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Ridge Augmentation
Dr. Neale asks:
I am presently treatment planning ridge augmentation to replace teeth #29 & 30. I plan to use allograft Puro.
My question involves placement of two stage dental implants at the same visit or to play it safe and do the graft and let heal, then go back and do the dental implants in 4 months.
Ridge height is adquate for 10mm length dental implants, however ridge widgth is inadequate. Provided inital stabilization is present, would this be considered too risky if approximtately 50% of the facial threads are exposed after osteotomy and dental implant placement? Am I asking too much from a grafting point of view to cover these threads should this amount of dental implant be exposed?
January 30, 2006 in Techniques and Procedures | Permalink
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Comments
Don´t take unnecessary risks. Perform a block bone graft and wait.
Posted by: Sergio Callamand | Jan 31, 2006 5:54:32 AM
I agree. . .especially with a 10mm fixture. 50% thread exposure is a risk I wouldn't be willing to take. I, too, would block graft obtaining the graft from the external oblique ridge. That said, I am never sure if I should use a resorbable membrane with a block graft. Some have worked fine without, but recently, I lost 2/3 of a graft in the Maxillary central area.
Posted by: | Jan 31, 2006 2:17:50 PM
I recommend performing a ramus block graft first. You do not have to use a membrane. I have done a few hundred of these with and without membranes. I only use a membrane if I'm also using some particulate graft on the periphery.
Posted by: Cornell McCullom | Jan 31, 2006 2:41:15 PM
Take a look at C-Graft. This is a natural marine algae graft material. No other material has the research or long term clinical use behind it - see Journal of Oral and Maxillofacial Surgery Dec 2005 issue
Posted by: Boyd Tomasetti DMD | Jan 31, 2006 2:58:58 PM
i think if you can be sure about pimary stability and even with 50%of thread exposed try xenograft materials with resorbable membrane .i did it it works perfectly ,but unfortunately you have to wait around 6 month
Posted by: dr.talal | Jan 31, 2006 3:19:46 PM
It is risky. I suggest to play safe. I usually use Bio-Oss with a Biomend extend membrane. It is best firmly attached with tacks or screws. But you also have to be sure that the flap covers the membrane completely. And use as an aid aclorhexidine gel and/or mouthrinse. Also, prophylactic
antibiotic therapy will be recommendable. Also if the patients agree you should use autogenous bone graft from the chin or the ramus
Posted by: Dr Ozawa | Jan 31, 2006 5:15:51 PM
Well, interesting question. I used to do it in two stages, but now I do it one-stage using plasma rich in growth factors (an evolution of PRP), and mix it with ridge bone harvested during the drilling, which I do at 50 rpm with special, more sharpened, drills. Bone harvested this way is, from a cellular point of view, alive, duly trabeculated and a better material for grafting (never use bone from the filter, it´s full of bacteria!!!). If additional bone is required, I get bone from the ramus with a trephine, or even the tibia or the hip. Hope this helps.
Posted by: Francesco Di Nograro | Feb 1, 2006 12:38:58 AM
i have been using Beta-tricalcium phosphate (alloplast) which is in a hydroxl sulphate matrix which makes it set hard thus no need for a membrane,thus improved blood supply for healing.In the last 2 years with this have had impressive results...truely osseoinductive and safe and easy to use...
Posted by: Peter Fairbairn | Feb 1, 2006 4:49:13 AM
Dr. Neale asks about treatment for ridge augmentation to replace teeth #'s 29 & 30 use Allograft Puro.
Dr. Hahn has a suggestion to use a 50/50 mixture of Pepgen Flow and Pepgen Particulate. Mixing the two together results in a marshmallow form easy to place. The pepgen flow allows spacing of the particles to enhance blood supply. I have used this mixture for the last three years and the results are predictable allowing implant placement in good quality bone after 120 days. I also would suggest smoothing the facial threads, flap the tissue, decorticate the bone surrounding the threads and place the above mentioned material. Interested to learn more, phone Jan at 888-898-2583.
Posted by: Dr. Jack Hahn | Feb 1, 2006 12:54:09 PM
The decision to perform a guided bone regeneration procedure synchronous with placement of a submerged or non-submerged implant in non- esthetic areas, is based upon many factors including the following; the ability to obtain adequate primary implant stability, quality of soft tissue cover at the site, ability to obtain passive coronal advancement of the cover flap over the graft/membrane complex, postoperative patient compliance during phase one bone healing, use of autogenous particulate cancellous marrow graft, use of suitable osteoconductive graft material, and stabilization of the graft and membrane.
Nevertheless, the most critical factors for predicting the successful reconstruction of the osseous defect and bone regeneration is the morphology of the defect, and in the case where synchronous implant placement is desired, whether the implant surgeon is able to place the implant within the confines of the existing alveolar housing. This information was detailed very well by Drs. Buser, Dahlin, and Schenk in their textbook; Guided Bone Regeneration in Implant Dentistry (Quintessence 1994). Preoperative CT images allow the surgeon to make this assessment prior to surgery. If a CT is not possible or practical, the surgeon can begin the osteotomy preparation and place a depth gauge to asses whether the fixture will be placed within the alveolar housing from a horizontal perspective. If so, the surgeon proceeds with autogenous bone graft harvest and preparation ( rehydration etc.) of the xenograft, Allograft, or synthetic bone graft expander, and shapes the selected membrane for a custom fit at the site and around the implant neck or abutment or over the crest of the ridge. Once the surgeon verifies passive flap coaptation and the site is isolated from saliva, the implant is placed and the GBR procedure is performed. Use of PRP greatly facilitates the delivery and stabilization of the graft and membrane. I use a 1:1 ratio of autogenous graft with the bone expander as well as a slowly resorbable collagen membrane. As a general guideline, I look for 75% of the fixture to be within the alveolus and recognize that the wider the defect, the more challenging the case. This approach has yielded predictable results for the last 12 years with both synchrounous submerged and non-submerged implant placements. If these conditions do not exist, I follow a staged approach with block and particulate grafting performed 4 months in advance of implant placement. If soft tissue cover is poor, soft tissue grafting is performed 3 months prior to bone grafting. If shallow vestibular depth is a problem , I compensate with an exaggerated curvilinear flap design as described in my textbook; Soft Tissue and Esthetic Considerations in Implant Therapy ( Quintessence 2003). In esthetic areas, I follow a completely different algoritm for reconstreuction of alveolar ridge defects
Posted by: Anthony Sclar | Feb 5, 2006 8:51:00 AM
Can anybody convince me why one should go to all this troble and still risk failure when staged approach can gauranty better predictability?
Posted by: Satish Joshi | Feb 5, 2006 10:28:57 AM
Great book Antony,I bought it recently..what are your thoughts on Beta tri-ca products as the results are very impressive in defect repair and sinus lift procedures over the last 2 years using the material..
Posted by: Peter Fairbairn | Feb 6, 2006 4:31:32 AM
Peri-operative risk is the most important variable in this case. If you are skilled like Dr. Sclar and similar surgeons with extensive experience with GBR methods and simultaneous implant placement, you can certainly consider combining the procedures. If you are not experienced in GBR methods, the safest approach is to first graft the site with a mono-cortical, autlogous bone graft with rigid screw osteosynthesis followed by implant placement 5 months later. Definetely consider the latter approach in risk-averse patients and patients with co-morbid conditions that may pre-dispose the patient to higher risk of infection or wound failure
Posted by: A. Lakha DMD | Feb 7, 2006 11:49:08 PM
Being a boarded periodotnist and having been doing these procedures for the last 16 years, I would like to pose a perspective that has evolved for me. This came mostly from listening and seeing the acknowledged leaders in the surgical fields.
From a results point of view, it is almost always best to do the staged procedure. You can always add more bone either a second grafting, at the implant placement or the uncovering procedure. In addition, the soft tissue can be modified at every surgical opening as well. The worst problem is when the implant integrates and there is exposed fixture surface or only soft tissue(thick or thin) on the facial aspect of the titanium. Now you have a real mess.
In the esthetic region I almost always graft and then return for placement. However if the esthetic case has an intact socket or has an integrity break with adequate dimension, these can be immediately placed and most likely flapless.
Posted by: rkahn | Feb 8, 2006 5:13:38 AM
Good comments on the subjects. I have been doing these procedures for the last 10 years, and used to do exclusively 2 stages (one for gratf, one for implant). With the advancement of slow resorbable membranes, I now use both approaches. IF you can get good primary stability, and place the implant in the correct 3D position regarding the esthetic restoration, the technique used by Dr. Buser and explained by Dr. Sclar is great, and still allow us to do soft tissue correction later if necessary. Conical implants, specially the 12 or 14 mm Straumann 3.3x4.8 TE is excellent for that, giving regular neck restorative emergency with small body,and great primary stability. I also do soft tissue augmentation at the same time as the bone regeneration with particulate autogenous bone, bone replacement (Algipore or C-Graft) and membrane (3I Ossix). However, if the defect does not allow correct 3D position and stability, then autogenous block from the ramus with GBR is the best choice, and 4-5 months later the implant is placed. Agree with Sclar's comments.
Posted by: waldemar polido | Feb 8, 2006 6:22:48 AM
send me more imformationabout bio oss
Posted by: walter Arruda | Mar 28, 2006 3:50:32 PM
why would the procedure be so different as long as implant stays buried under primary closure or primary closure with a resorbable membrane such as biomend or such as Tefgen. I can understand that possibility of complication will be more with a membrane such as tefgen since one does not have a primary closure but in reality, why would placement of implant would make such a big difference for buccal onlay graft? as one of the dr suggected, osteotomy site can produce some autogenous mixture which can be more beneficial, implant can provide some rigid support for the graft material. combine that with a graft material such as reginoform, I think it can be a success.
Posted by: chanda kale | Jun 13, 2006 5:53:23 PM
Simultaneous implant placement and grafting over the implant could be problematic because the graft material lacks contact with host bone tissue at the area that the graft is in contact with the implant.
Blood supply, antibiotic penetration, osteoconduction, osteogenesis, osteoinduction, and other vital bone graft healing physiology processes are compromised when the graft material is placed over implant instead of host bone.
Posted by: TW | Jun 13, 2006 6:29:40 PM
The tricalcium phosphats are not suitable nevertheless they cost only 0,25 € Kg. It is generaly used in the finishing of the walls of our homes and you can buy it in local markets. It is great material for periodontic treatments but is absorbable in 3 weeks.
when using onlay grafs the only suitable and success technique is autografts in bloks without membrane. Other way you have to use titanium membranes and any alograft absorbable for 4 to 6 months (i mean any - it is just to help keeping the space from gum cels and fibroblasts). The bone formation wou can read it in Lindle Books is between 2,5 and 4 months - that is the time to wait to put your implant and the wait another 4 to 6 month. To put the implant and the graft you have to be sure you have primary stability in at least 4 mm of the implant but the succes rate is worst.
You can use osteotomes and GBR only with few bone needing, if you want success! Remember your pacients pay you to do a job not to try out, if you can not do it don´t. If anything fails you have a problem, a 1 to 2 year to resolve it, is is not suitable.
Posted by: | Jun 14, 2006 5:05:15 AM
Can anyone tell me why a membrane to prepare the bone regeneration would cause an accumulation of a mass in the lower gum line as well in the facial area?
Posted by: | Jun 17, 2006 5:13:05 PM
The use of beta TCP for ridge augmentation will soon become a new modality. We are currently using TCP blocks infused with rhPDGF and stem cell aspirates with beautiful results. We will be publishing our results in the near future. I am of the opinion that the days of autogenous block grafting will be coming to an end. We will see a new era of alloplastic bone substitutes, infused with the appropriate cocktail of growth factors, that will become a new "platinum standard" for augmentation in the maxillofacial complex.
Posted by: Robert J. Miller | Jun 20, 2006 3:12:28 PM
I am patient and I have received conflicting views from 2 different oral surgeons on the most appropriate grafting material for my implant. One of the oral surgeons insisted that autogenous is the ONLY way to graft. But, that involves additional surgery, healing time and risk of infection at donor site. Any thoughts from the experts?
Posted by: | Jul 4, 2006 12:31:02 AM
Of all the available bone grafting materials, autogenous bone has the most studies. It doesn't mean that other materials are not good. Currently, with the ongoing case of a tissue harvesting company obtained bone and other tissue by stealing from funeral homes, it highlights the potential risks of using donated bone. Other man-made materials come and go, and any new material needs to withstand the test of rigorous studies which are not common in the dental field and/or the test of time.
As an oral surgeon, I believe the other important question beyound the ones concerning graft material is soft tissue break-down. This is one of the most common cause of bone graf failures. Ask your surgeon his/her view on this.
The other question to ask, regardless of source of graft material, is the overall sucess rate when implant is placed in grafted bone.
Posted by: TW | Jul 4, 2006 2:47:05 PM
I am a patient with a most unusual case. I have lost 75% of the bone around my teeth; most are somewhat mobile. Absolutely no perio-
dontal disease--just disappearing bone. I do not know how to proceed. Am assuming the teeth cannot be
saved. Should extraction sockets be filled with non-resorbable material? Thank you for any comments. Judy
Posted by: Judy | Jul 10, 2006 9:22:52 AM
Judy:
No non resorbable material.
Probably implants and grafts inmediately after extractions and hopefully you can get a temporary implant supported fixed prosthesis for your healing process.
Posted by: Alejandro Berg | Jul 11, 2006 3:45:27 PM
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