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Bone Grafting for Socket Preservation

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Bone Grafting for Socket Preservation 11/21/17 Bone Grafting for Normal extraction Socket facial bone loss. Preservation Excessive force. Dr. Karl R. Koerner Commonly the thickness of facial bone. Hussain, A. et al. Ridge preservation comparing a nonresorbable PTFE membrane to a resorbable collagen membrane: a clinical and histologic study in humans. Implant Dentistry. 25(1):128-134, 2016. Why a barrier membrane? • Prevent epithelium and connective tissue from migrating into the grafted site, • Facilitating repopulation of the bone graft with progenitor cells from adjacent bone. Retzepi M and Donos N. Guided bone regeneration: Biological principle and therapeutic applications. Clin Oral Implants Res. 2010:21(6):567-576. Greenstein, et al. Utilization of d-PTFE barriers for post-extraction bone regeneration in preparation for dental implants. Compendium 2015:36(7), pp.465-472. July/August. 1 11/21/17 How long does it take a bone How can socket grafts fail?? graft to not need • Bone graft material comes out. protection any more… – No membrane. – Inadequate membrane. to not need a barrier – Closure opens up after surgery. membrane any more… – Membrane lost from patient non-compliance. • Stays in but is contaminated and does not to become “osteoid”? become “osteoid”. Stays particulate. • Disappears or loses volume from lack of nutrients, inadequate blood supply. Minimum 3-4 weeks. The problem. Part of the solution. 1. 2 week post-op. Too many choices for socket grafts? • BioGide, Ossix Plus • BioGide, Ossix Plus, • Cytoplast (PTFE) • BioXclude other collagens… • Epiguide • Cytoplast (PTFE) 1 month post-op. • Laminar bone • Osteogen Plugs • BioXclude If nearly closed (within 3-4 mm) • Epiguide can use collagen membrane. If open more than that, PTFE • Laminar bone more predictable. • Osteogen Plugs 2 11/21/17 Socket healing: Types of bone grafting materials: Autogenous (from the patient) • About 4 days: The blood clot is replaced with granulation tissue. Allograft (from another person). Advantage: rapid turnover ≈ 4 • 21-28 days: Granulation tissue is converted to connective tissue. months. Osteoblasts initiate bone formation by secreting osteoid as several Mineralized (cortical, cancellous, or mixed)* Osteoconductive. specific proteins. Demineralized (may have osteoinductive capability due to bone o Osteoid (fibers and ground substance) is a precursor to bone. morphogenic proteins) o Osteoid tissue organizes and mineralized to become woven bone. o Osteoid doesn’t need a protective membrane. Mixed mineralized and demineralized. Has advantages of both. * cortical bone alone will take longer to turnover. ≈ 6 months • About three months: the socket is filled with woven bone. • About four months: Mineralizes to become lamellar bone. Xenograft (from a species other than human). Bovine. Usually takes longer. ≈ 6 months • For the next year: Lamellar bone continues to mineralize. Alloplast (synthetic). HA, TCP, bioactive glass, or polymer. Usually In a favorable situation, an implant can be placed in about take longer. > 6 months four months. Where to use which bone graft: Peri-implantitis repair? • For future implant. • For pontic site. • Want to do the implant ASAP. • Peri-implantitis repair. • By 2020, 2-4 million implants will be placed • Not going back in. annually in the U.S. 1. Mineralized allograft cancellous, • Bovine bone cortical OR blend of • Resorbable HA • 2-3% will be lost before prosthetic loading. cancelous/cortical • Then, 2-3% with fixed prostheses will fail over 2. Demineralized Allograft or blend of demineralized + mineralized 5 years. 3. DBM (demineralized bone matrix) • One author estimates there is an 8.5% 4. Tricalcium phosphate (TCP). occurrence of peri-implantitis over 5 years. Blend of TCP and other products …Requiring continued need for bone grafting. Types of bone barrier membrane materials: Resorbable § Usually tucked under periosteum on buccal and lingual § More predictable if have primary closure § Many types can be successful without primary closure, especially if only open 3-4 mm. Bovine collagen, bovine pericardium Allograft collagen, allograft pericardium • AlloDerm, Fascia (thicker 0.8 - 1.0 mm) • pericardium (strong, double layer collagen) Laminar bone BioXclude (amnion/chorion) Polyglycolic acid (EpiGuide) Dentistry Today 2015; April; 15:43; CE 184; 1-16 3 11/21/17 Xenograft collagen membranes. Non-resorbable e-PTFE. Effective but can become infected after about 4-6 weeks if exposed. d-PTFE. Advantages: Disadvantages: Need not be submerged. Needs to be removed. Don’t need primary closure. Should not touch an adjacent Don’t need periosteal release. tooth. Can remain open the width of the socket. Can blunt papillae in anterior thin 4 week removal. Could be as long as 6. phenotype cases. Assures the presence of keratinized tissue. One month post-op. One month post-op. 4 11/21/17 Greenstein G and Carpentieri, JR. Utilization of d-PTFE barriers For post-extraction bone Regeneration in preparation 3 weeks postop 4 weeks postop For dental implants. Compendium. 36:7 465-472. July/Aug. 2015 8 weeks postop 3 months postop Left: Gap created by teasing out an incision made in the periosteum. bone Above: Periosteal release done by the instructor (not required when using PTFE). The double April 13, 2017. envelope flaps help achieve partial Ridge augmentation in preparation for an implant. Bone graft: Allograft putty closure. (demineralized bone and mineralized cortical chips). Membrane: PTFE. White lines: Proposed incisions. Right: Fenistrations to provide nutrients for the bone graft. PTFE (Teflon) Pre-op PGA sutures placed. Follow-up with patient membrane (rough side up). and suture removal in 14 days. Membrane removal in one month. Bone graft. Optional: PTFE with titanium strip when trying to re-create buccal fullness. Post op instructions: PTFE tucked 4 mm under the lingual Follow up visits. flap then bone graft material placed Antibiotic. on the buccal side of the ridge. Peridex applied to the site membrane brought over the top bid for six weeks and placed over the bone graft Avoid chewing in this area on the facial side (without touching for 6 weeks. the adjacent teeth). PTFE membrane removed in 1 month. Amoxicillin starting preop. 500 mg, 2 Call surgeon if problems. stat then 1 tid for 6 days. 5 11/21/17 Adjunctive bone grafting supplies and techniques for more difficult cases. • PRF Need IV blood draw • Gem 21 Osteohealth $249 (0.5cc) • Infuse Medtronic $950 (1 kit) • Emdogain Straumann $165 (1 pack) 2 week post-op. Both 4 week post-op. Granulates in as keratinized tissue. • Blood draw Socket Preservation • Spin down • Fibrin clot Use in bone vs. graft and as a membrane. Ridge Augmentation • 7953 (Socket Preservation) – Graft IS placed same day as extraction – Includes graft material but not membrane • 7950 (Ridge Augmentation) – Graft IS NOT placed same day as extraction – Includes graft material but not membrane Barrier Membrane Codes • 4266 – resorbable • 4267 – non-resorbable (includes removal usually about 3-4 weeks later) 6 11/21/17 Easy Fix (when not open more than 2-3 mm) For smaller areas of Bridge pontic site with provisional. Smashed ½ non-closure (2-3 mm). of a Colla-Plug. Bone graft (Resorbable HA). HYBRID: OsteoGen Plugs • All-inclusive: bone graft and membrane. • Easy to use – molds to the socket. • For socket grafts - must have buccal plate present. – Requires a “minimally invasive” extraction • For future implant or pontic site. • Routine use by general dentists. • Calcium phosphate-based (synthetic) graft -- intermixed with Type I bovine collagen. • $50 cost per socket Immediate post-extraction. 7 11/21/17 7 weeks post-extraction. 3 months post-extraction. OsteoGen Plugs • Takes 3-5 months to be able to place an implant. • Deliver to the socket dry and let hydrate with blood. - Increase blood supply if needed by decorticating the socket lamina dura (#2 round bur or equivalent) Four months post-op. What is it? 1. Collagenous, made from placenta. 2. Amnion/chorion layers. 3. Has growth factors and other substances that enhance healing. 4. Doesn’t just protect the bone graft. It impregnates and becomes part of it. 5. Bioactive and anti-bacterial 8 11/21/17 Can place double layer, can fold on itself. Tuck 1-2 mm under soft tissue. Suture over top. 2 week and 4 week postop checks. Patient: No acidic foods (soda, Gator Aid, citrus drinks, etc.), no Peridex. Rather, milk, water. Don’t brush, saline rinses 3-4/day. 9.
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