Fig. 4 Cortical perforations are made with a
diamond round bur to enhance and promote
bleeding. Two tenting screws are inserted to
support the overlying membrane and the
particulated graft. Autogenous bone chips are
harvested in situ at the distal- lateral aspect of
the mandibular ramus.
Fig. 5 Autogenous bone chips are mixed in a 1:1
ratio with Geistlich Bio-Oss®.
Fig. 6 The particulated graft is placed around the
tenting screws and over the atrophic mandible.
Prior to this, the membrane is fixed lingually by a
mesial and a distal screw.
Fig. 7 The titanium-reinforced e-PTFE membrane
is shaped to adapt to the defect without touching
the distal margin of the adjacent tooth. The
membrane is secured buccally by two fixation
screws.
Fig. 8 A releasing incision in the periosteum is
made at the base of the buccal flap to enhance
the elasticity and to achieve tension-free
approximation at closure. Primary wound
closure is performed with alternating nonresorbable horizontal mattress sutures and
interrupted sutures. The patient is given
antibiotic prophylaxis and is advised to perform
mouth rinses with 0.2 % chlorhexidine gluconate
for 15 days. To minimize swelling and pain, the
patient is given steroids (once post-op) and
anti-inflammatory agents (for 4 days post-op).
Fig. 9 Check x-ray of the titanium-reinforced ePTFE membranes in place with the tenting and
fixation screws. The sutures are removed after
12 days. Healing is uneventful. The patient is
checked weekly during the first months and then
once a month until the second stage surgery.
Fig. 10 Clinical appearance after 6 months.
The augmented site appears healed correctly.
The underlying hard tissue volume can be
appreciated.
Fig. 11 Clinical view of the re-opening of the
site. The titanium-r einforced membrane appears
stable with the fixation screws in place.
Fig. 12 All four screws (two buccal and two
lingual) and the membrane are removed. A layer
of connective soft tissue of variable thickness is
always visible. The heads of the tenting screws
are visible.
Fig. 13 The tenting screws are removed and three
titanium dental implants are placed.
Fig. 14 A x-ray shows the three implants in place
after 2 years.
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