate that in between the buccal and the palatal bone plates, we have the medullary bone, which has cellular, vascular, and growth factor supply to nourish the graft that’s going to be positioned, as opposed to the defect on the right that you cannot see the medullary spaces in between the cortical plates. As a matter of fact, it’s only one cortical plate present. We also like to say this is a knife-edge defect. So how to treat the vertical deficiencies. You can do, for instance, a bone block procedure which is a very popular procedure. A lot of people would do that. But I think this is not a very good alternative to use in the vertical deficiencies, because the bone blocks are very difficult to shape, to adapt, to fixate, and most importantly, they are difficult to be revascularized. So I don’t think it’s a very good idea to do a bone block in the vertical deficiencies. Another option to treat the vertical deficiencies is the destruction of the genesis procedures, which are solid alternatives with very, very nice results. But they are very technically sensitive, and they do not apply to every configuration of the defect. So in my opinion, another alternative is the guided bone regeneration, which is definitely the most versatile technique that we can use in those procedures, because the membrane that is the key to use the guided bone regeneration can be applied to any kind of configuration of the defect. It doesn’t matter if it’s horizontal. It doesn’t matter if vertical. You just can apply and wrap the defect using your membrane in a very nice way, in such a way that the membrane will preclude the soft tissue cells to participate in the healing process below the membrane, allowing participation of the cellular components from the bone to take over and create the nice environment for the recreation of new bone. So this is what we do in the vertical ridge augmentation as well as the horizontal ridge augmentation procedures. Specifically in the vertical ridge augmentations, the membrane or the device has to be rigid in order to really be able to contain the graft material that’s going to be positioned below that membrane. And we can either use titanium reinforced barrier membrane or you can use a titanium mesh. But a titanium mesh is not a membrane, because it’s perforated. So it doesn’t fulfill the criteria for guided bone regeneration. So if you are using a titanium mesh, you should cover it with a resorbable barrier membrane. The vertical defect to be treated with a guided bone regeneration, you should use rigid device. So you can use either a titanium ring force at the barrier membrane or a titanium mesh. And this is very important because the configuration of the defect is very challenging. So you must have something rigid to really be able to contain the graft below the device, creating a nice shape, like a box shape, to contain the graft and keep it there for the healing period. So if you are using a titanium mesh, which is perforated, it doesn’t fulfill the criteria of the guided bone regeneration. So in order to fulfill that, you should cover it with resorbable barrier membrane. Both alternatives should work well, and they do work quite interestingly. However, when you have exposure of the devices, you can really understand the difference between those. So when you have exposure of the titanium reinforced membrane, you have something very inflamed and with the tendency to accumulate pus below the membrane, because the membrane is stiff and the plaque accumulation will migrate under the flap, which will create all this dramatic scenario that is very difficult to manage. On the other hand, when you have exposure of a titanium mesh, because of this porotic nature of titanium mesh, it doesn’t allow the plaque to migrate below the flap. So that is a little bit more friendly for the soft tissues. So we have to weigh whether using one device or another device. I have to tell you that the titanium mesh, which is friendly for the soft tissues, is also very difficult to remove, especially when you have thin tissues. So the clinician has to anticipate what to use in each situation. In our decision tree, we like to use the titanium reinforced barrier membranes in the posterior area of the mouth, either the maxilla or the mandible, because it’s easier to adapt, easier to place, and most important, easily to be removed. But when there is a problem, the soft tissues will suffer a little bit more. But that is in the posterior region of the mouth. On the other hand, when we are treating anterior defects, we like to use the titanium meshes that, of course, are more challenging to place and most importantly to remove. But when there is a problem, the soft tissue problems are better handled because of this nature of these porotic characteristics of the titanium mesh. Whenever you are doing the vertical ridge augmentation, we like to use the tenting screws to support the membrane. That will create like a reference for our vertical augmentation. And that will also help the membrane not to collapse to the inside of the defect. And that shall help you to improve your clinical situation. What is very important to understand is the height of the head of the screw. Whenever you are doing the vertical deficiencies, the tenting screws should be positioned to the height of the bone adjacent peaks, which will determine the magnitude of anticipated bone augmentation that can be achieved in your cases. And of course, you have to use the grafting material, which is particulate. And below the membrane, we should put our particulate graft, which is composed of 50% of autologous bone and 50% of xenograft. This combination is pretty much used, and there’s a lot of scientific information supporting it’s efficacious. And we should always use the autologous bone at 50% in order to bring with the autologous bone the necessary information to the recreation of bone. So we need the cells and the growth factors that are inside the autologous bone. In our understanding, we should not use 100% of autologous bone, because when you use 100% of autologous bone in those defects, the morbidity associated to the harvesting procedure has to be considered, number one. And number two, and most importantly, that there is a tendency that the bone formant is a little bit softer. And a softer bone has a tendency to resorb through time. So we have to add this 50% of xenograft Bio-Oss– particulated Bio-Oss– and that will decrease the morbidity related to the bone harvesting procedure, because now we have only to remove 50% of the bone necessary to fill the defect. The xenograft has a low resorption rate, which will keep the volume of the regenerated bone in a very nice way. And there is a tendency not to lose that bone, which is a little bit harder, as opposed to only 100% of autologous bone. Some people ask why should we not use 100% of Bio-Oss in those cases? And that is because Bio-Oss is only a matrix to help the formation of bone. It doesn’t have within the information– the biological information– necessary to recreate the bone. So this kind of combination seems to be very important. In this moment that you have this bone composite graft in position, you can add whatever you want. Any kind of biologics that you like to use like BMP or PDGF blood-borne product. They are also very nice materials to speed up the process and help the bone formation to take place. But don’t use this kind of combination of 50% of autologous, 50% of Bio-Oss in order to be really successful in your cases. How can we treat the horizontal defects? So the favorable horizontal defect, which is this one in which you can appreciate the presence of medullary bone in between the cortical plates, you can treat in several ways. Sometimes it’s possible to do the ridge splitting procedure when you have a sufficient amount of bone, at least 3 millimeters of thickness. Of course, the presence of the medullary bone in between the corticals. The height of the residual ridge would be at least 10 millimeters. And most importantly, the length. And most importantly, the long axis of the implant that is intended to be placed has to be parallel to the preexisting ridge in order to be able to insert the implant in the prosthetically driven procedure. So if you do the ridge splitting procedure, you should also think about adding to this procedure the bone graft, which in this case is only xenograft, in between the expanded bone plates and on the external ridge in order to increase the dimension of that area. And you should obviously cover that with a resorbable barrier membrane in this situation. Sometimes you can do a bone block procedure, which is a very, very nice indication for this situation. As a matter of fact, in my opinion, this is the only indication for the bone block procedure in the horizontal favorable defect. Why? Because you have some residual thickness that will enable you to screw your block into position. And the residual ridge has the medullary spaces with the cells, the vessels, and the growth factors that are necessary to revascularize and make this block to take in this area. If you do a bone block procedure, you should complete the procedure as well using the guided bone regeneration procedure, which is placed in the xenograft around and on top of your block. And you have to cover that block with Bio-Gide membrane in order to avoid some resorption of that case. This is a very nice alternative, as you can see here. But in my, opinion I really don’t like using the bone block for my patients, because it has a lot of morbidity associated to the harvesting of the bone blocks, number one. And number two and most importantly, the ridge resorbs from the buccal and the palatolingual aspect. When you do a bone block procedure, you are growing the bone only into that direction. You are not growing the bone in the lingual direction. So that means that the ridge augmentation is not three-dimensional. So I like to use a more three-dimensional approach with less invasivity to my patients. Because of that, I’m not using this technique, and I’m pretty much using the guided bone regeneration in those cases. Well, in that situation, we should always use the tenting screws or at least this is a good alternative to be used. So the tenting screws as well will have to support the membrane from collapsing to inside the bone deficiency. And that will create like a reference for our reconstruction. Again, the height of the head of the screws should be leveled to the bone prominences of the adjacent teeth in such a way to recreate the shape of the preexisting bone that was there before the tooth was lost. So observing the adjacent teeth is pretty much going to tell you the amount of bone that is required for that reconstruction. And the height of the screws should be leveled or a little bit far away but not too much to this height of the bone prominences of the adjacent teeth. What is the number of tenting screws that you should use? It’s pretty much depending on the clinical situation. You can place one, two, or three, sometimes even more, but pretty much it’s like a decision in the moment, in such a way that you can apply the screws at the specific points in such a way to avoid this collapsing of the membrane inside the material. Now we’re going to use our graft material, which is 50% of autologous, 50% of xenograft, for the same reasons that I just mentioned to you, to the vertical ridge augmentation. And you should probably use your membrane. And the membrane that should be used on top of that is a resorbable barrier membrane, because this material is very effective to contain the grafting material. And the same moment, if there is a problem like a dehiscence, the exposure of that membrane is going to be very quickly resolved by the body, because the membrane is going to resorb, and the tissue will close like automatically without a problem. The treatment of unfavorable horizontal defect is a little bit more challenging. It much more resembles to a vertical deficiency, because you don’t have the cells, you don’t have the vascular supply and the growth factors in that area, because the site is lacking the medullary spaces in that area. So you cannot apply the same techniques that are just described for the horizontal favorable defects. You cannot apply the ridge splitting technique, of course. And it’s very difficult to apply the bone block procedure in this kind of defect. Why? Number one, it’s difficult to fixate the block, and even if you can fixate it in some place, there is no cellular, vascular, and growth factors in that area to nourish and revascularize that graft. So that situation is not well indicated to the unfavorable horizontal defect. So actually what we do in those cases is applying particulated graft like a 50% autologous, 50% xenograft the same way and cover that with resorbable barrier membrane. But in this case, it’s not possible to place the tenting screws, because the bone is so thin that you cannot really stabilize it. So in this situation, sometimes even the fixation of the membrane is a little bit difficult. So because of that, we like to treat the horizontal unfavorable defect as if it was a vertical deficiency. So we apply the same grafting material, 50% autologous, 50% xenograft, and instead of using a resorbable barrier membrane, we’re going to use a rigid material. And that can be either titanium-reinforced barrier membrane, again, using the posterior region of the mouth or you can use titanium mesh that is covered by a Bio-Gide specifically in the interior region of our patients. So having said that, now let’s go for some clinical procedures to demonstrate this. And the first case that I’d like to show you is this very young and beautiful lady who unfortunately lost her anterior teeth in an accident. And you can see here that the smile line of this patient is quite high, showing this deficiency. And whenever we ask the patient to remove the partial prosthesis that she is wearing, she starts crying. So you can anticipate the challenge that we have in the emotional aspect of this patient. But when we look to the case, we have to consider what kind of defect we are talking about and try to deliver the best solution for that patient. So on your left, you can see the patient is smiling using that removable appliance which is, of course, not good looking for this patient’s face. When she removes it, we can anticipate the presence of this deficiency and [INAUDIBLE]. So in the frontal view of the patient, it seems that she has a vertical deficiency when you look to the outline of the soft tissues. But in order to really cut the kind of defect that the patient has, you have to look at the CT scan of the patient. And when you evaluate the CT scan, we can see that it’s a horizontal deficiency, because the bone peaks adjacent to the defect are in the same height of the base of the bone. So it’s a straight line connecting both adjacent bone peaks to the defect. And when you look at the sagittal images of the CT scan, you can see that in between the cortical plate, the buccal and the palatal cortical plates, you have the medullary space. So we are talking about a horizontal favorable defect. And if we are talking about the horizontal favorable defects, I’m going to use tenting screws. I’m going to use the particulate graft, 50%/50%, and I’m going to use a resorbable barrier membrane. The incision has been performed crestally a little bit more towards the buccal in association to one vertical-releasing incision in the distal of the canine, sometimes we can go over two teeth away from the area. And whenever possible, like in this case, we try to avoid performing a second vertical-releasing incision. After reflecting the flaps buccally and palatally, in the palatal aspect, one or two teeth intrasulcularly are incised in such a way that the flap can be also elevated in a good way. The mucoperiosteal flap elevation is performed in such a way that you can full visualization of the defect configuration. In this case, we cleaned out the nasal palatine canal in such a way to have more room and more space for the grafting material. And of course, that we applied our tenting screws. In this case, two tenting screws, one for each one of the teeth that has been lost. It is very important to perform the decortication. In every single case, it’s important to perform several perforations in the bone in such a way that you can access the cells and the vessels and the growth factors that are in the medullary space coming towards the grafting material that’s going to be placed in this area. Now it’s time to harvest the bone. And there are several alternatives to harvest the bone. What I like typically to do is to use this special bur, which is called Auto Chip Maker from this company called NeoBiotech. And it’s very effective because it seems like a trephine, but it has blades inside. And this silicone protection works like a coin to avoid that the bur goes too deep inside. And meanwhile, it collects the bone in a very nice way. So you can harvest in a quick way a very, very nice amount of bone in the procedure. So the typical place I like to use is the posterior mandible. So the retromolar area is the number-one area that I like to harvest the bone. And sometimes we can also harvest the bone from the chin area but especially when we are treating this area of the mouth. So it’s a very simple procedure. We open the flap in the posterior mandible exactly the way we would do to harvest a bone block procedure in that area. But instead of removing a bone block, we apply this specific bur, and it has a rotation of 250 RPMs, with very little irrigation. You don’t have to rinse too much, not to lose the bone that can be going out of the bur. And you harvest a very, very nice amount of bone. So just for the sake of the visualization of this procedure, you can see here in this video the way we do it. So after the flap is elevated, we use a little bit of pressure in the control angle in such a way that the motion of the control angle and the pressure will create these small holes in which the bone will be particulated and going to be inside this [INAUDIBLE]. The silicone is [INAUDIBLE] that you see there. So we can collect pretty much good amount of bone in a very quick way, as you can see here. You can make as much holes as you need. The depth of each perforation is about two to three millimeters. So it’s very shallow, protecting the area. And you have to remove the bone until you reach about 50% of the bone that’s required to fill the area. Of course, that you can use also scrapers such as the Safescraper, which is a very, very nice instrument. It takes a little bit more time to really harvest the bone in a good way. Your hands sometimes get a little bit tired using that. But anyway, it’s a very effective way of harvesting bone. After that, you have to mixture the autologous bone that you just collected, the 50% content of autologous bone to the 50% content of Bio-Oss to that area. So you make a mixture. And again, this is the moment, if you want, to place some biologics in this area you are able to do that in a very good way. So the bone material now is positioned first in the palatal area. So we like to place the bone graft first in the palatal area. So then we go to the buccal, and a final layer of xenograft in order to shield or protect the bone that’s going to be placed in that area. Now we have to cover everything with our membrane. So the resorbable membrane has been positioned and has been tacked in the palatal aspect with one or two tacks or screws. And then you have to apply the membrane on the buccal aspect as well, really give some tension to that membrane in order to stabilize and contain the biomaterial below the membrane. And it’s very important, as you can see here, to place as many tacks as you need in order to stretch this membrane on top of the biomaterial to really shape it in the best way in order to have the best outcome in terms of bone volume that will be formed. Of course, that is very important to release the flap. So I normally like to release the flap before the bone grafting material is positioned. In this case, I did that in the end of the procedure. So in this moment it is important to apply some more anesthetics in such a way that the patient doesn’t bleed too much in this moment. So you have to cut through the periosteum and have a very passive flap elongation, in such a way that you can close the area without any kind of tension. It’s very important to use the perfect suture material in this area and the perfect technique. We like to use polytetrafluoroethylene material, which is very stable and easy to apply to these areas. And of course, the technique is the horizontal mattress suture, which is the most important suture that you apply across the incision line, connected with some isolated simple sutures to really lock the margins of the flap. And you have to wait. So the patient was treated accordingly in the prosthetic aspect as well in such a way that an adhesive bridge has been prepared for this patient. And meanwhile, the tissue is healing. We also placed some mini implants in order to move the teeth orthodontically to improve a little bit the positioning of her teeth. And after some months, we like to wait at least at least six months before we reopen the site. We got the CT scan, and we can appreciate a beautiful reconstruction of the ridge by the use of this technique. You can leave from a very, very thin ridge, as you can see below, to a very, very widened ridge that will enable us to place the implants in a very, very comfortable way. So this is not one simple case or only one case. We can show you several, several cases with the same kind of predictability. So you can see here X-rays showing the benefit of this technique. And you can also see several clinical cases with the same kind of resolution, always improving a lot the width of the preexisting bone in a very predictable way. Coming back to our patient, of course, that’s several months later, she has some staining on her provisional restoration. But that’s OK, because now we can go for the implant positioning. And we can improve a little bit the aesthetics in the new set of provisional restoration. So you can appreciate that very, very nice volume of tissue has been created. So this is the moment to remove the provisional restoration and start to think about the surgery aspect of implant placement. So in this case, we used a surgical stent to also correct her gummy smile appearance related to this altered passive eruption in which we have more soft tissue than we needed in this situation and, of course, to guide the placement of our implants. So the mini screws have been removed and using the surgical stent, we created the gingivoplasty, the outline of the future gingival margin positioning of the patient, using the surgical stent. So after that, we removed the soft tissues. And now it’s time to open the flap. And as you can see here, a very, very nice reconstruction of the ridge. As compared to the lower images of before and after, it’s very interesting to note that many times the bone that is formed is over the pins that have been positioned as the tenting screws, so have to remove a little bit of the bone from that area and unscrew those pins in such a way that you can go for the placement of your implants. Using the surgical guide, again we perform on the crown lengthening procedure itself. So a little bit of osteotomy and osteoplasty around the teeth that are associated with the gummy smile appearances. And I call your attention to the height of the suggested cervical margin of the restoration as opposed to the height of the bone. So in order to be able to place the implant in the depth that is required, we did a little bit of osteotomy around the cervical areas of our surgical guide in such a way that we recreate this outline of the bone, which resembles the outline of the soft tissues that we would like to find in this positive architecture in the future restoration when it’s performed. And after we do that, it was possible to drill through the bone in a very, very nice quality of bone in such a way that the implants were positioned in a prosthetically driven way. It’s always debatable the number of implants in these cases when we have adjacent situations. But in this specific case, I thought that the horizontal space in between the two adjacent teeth would enable me to place two implants with a comfortable distance in that area. So after placing the implants accordingly to the prosthetic needs of this situation, I harvested a connective tissue graft from the palatal area and put it over the area to improve a little bit more the soft tissue dimensions. So everything was sutured again, and now we have to wait until the maturation of the oss integration period and the maturation of the soft tissues. A new set of provisional has been delivered to the patient, and now she can wait for some months. In this case, we waited about three to four months until the osseous integration but most importantly for the soft tissues to heal. It’s important to anticipate in this moment already that we were able to recreate a very nice horizontal ridge. But we don’t see the papilla in between the central and the lateral that were missing in that area. And that is because whenever you lose adjacent teeth, you lose the interproximal bone peak, and that cannot be recreated in a predictable basis. So it’s important to discuss with your patient that most likely she is going to have a little bit of missing papilla in that area. But that’s not a problem when you show that beforehand to your patient. After the healing period, we reopen the site to deliver the implant-supported restorations. And we used some very interesting sutures, trying to bring even more of the soft tissues towards the cervical area, trying to improve the possibility of creating papillae for these patients. After two months, we decided to go for a connective tissue graph on the other implant, which has been also performed on the same day. But in that case, no ridge augmentation was performed. So we could see that there is a bit of lack of volume in that area. So a connective tissue graft would improve the area, as you can see here. And the lower image would show 15 days after soft tissue grafting around number 22 and about two to three months after the provisional restoration is delivered to the implants that were now rehabilitated. Again, you can see here that there’s still a little bit of soft tissue maturation in this area. But it has to wait until the time can improve the area. And after six months of the delivery of the provisional restorations, now we can appreciate that the bone is quite stable and that soft tissues are slowly by slowly growing inside that area, improving a little bit in terms of the beginning of the case. And this is actually after nine months of the delivery of the provisional restoration, where my colleague from the prosthetics, Dr. Oswaldo Scopin, he has performed a new set of provisional restorations. And we can see here already a remarkable improvement in the profile of the soft tissues, with increasing height of the papilla in between the lateral and the central incisors, which are implants– restorations– in those areas. And of course, that we are still working a little bit with the soft tissues, he’s now starting to put a little bit of pressure, especially on the lateral incisors, to level the gingival margin of that patient. And anyway, it is an ongoing case, but we could take this patient from a very, very dramatic situation towards a very, very interesting situation such as this one. Now moving forward to vertical deficiencies, which are the most challenging cases as you can find in your clinical practice. It’s very common to see patients with those functional problems and ridge augmentation in those cases is not an aesthetic solution but a functional solution with a very reasonable aesthetic situation. It’s very important to understand that, such as in this lady who has this very, very bad situation in terms of her rehabilitation. And she came to our practice after being in several other colleagues, and all of them have suggested to remove all her teeth and to perform like a fixed detachable prosthesis, which is a very nice alternative, of course, but the patient requests and wants something that will not remove her teeth. And the question is, is it possible to do that? Yes, of course it’s possible to do that. It’s not easy, but it’s possible to do. It’s not a simple procedure. You have to go through a very important learning curve, and I encourage you to follow guide because Sasha has such an incredible knowledge on this topic, and he can really provide you the best of the world in terms of understanding of this procedure. So in this situation where we have these very big posterior deficiencies, but we have what is important, which is the bone peaks adjacent to the defect, more coronal position to the base of the defect. If that is the case, we can do the vertical ridge augmentation procedure. So I’m going to show you a small video of another surgical procedure, which is not the case that you are seeing right now, just to give you an appraisal of how it looks like clinically. So we have to perform a crestal incision coming from the distal aspect towards the most mesial tooth. It’s very important that the blade really reaches that area in such a way that not tear the soft tissues when you are releasing your flap. We like to use a vertical release incision, not only anteriorly but also posteriorly in the buccal aspect to really be able to reflect a very, very nice flap and exposing completely the area. The vertical release incision in the mesial is generally one or two teeth mesial to the defect. Now, we reflect a mucoperiosteal flap elevation, exposing the nerve. And in the lingual, we perform a sulcular incision like ranging from one to three teeth mesial to the last tooth involved at the defect. And after that, we have to elevate the flap in the lingual aspect, which is performed bluntly. So we use a plier and with a gentle pull upwards and towards the tongue of the patient and applying like this shaving movement in the lingual aspect, we can separate the superficial and the main fibers of the muscle in that area, elongating the flap in a very, very nice way. In the buccal, we have to use a new 15C blade to cut through the periosteum in order to have this very nice passivity of the flap. It’s very important, of course, to protect the nerves in that area. Now, using the probe, you connect the two adjacent bone peaks to the area in such a way that you can understand the height of the tenting screw that’s going to be positioned to that level, indicating the height of the bone that’s going to be formed. And you’re going to perform as many holes as you can here, the decortication procedure, in order to access the medullary spaces of the bone, creating the best way to the cells and vessels and growth factors to leave from the inner to the outer side of that area. Now is the critical moment, which is going for the membrane. It’s important to change your gloves right now to avoid any contamination. And using a plier, we go shaping the membrane in such a way that the membrane would fit properly to that area. So in the mesial aspect, it’s always interesting to create this C-shaped kind of cut in such a way that it can adapt perfectly to the cervical area of the last tooth. And using a screw, we go for in a very easy way using this Pro-fix instrument, you’re using the contra-angle. One screw in the lingual and the mesial, one screw in the distal generally is OK to be able to stabilize the membrane in the perfect situation. Now we use our graft material and below the membrane in such a way that we completely fill the area with the grafting material, again, 50% autologous, 50% xenograft. It’s very important that all the material is packed below the membrane, and some tension of the membrane is going to be applied on top of it in such a way that the material doesn’t move below the membrane. So after you pack all the material below the membrane, as you can see here in a gentle way, don’t forget that the last layer of the bone, if possible, to use pure xenograft to shield the material. Now you put some pressure on the membrane to close it in a very gentle way. And the screws again are positioned. Generally, two or three screws are used in the buccal, normally two or three in the lingual as well. So ranging from four to six screws are enough to really stabilize the membrane. What is very important here is the membrane cannot touch the distal aspect of the tooth in such a way that the plaque cannot go through the gingival sulcus and contaminate this area. So this is our patient just before, just after the ridge augmentation procedure. In one side of the mandible you can see here already three implants have been installed. And the other side of the mandible, we are just about to reopen the site to remove the membrane and place the implants. So lower in your left, you can see the previous clinical aspect of the patient with the very huge bone deficiency in that area. So after the flap has been elevated, the membrane was removed and very frequently, again, we don’t see the tenting screw, because bone is formed on top of the ridge. So we have to remove a little bit of the bone and, of course, the implant is going be placed in the three-dimensional way and being able later on to place the provisional to this patient. What is the time that we require for the vertical ridge augmentation? Generally speaking, we wait between 9 and 12 months until we reopen the site and place our implant for the maturation of the bone. So histologically we can see here, basically new living bone associated with the residual xenograft in this area and a lot of vessels and vascular tissue around that area. So this is the patient before, and this is the patient after several months of treatment in which, again, you can anticipate a very nice prosthetic resolution which is functional to this case but with a very reasonable aesthetic resolution as well. So I always like to say that whenever you lost the natural architecture of the tissues, it’s very difficult to completely reconstruct the ridge because pristine cannot be brought back in those cases. However, we can improve a lot the quality of the area and improve as well the quality of the life of those patients. So these are some lateral images showing very, very nice resolution on this patient. And this is before and after in which you can appreciate here a very good leveling of the bone and a very stable bone that has been formed in this area. This is not also one single case. We have several, several cases with the same kind of resolution. So I can tell you, after passing through and still the learning curve, always in the learning curve, but after passing a lot of mistakes and a lot of problems using this technique, I can tell you today that it seems to be a very predictable technique that can be applied to any kind of configuration. We can use it in the posterior mandible, such as in this other case. Another situation here in which we can see before and after a very, very nice ridge reconstruction and finally a stable bone around those implants. Another case in the posterior mandible a very, very big bone deficiency in that area and other places such as in the lower mandible, which seems to be a most challenging situation, in my opinion, because of the lingual flap it’s very, very difficult managed in this area. But even though, we can start from a very, very big deficiency again in this case, because if it is in the interior region, I decided to use titanium mesh that, of course, was covered with Bio-Gide on that area. Tenting screws have been placed, and the 50%/50% mixture has been applied. And after 9 months, or in this case I think 10 months, we remove the titanium mesh, and you can see a beautiful reconstruction of that area, enabling the patient to have a still provisional restoration but a very reasonable situation as compared to the beginning of the case. People always ask if it’s a predictable procedure and if the stability of the bone is really good in these procedures. And there are a lot of long-term evaluation papers showing that, but this is the only paper that would combine the four creators or among the four creators of this technique– Massimo Simion, Sascha, Carlo Tinti, and Stefano Parma-Benfenati. Those four have been involved in the creation and the setting of this technique for such a long time ago. And this paper that they put together would show that after performing this kind of procedure, through time, the bone that is formed is pretty much the same. And what they have seen is that the vertically regenerated bone responds just as the native bone that is not regenerated. So regenerated bone is bone. And you can trust on that bone in terms of his long-term maintenance. Of course that I don’t have 25 years evaluation cases as those guys have, but I have my very first case, which is this one. In this case, I treated this patient with the vertical ridge augmentation. And after seven years, I was able to deviate this patient from using dental gingival restoration to this very, very interesting clinical situation. It’s not perfect in terms of aesthetics, again because vertical ridge augmentation is a functional solution with reasonable aesthetic solution as well. But anyway, we could improve the quality of life of this patient in a very good way. And with that, I’d like to thank you for this opportunity and taking your time seeing my presentation. Thank you very much.