GUIDED BONE R E G E N E R AT I O N FOR DUMMIES
Francisco Teixeira Barbosa & Francisco Carroquino
ABOUT THIS EBOOK T H I N G S Y O U S H O U L D K N O W B E F O R E S TA R T R E A D I N G
We created this ebook with 3 main goals: 1. Give you some tips about guided bone regeneration. 2. Make you aware of the scientific literature and its importance. 3. Gather the most useful clinical tips from the scientific literature. To make it in a different and interactive, you´ll see that in some pages there are some links to some valuable resources.
Wherever this icons are present, there is a link or interactive content.
Just click the text fragments that have a different color, and you´ll access to the content.
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WHY THIS EBOOK
P R E FA C E Research and curate content.
We live in the digital era. We can learn about everything, with just a click, and this was almost impossible when I was finishing my dental degree, 12 years ago now. I have to say, that I learn a lot of periodontal surgery on Youtube. I´m not proud of it, but what I mean is that, if you can curate the information that gets into
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your hands, you´ll learn faster and easier than you used to. The problem about learning is all about that: curating the information, analyzing the data, and making it useful. Unfortunately there is a lot of crappy information out there that will take you to dead ends, or what is worse, turn your ideas even more foggy. We decided to work on this topic, mainly because our audience asked us to do so: Ok, Indian food recipes are in second place, and we´ll get back to that latter with a tutorial on youtube, about how to prepare a delicious Nan bread.
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But also because it is a topic where it is sometimes difficult to find a consensus about some techniques. - Is vertical bone regeneration possible?
Information that can be immediately useful for your daily practice. But the most important thing: make you curious about the topic, and inspire you to research it by yourself. That´s our big goal.
- Are all the biomaterials the same? - Cisco & Kurro- Is horizontal bone regeneration just a trend? - Or, what is the future of bone regeneration? It´s obvious that won´t answer all your questions in this ebook (sorry about that), but we filtered and gathered a lot of information.
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CHAPTER 1
BONE BIOLOGY
BONE CELLS SECTION 1
WHAT ARE CONSIDER BONE CELLS? 4 TYPES
Mesenchymal Stem Cells They are multipotent stromal cells present in the bone marrow and most connective tissues.
Capable of differentiation into osteoblasts, chondrocytes, and adipocytes. During bone healing, they differentiate into chondroblasts and osteoblasts to induce callus formation. 6
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Osteoblast They are primarily responsible for secretion of the organic matrix of bone. The osteoblasts deposit unmineralized matrix (osteoid) during the early phase of bone formation. We have to keep in mind that the Alkaline phosphatase, produced by the osteoblasts are the responsible for bone mineralization.
Mesenchymal cell image from www.nature.com/
Through a complex of intracellular signaling pathways, they start the osteoblast differentiation.
The bone matrix produced by the osteoblasts is composed of collagenous protein mainly collagen type I, and non-collagenous proteins including osteopontin, bone sialoprotein and osteocalcin.
This bone matrix undergoes mineralization, regulated by the alkaline phosphatase. 7
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Paradoxically it is like to that moment in life when you get trapped by something of your own creation. Like the Dr. Jekyll and Mr. Hyde story. Osteocytes You may think that these cells are boring and inactive, but they represent more than the 95% of the overall bone cells. Osteoblast image from www.dxline.org/
Osteoblasts finish their work as bone forming cells, once they are embedded in the bone and become osteocytes. You canwww.youtube. watch this video where osteoblasts are finally trapped, and transformed into osteocytes.
In the next section, when we explain the mechanostat and the mechanotransduction theory you´ll realize how important these cells are. Osteocytes occupy spaces (lacunae) in bone tissue, and communicate with each other through small channels called canaliculi.
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Osteoclasts These cells are mainly involved in the roll of bone resorption. We could say these are the "bad guys", but without them, bone regeneration would be impossible.
Osteocyte image from www.theconversation.com
Osteocytes act as mechano-sensors to control adaptive responses to mechanical loading of the skeleton. But this will be better explained in the next section. When these cells are damaged, the bone remodeling process starts. Osteoclast image. font: www.ectsoc.org/
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They create an acid environment when the osteoclast releases hydrochloric acid. Due to the acidic environment, Howship's lacuna is formed as result of the dissolution process of the mineralized matrix. Inflammatory Cells Inflammatory cells include polymorphonuclear cells, monocytes and lymphocytes. These cells are present during the inflammation process and they have some functions like, ingesting foreign particles, bacteria and dead cells.
Bone inflammatory cells are composed mainly by PMNs, monocytes and in this image, lymphocytes.
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BONE HEALING PROCESS SECTION 2
1.
INFLAMMATION
2. BONE FORMATION 3. BONE REMODELING
BONE HEALING Bone healing is a well-orchestrated process, involving multiple cells, as we explained before, that interact with proteins, expression of various genes, to restore the function of the bone structure. The main cellular events that take place during bone healing are:
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- Migration.
These event initiates a cascade of blood coagulation and formation of a blood clot.
- Proliferation.
Imagine this blood clot, or hematoma, as a network that provides the ideal structures for the cellular migration.
- Chemotaxis.
- Differentiation.
The platelets and the inflammatory cells, that we explained in the previous section, migrate into this blood clot, where they release growth factors and cytokines.
- Synthesis of extracellular proteins.
This will regulate the early cellular events:
Although bone healing is a continuous process, we can divide into three phases:
- Cell migration.
1. Inflammation When damage occurs to the vasculature, bone matrix, and the surrounding soft tissues, it is associated with vascular endothelial damage that results in extravasation of blood and platelet aggregation at the injury site.
- Cell proliferation. - Synthesis of tissue matrix. Some cells, like fibroblasts and endothelial cells, release angiogenic factors that act as a chemotactic stimulus for inflammatory cells and osteoblasts.
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Furthermore, the pro-osteogenic, transforming growth factor (TGF-ß) superfamily and BMPs are also produced during the early phase of healing, and play a significant role in the proliferation and differentiation of mesenchymal cells to fibroblasts and osteogenic lineages. So during the first days of healing, fibroblasts produce collagen to form granulation tissue, and extracellular matrix and new blood vessels are formed. 2. Bone Formation There two types of ossification process: intramembranous and/or endochondral.
For the intramembranous ossification, bone formation occurs directly without the formation of cartilage callus.
On the other hand, the endochondral ossification begins with the formation of a cartilage template where a cartilagenous matrix will be produced.
The example to differentiate these two types of ossification could be the process of bone repair in the bone fracture injury in the endochondral ossification.
In drill-hole bone injury, which occurs in the case of creating a cylindrical bone defect, the intramembranous route is the principle process in bone formation
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After matrix calcification, blood vessels penetrate the area, transporting osteoprogenitor cells to the site, which lead to the replacement of the cartilaginous matrix by trabecular bone.
- Oxygen tension. To start bone formation, the first cells that we need are mesenchymal cells. The main sources of this type of cells are: - Local periosteum
Several factors will influence the type of ossification after bone injury:
- Bone marrow
- Type of injury
- Blood circulation
- Defect size
After this, mesenchymal cells are stimulated mainly by BMPs and TGF-ß to differentiate into the chondrocyte/osteoblast cell line.
- Stability of the site
- Blood supply
3. Bone Remodeling Bone remodeling is a lifelong process of bone removal and replacement, to preserve the integrity of the skeleton.
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The bone remodeling process
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It also occurs during bone healing to alter the woven bone to lamellar bone structure, and restore the original shape and strength of the bone. This is also something very important during the osseointegration process. You can watch a videowww.youtube.com/watch? about it here. v=kVF8ci9m8ak The poorly placed trabeculae during this phase undergo bone resorption promoted by the osteoclasts, and osteoblasts promote bone formation at several bone sites .
The osteocytes are also another important type of cell involved in the remodeling process by their special mechano-sensory function.
The osteocyte mechano-sensory function will be well explained in the next section.
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THE MECHANOSTAT THEORY SECTION 3
WHY THERE IS BONE RESORPTION? If we want to solve the problem of an atrophic alveolar bone, we have to understand why there is bone resorption. Several theories have been reported, but let´s start for the easiest one to understand: The Mechanostat Theory (Frost 1996). This theory explains what happens to the bone, when different stimuli are applied, with different frequency and intensity. Check the image for a better understanding of this concept: 1. If the strain is of too small value, resorption dominates formation of bone tissue and the bone goes atrophic.
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Image 1.1 The mechanostat theory
THE MECHANOSTAT CONCEPT FROST (1996)
2. If the strain is adequate, resorption balances formation and the bone maintains its volume. 3. If the strain is of an adequately high value, formation at last dominates resorption and the bone goes hypertrophic. 4. If the strain value is high by the overloading outreaching the range of physiological limitation, the strain is accumulated in the bone tissue causing microdamage leading to fatigue failure. 5. Finally, if the strain value is above the limit of yield strength the bone goes spontaneous fracture. 18
Image 1.2 The mechanotransduction theory.
MECHANOTRANSDUCTION (BURGUER 1999)
Nowadays we have more information about skeletal adaptation. Since Burguer in 1999 described for the first time the mechanotransduction theory, we now have a more clearer idea about bone dynamics (Burguer 1999). What this theory tells us, is that the strain-derived fluid flow, transduces the strain information through the annular porosity produced by the osteocytes and their lacuno-canalicular hollow. This transduced information stimulates bone metabolism. The image 1.2 explains the whole thing. 19
BONE HEALING AND DYNAMICS AFTER AN EXTRACTION SECTION 4
1. BONE HEALING AFTER AN EXTRACTION 2. BONE DYNAMICS 3. DIMENSIONAL CHANGES AFTER AN EXTRACTION
Bone Healing After an Extraction Perhaps you have read a lot of articles or attended a few lectures on this topic. In implant dentistry it is important to know what events take place after an extraction in order to prevent them.
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If we take a look at the literature, we should know that (Schropp 2003): Major changes in an extraction site take place during the 12 months following tooth extraction.
After this period, bone remodelling takes place. 1 mm height loss is expected.
There is around 50% reduction of the total width the first year, which means 5-7 mm variation (Johnson 1963).
Approximately two thirds of this reduction occurs within the first 3 months after tooth extraction. It does not matter if the extraction is in the mandible or maxilla. Similar volumetric change is expected. Bone formation is the most common phenomenon during the first 3 months. 21
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Bone Dynamics On the other hand, from an histological point of view, some events take place after an extraction (Cardaropoli 2003).
The first element that is present is a blood clot, that is replaced by granulation tissue during the first week. The granulation tissue is present mainly in the most coronal portion of the socket, while in the
Bone dynamics after an extraction. This chart shows the variation of the different structures during bone healing. 22
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other 2/3 the blood clot is replaced by a provisional matrix. The creation of this granulation tissue in the most coronal portion of the socket, is filled with inflammatory cells. This is in response to the presence of infectious material in the oral cavity. After 30 days the socket is sealed with a keratinized mucosa.
Hard tissues formation starts after 2 weeks of healing, where the 50% of the 2/3 of the most apical part of the socket, are filled by woven bone. After 2 months of healing, a hard tissue bridge covers the marginal portion of the socket, and a periosteum is now present which is attached to the lining mucosa. The woven bone is gradually replaced by lamellar bone. 24
SECTION 4
Dimensional changes after an extraction We already wrote about some dimensional changes that take place after an extraction, based on the Schropp article (Schropp 2003).
in some cases represents the entire buccal wall (Januario 2011). When this bundle bone is entirely resorbed, there is a collapse of the buccal bone.
But other questions, regarding dimensional changes that occurs after an extraction, may come to mind.
That´s when all the problems begin and that´s why immediate implants in the aesthetic zone should be considered with caution.
Why is the collapse is more likely to happen in the buccal wall?
If you watch this video 2AFigure -.-you´ll better understand this explanation.
The answer to this question is well explained in the scientific literature (Araujo 2005). There is a structure, which is called bundle bone, that is dependent on the blood supply from the periodontal ligament, and is resorbed when the the extraction is performed. The average thickness of the bundle bone is around 0,2-0,4 mm width (Araujo 2015), which
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SECTION 4
Dimensional changes after an extraction. Bundle bundle is resorbed which leads to a volumetric variation, mainly in the buccal wall.
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CHAPTER 2
GRAFT TYPES
BONE GRAFT TYPES
If you are familiar with cooking, you know that to be successful as a cook, you need: a good recipe, spectacular ingredients, and of course, someone to taste it. But if you have a only a great recipe but your ingredients are not the best, and if you are the only one who´s going to taste the dinner, in this case it will be only an acceptable dinner.
G O L D S TA N D A R D WE ALL SEEK TO USE A BIOMATERIAL WITH THE 3 PROPERTIES: OSTEOGENIC, OSTEOINDUCTIVE AND OSTECONDUCTIVE.
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But we all seek for the gold standard, and in bone augmentation that is a graft material that has the osteogenic, osteoinductive and
Autogenous Bone Graft
AUTOGENOUS BONE GRAFT
An autogenous bone is a bone tissue transferred from one location to another within the
Autogenous bone graft is the gold standard: osteogenic, osteoinductive and osteoconductive properties
osteoconductive properties.
same individual.
And in oral surgery, the one that has the 3 properties is the autogenous bone graft.
It is the gold standard: osteogenic, osteoinductive and osteoconductive properties.
AUTOLOGOUS BONE HARVESTED DURING THE BIOLOGICAL DRILLING
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AUTOGENOUS BONE
IN THIS CASE THE AUTOGENOUS BONE WAS USED TO FILL THE GAP AFTER AN IMMEDIATE IMPLANT.
It can be harvested from intraoral sites, like ramus, symphysis or even from the drills, during site preparation with the biological drilling protocol (Anitua 2007).
There are only two disadvantages in using autologous bone: - Limited availability. - Morbidity at the donor site.
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Allogenic Bone Graft Allogenic bone graft is bone collected from human cadavers or living donors. It has an unlimited availability and the advantage of avoiding the morbidity caused by the wound at the donor site. CLICK THE IMAGES TO GO TO THE VIDEOS.
DESCRIPTION: The allograft is prepared before it is placed in the receptor site.
DESCRIPTION: Then integration of the allograft is visible in this image.
DESCRIPTION: Its unlimited availability and osteoinductive properties are some of the advantages of this type of graft.
ORALSURGERYTUBE PHOTOS.
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ALLOGRAFT
Allogenic graft has osteoinductive and osteoconductive properties but no osteogenic potential due to the lack of viable osteogenic cells. The main disadvantages of the allografts are: - Risk of infection transmission. - Host rejection.
A L LO G R A F T I N T E G R AT I O N
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Xenograft Xenograft is a graft that is harvested and transplanted into a different animal species.
Deproteinized bovine bone (DBB) is the most commonly used in implant dentistry.
“Xenograft is the most popular biomaterial in implant dentistry.”
The most common xenografts are porcine and bovine.
BIO-OSS® (GEISTLICH-PHARMA, SWITZERLAND) MIXED WITH PRGF®.
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Synthetic bone substitutes Various types of CaP biomaterials have been commercialized for clinical bone augmentation. Particular attention has been given to HA due to its bioactivity, and to β-TCP due to its bioresorbability.
ß-TCP (KERAOSS-KERAMAT,SPAIN), MIXED WITH PRGF®.
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CHAPTER 3
MEMBRANE TYPES
MEMBRANES IN IMPLANT DENTISTRY
MEMBRANE TYPES To make this chapter more dynamic we decided to answer the most usual answers around the topic "membranes in implant dentistry".
SOME QUESTIONS AND ANSWERS
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MEMBRANE TYPES
#1. What is the criteria to choose a membrane? The membrane should match these properties (Hardwick 1994): - Biocompatibility - Integration by the host tissue - Cell occlusiveness - Space-making ability - Adequate clinical manageability. If you have already decided which membrane you are going to use, make sure that it has all the properties mentioned before. MEMBRANES SHOULD HAVE THIS PROPERTIES
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#2. what kind of membranes can we use in our daily practice? There are two main groups: Nonresorbable Membranes Expanded polytetrafluoroethylene (ePTFE) membranes were the first generation of nonresorbable membranes. e-PTFE is a synthetic polymer with a porous structure, which does not induce immunologic
reactions and resists enzymatic degradation by host tissues and microbes (Hammerle 2014).
“e-PTFE membranes resists enzymatic degradation by host tissues and microbes.”
Incorporating a titanium reinforcement within the membrane, provides extra stability. The titanium reinforcement also allows it to be reshaped and adapt it to the different defects. It is also an important feature when the remaining bone structure is insufficient to provide stability to the membrane. E-PTFE MEMBRANE SURGERY. CLICK HERE TO GO TO THE VIDEO.
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These membranes are especially useful in vertical bone regeneration (Simion 1998). The main disadvantages in the use of e-PTFE membranes are: - Premature membrane exposure (Chiapasco 2009). - When the exposure happens, the e-PTFE porous surface is rapidly colonized by oral
bacteria. This will lead to infection and impaired bone regeneration. The membrane has to be removed as soon as possible (Tempro 1993). - The other disadvantage of the nonresorbable membranes is the need for a re-entry surgery to remove the membrane. This can cause tissue damage and patient morbidity (Benic 2014).
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MEMBRANE TYPES
Resorbable Membranes Resorbable membranes have a few advantages: - No need for membraneremoval surgery. - Better cost-effectiveness. - Decreased patient morbidity. - Some resorbable membranes have a spontaneous healing if a dehiscence of the soft tissue occurs. THE MAIN PROPERTIES OF THE RESORBABLE MEMBRANES
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Disadvantages: - Difficulty to maintain the barrier function during an appropriate length of time. - The resorption process of some resorbable membranes, may interfere with wound healing and bone formation. - As they don´t have any reinforcement within their structure, they need to be supported by pins, screws or other membrane supporting materials.
Pins are sometimes mandatory to stabilize the resorbable membrane. There are other techniques to stabilize it, like the double layer technique.
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Native collagen membranes These membranes are well documented in the scientific literature and they exhibit good tissue integration, fast vascularization and biodegradation (Zitzmann 1997, Friedmann 2002). They are the most common choice for standard bone regeneration in implant dentistry. Also they have the big advantage of spontaneous epithelization when a dehiscence in the soft tissue occurs (Friedmann 2002).
Bio-Gide® is the most popular membrane and also the one that has more scientific publications.
The main drawback of native collagen membranes are the degradation time, and the poor mechanic stability.
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Cross-linked membranes Cross-link membranes were developed to prolong the barrier function and the degradation time of the membrane. Some investigations showed that inflammatory cells are involved in the resorption process of cross-linked collagen membranes.
without impaired bone regeneration (Friedmann 2011). There is not a consensus about cross-linked collagen membranes. There are different outcomes between different brands.
When a dehiscence happens and a cross-link membrane is exposed, there is an impaired bone regeneration, and wound infection is more likely to happen (Bornstein 2007, Annen 2011). On the other hand, another clinical trials found a successful bone regeneration similar or even superior to that achieved with native collagen membranes (Von Arx 2005). Ossix@ membrane is an example of a cross-link membrane.
Also there are other publications where premature exposure of a cross-linked collagen membrane was followed by complete spontaneous secondary epithelialization 43
Synthetic resorbable membranes
- Other copolymers
They are mainly are composed of:
These kinds of membranes are associated with some disadvantages, such as inflammatory foreign-body reactions associated with their degradation products.
- Polylactic acid
- Polyglycolic acid
- Trimethylcarbonate
Another material with promising results is the polyethylene glycol membranes (Mihatovic 2012).
POLYETHYLENE GLYCOL MEMBRANE (STRAUMANN). CREDITS TO PROF. JUAN BLANCO (SANTIAGO DE COMPOSTELA UNIVERSITY).
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CHAPTER 4
CLINICAL APPROACH
NOW, THE REAL ACTION TAKES PLACE 😄
CASE EVALUATION AND TREATMENT PLANNING SECTION 1
CASE EVALUATION AND TREATMENT PLANNING 1. CASE EVALUATION AND TREATMENT PLANNING 2. WHAT IS THE CRITERIA TO MAKE A DECISION REGARDING THE OPTIMAL BONE AUGMENTATION PROTOCOL AND THE SELECTION OF MATERIALS? 3. RIDGE PRESERVATION 4. WHAT BIOMATERIAL SHOULD WE USE?
Before starting a clinical case, we have to analyse the singularity of every case. Every therapeutic decision that we take, must have a goal and all the risks must be contemplated. Its widely accepted that the implant position is driven by the prosthetics aesthetics, function and biomechanical considerations (Misch 2015). We should also consider the patient´s health condition, the soft tissue and the bone morphology. 46
Soft tissue must be intact to allow a successful coverage of the regenerated area, tension free. If an insufficient mucosa is present in the site where we want to perform a bone regeneration, we have to consider soft tissue augmentation before starting with the regenerative procedure. These are the soft tissue conditions that we have to evaluate:
- Presence and extent of soft-tissue defects. - Gingival biotype. - Level of the soft tissue at the teeth neighboring the gap. - The amount of keratinized mucosa. - Presence of invaginations, scars, discolorations and pathologies in the mucosa at the site to be augmented.
Soft tissue conditions after immediate implants are not ideal to perform a guided bone regeneration. 47
SECTION 1
#1. What are the criteria to make a decision regarding the optimal bone augmentation protocol and the selection of materials? This decision is made based on the defect morphology and if the ridge contour needs to be augmented. To help you to make a decision whether to place the implant and regenerate the defect simultaneously, or whether to perform a staged approach, some classifications have been proposed (Hämmerle 2014). The best choice is always to make a combined approach: less treatment time and less patient morbidity. In some cases the implant cannot be placed in an ideal position or the remaining bone does not allow the placement with an optimal primary stability. In that case a staged approach should be the chosen option.
CONTOUR DEFICIT TYPE 0
INTRA-ALVEOLAR DEFECT: CLASS I
DEHISCENCE-TYPE DEFECT: CLASS 2
DEHISCENCE-TYPE DEFECT: CLASS 3
HORIZONTAL DEFECT: CLASS 4
VERTICAL DEFECT: CLASS 5
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Ridge Preservation We already described the events that take place after an extraction and its consequences on the overall bone volume that will be available. For that, ridge preservation is an option that we should keep in mind if we are planning to place an implant with a delayed approach. This kind of procedure is well documented and its a reliable option if the immediate implant cannot be carried out. You can see here more about immediate implants to help you to make a http://periospot.com/tag/immediatedecision when they should be performed (Iasella 2003, Elian 2007, Vignolleti 2012).
Ridge preservation has been proved has a reliable option when there is an aesthetic risk. In case of type II socket (Elian Classification), an ice cone technique can be performed to restore the architecture of the socket.
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Regarding the time that you should wait after a ridge preservation, you can check The infographic about RP this infographic. There are no clear guidelines regarding the surgical procedure or the type of biomaterial to be used for ridge preservation (Vignolleti 2012). However it was suggested the option of placing a bone substitute in the socket, after the extraction, and placing a soft tissue graft harvested from the palate, covering the graft. This technique maintains the ridge contour and also the colour of the graft blends in with the receptor site (Jung 2004). After 4 months the color of the grafted site matches with the surrounding tissue. 50
#2. What biomaterial should we use? Deproteinized bovine-derived bone mineral is the best documented bone substitute for guided bone regeneration of dehiscence- and fenestration-type defects concomitant with implant placement (Jensen 2009). Bio-Oss® is the most well documented bone substitute in guided bone regeneration.
Xenograft is the most common bone substitute in implant dentistry. In this photo Bio-Oss® mixed with PRGF®.
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CONTOUR DEFICIT TYPE 0 SECTION 2 CONTOUR DEFICIT TYPE 0
CONTOUR DEFICIT TYPE 0 In this cases the implant will be surrounded by bone but an augmentation is recommended to enhance the buccal volume.
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This also should be performed when a thin bone wall is present after placing the implant. If the buccal bone wall thickness is inferior to 1,8 mm, it will be resorbed (Spray 2000). You can watch a video about thisspray concept here. This video 2000
Ridge 3 months after an extraction. Type IV implant placement (Hämmerle 2004).
Implant placed (Aurea RP, Phibo)
Autogenous bone harvested during the drilling is placed to create an over-contour.
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INTRAALVEOLAR DEFECT: CLASS I
SECTION 3
INTRA-ALVEOLAR DEFECT: CLASS I This happens typically when an immediate implant is placed.
INTRA-ALVEOLAR DEFECT: CLASS I
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A gap will remain between the socket and the implant. Some authors claimed that if this gap is inferior to 1,5 mm, it is not necessarily need to be filled (Pauloantonio 2001). However Araujo and Lindhe stated that this gap should allways be filled to maintain the peri-implant contour (Araujo 2011). You can read more about immediate implants in thisPost ebook Blog entirely dedicated to this topic.
Also there isBlog this blogPost post that will provide you extra insights about immediate implants.
A site is prepared after an extraction
An immediate implant is placed (Aurea RP, Phibo).
The gap is filled with a xenograft (Bio-Oss®).
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DEHISCENCETYPE DEFECT: CLASS 2 SECTION 4 DEHISCENCE-TYPE DEFECT: CLASS 2
DEHISCENCE-TYPE DEFECT: CLASS 2 It is characterized by the presence of a dehiscence which the volume of the area to be augmented is provided by the adjacent bone walls. 56
Dehiscence of the buccal wall during the implant placement is the most frequent complication, and so, guided bone regeneration of this kind of defects is well documented in the scientific literature (Palmer 1998). We can say that the regeneration in this kind of defects is very predictable (Kohal 1999). In posterior and in aesthetically sensitive sites, regeneration with particulate bone substitutes and a resorbable membrane is the treatment of choice. This will provide volume augmentation in the buccal wall. To improve bone repair and vascularization of the graft, some perforations can be performed in the cortical bone (Rompen 1999). Particulate bone is applied on the exposed implant surface and a membrane is shaped and adapted to extend 2 mm beyond the defect margins.
Implants placed in the posterior mandible with a dehiscence and a thin remaining buccal wall.
MinerOss® allograft is applied buccaly.
A membrane is used to cover the graft (Mem-Lok®). 57
Also autogenous bone can be applied as a first layer over the implant surface. This will provide two properties that are missing in the xenograft: Osteogenic, and osteoinductive. After applying the autogenous bone layer, another layer of particulate bone substitute is placed and finally a resorbable membrane to cover the bone substitute. This technique is named the "Sandwich Bone Augmentation Technique" (Hom-Ley Wang 2004). To perform this technique, the use of a membrane is mandatory (Jia-Hui Fu 2013).
The Sandwich Bone Augmentation Technique step by step. After implant placement a dehiscence was present. A first layer of autologous bone is placed, a second layer of ß-TCP (KeraOs®, Keramat) and finally the resorbable membrane (Bio-Gide®, Geistlich).
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During healing there are compressive forces that will collapse the regenerated site. We should always perform an over-augmentation because shrinkage of the overall volume must be anticipated. Additional fixation should be provided to stabilize the grafted area. This can be done with fixation pins, suturing the membrane, using the double layer technique or the healing cap.
Sandwich Bone Augmentation Technique for a type 2 dehiscence. Autogenous bone harvested during the drilling protocol with low rotation and with no irrigation. Xenograft placed over the autogenous layer. Resorbable membrane (Heart, Normon) is placed over the graft and secured with pins.
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Also a new technique involving sutures to fixate the membrane was proposed (Urban 2015). Transmucosal healing of a guided bone regeneration has been reported as a successful procedure (Lang 1994, Hämmerle 1995, Bragger 1996, Hämmerle 2001).
The Periosteal Vertical Matress Suture Technique proposed by Urban (Urban 2015). The suture is fixated below the release incision at the periosteum and the final knot is performed in the palatal flap.
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But to perform this kind of approach, an optimal primary stability of the implant is mandatory. A desirable torque above 35 N·cm or an ISQ superior to 60 are some of the parameters that we should look at to perform this protocol. Keep in mind that the implant should not have a micromotion superior to a threshold of 50-150 µm during the healing phase (Szmukler-Moncler 1998).
The healing abutment is placed on the same day of the implant placement. This is only possible when an acceptable primary implant stability is achieved. Osstell® IDX is a device that provides a value between 0 and 100. When the implant has more than 60 ISQ, this kind of approach can be performed.
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Above these values a fibrointegration of the implant and a total failure of the regeneration should be expected.
transmit undesirable forces to the implant. - Soft tissue corrections are planned before the prosthetic phase.
“When soft tissue corrections are planned, is mandatory to allow a submerged healing”
There are situations where a submerged healing is desired. Mainly in 3 situations: - Non optimal primary stability. - The use of a removable prosthesis during the healing phase that can
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DEHISCENCETYPE DEFECT: CLASS 3 SECTION 5 DEHISCENCE-TYPE DEFECT: CLASS 3
DEHISCENCE-TYPE DEFECT: CLASS 3 These kinds of defects are characterized by a peri-implant dehiscences, in which the volume stability of the area to be augmented is not provided by the adjacent bone walls. 63
In these defects we will need support for the surrounding soft tissue, and to achieve a stability of the grafted site. reinforced e-PTFE membranes are mandatory. Regeneration of class 3 defects step by step: - Perforation of the cortical bone around the implant (Rompen 1999).
A step by step guide for a type 3 defect: Perforation of the cortical, autogenous bone as a first layer, and xenograft on top mixed with autogenous bone. A e-PTFE membrane is finally placed. 64
- Application of particulate bone substitute. Autogenous bone mixed with Bio-Oss® (50/50) has been reported as a reliable option to add potential osteogenic properties to the graft (Urban 2011). - Resorbable membranes can be applied over the e-PTFE membrane to facilitate spontaneous wound healing in the event of soft-tissue dehiscence.
Horizontal and vertical bone regeneration using a e-PTFE membrane. This case the fixture was placed simultaneously to the augmentation. A collagen membrane was used to cover the e-PTFE membrane and also a fibrin clot to enhance the soft tissue healing. After 7 months the regeneration was evident. 65
- Sutures should be adapted to allow a submerged healing. - De Stavola showed that minimal tension (less than 5g) on the flap margins did not interfere with primary wound closure.
More tension means more risk and greater complications, so, De Stavola proposes a Suspended External-Internal suture (SEI), in order to reduce marginal flap tension after bone reconstruction (Stavola 2014).
Schematic view of the Suspended External-Internal Suture (SEI). The suture involves only the inner part if the buccal flap, to avoid the “killer loop effect”. After a horizontal mattress and simple suture are performed.
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- If we seek a vertical gain, a staged approach is recommended: first regenerate and then place the implants (Artzi 2010).
“When a vertical bone augmentation is needed, there will be a better outcome with a staged approach”
Buccal augmentation for lip support enhancement. Periocentrum Group Protocol.
67
HORIZONTAL DEFECT: CLASS 4 HORIZONTAL DEFECT: CLASS 4 SECTION 6 HORIZONTAL DEFECT: CLASS 4
Class 4 horizontal defects are characterized by a crest with a reduced width. This remaining crest does not guarantee and optimal primary stability of the implant. 68
SECTION 6
This situation also makes it impossible to place the implant in an ideal prosthetic position. In these cases a staged approach is recommended. Autogenous bone blocks are the first option in these cases.
E-PTFE membrane, in combination with particulate deproteinized bovine-derived bone mineral, is a reliable option and a welldocumented alternative procedure.
This alternative avoids the possible disadvantages of harvesting autogenous bone.
They can be placed alone or in combination with a bone substitute , with collagen membranes. This approach is the most predictable and reliable for large defects (Jensen 2009). The retromolar mandibular should be the first choice as a site for intra-oral harvesting of autogenous bone blocks.
Chin is also an alternative, but it is related with more postoperative morbidity and complications.
69
VERTICAL DEFECT: CLASS 5
SECTION 7
VERTICAL DEFECT: CLASS 5 VERTICAL DEFECT: CLASS 5
70
SECTION 7
Class 5 defects are characterized by reduced ridge height. This atrophy do not allow the placement of the implant in an ideal position, but also lacks of natural appearance due to the lack of soft and hard tissue support. A staged approach is mandatory in this cases with: - Block grafts - E-PTFE membranes with autogenous bone mixed with particulate deproteinized bovine-derived bone mineral.
This kind of procedures are advanced procedures that should be consider in another publication. The rate of soft-tissue complications are higher when vertical augmentations are performed.
We strongly recommend you to take a lookThis at this books to know more about vertical books regeneration.
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CHAPTER 5
SUTURES
SUTURES
SECTION 1
What is a suture? A surgical suture is one that approximates the adjacent cut surfaces or compresses blood vessels to stop bleeding.
1. WHAT IS A SUTURE 2. WHY SUTURING 3. SURGICAL TECHNIQUES
73
SECTION 1
Why suturing? • To provide an adequate tension of wound closure without dead space but loose enough to obviate tissue ischemia and necrosis. • Maintain hemostasis • Permit primary-intention healing • Provide support for tissue margins until they have healed and the support is no longer needed • Reduce post-operative pain • Prevent bone exposure resulting in delayed healing and unnecessary resorption. • Permit proper flap position QUALITIES OF THE IDEAL SUTURE MATERIAL Pliability, for ease handling
Nonreactivity
Knot Security
Adequate tensile strength for wound healing
Sterile
Chemical biodegradability as opposed to foreign body breakdown
Chemical biodegradability as opposed to foreign body breakdown
74
SECTION 1
MATERIAL CHOICE The decision is based on factors such as the surgical procedure, biocompatibility, clinical experience and personal preferences, quality and thickness of tissue and rate of absorption versus time for tissue healing.
Suture
Coated Vicryl (poliglactin 910)
Type
Braided coated
Absorption
Hydrolysis 56-70 d
Dexon (Polyglycolic acid)
Braided coated
Slow Hydrolysis after 60-90 d
PDS (Polydioxanone)
Monofilament Braided
Slow Hydrolysis 180-210 d
Suture tensile strength
+++
+++
++++
Tissue Reaction
Mild (++)
Mild (++)
Slight (+)
Knot tensile strength
Indications
++
Subepithelial mucosal surfaces; Vessel ligation; General closure
++
Subepithelial sutures; Mucosal surfaces; Vessel ligation
++
Absorbable suture with extended wound support
75
SECTION 1
Suture
Type
Absorption
Suture tensile strength
Tissue Reaction
Knot tensile strength
Indications
Surgical Silk
Monofilament Braided
Usually can not be found after 2 yr
++
Moderate (+++)
+
Mucosal surfaces
Nylon Duralon Ethilon
Monofilament
Degradates a rate of 15-20% yr
+++
Extremely low
++
Skin closure
Nylon Duralon Suegilon
Braided
Degradates a rate of 15-20% yr
+++
Extremely low
++
Skin closure; Mucosal surfaces
Peolene (polypropylene)
Monofilament
Nonabsorbable
+++
Minimal
++
Plastic and general surgery
Gore-Tex
Monofilament
Nonabsorbable
+++
Extremely Low
++
All types of soft tissue approximation
Monocryl (Poliglecaprone 25)
Monofilament
Hydrolysis 90-120d
++++
Minimal
+++
Soft tissue closure
76
SECTION 1
Surgical Procedure Apically positioned Periosteal Suturing flaps
Plastic procedures
Regeneration
Extractions
Suture site
4-0 to 6-0
3-0 to 5-0
4-0
3-0 or 4-0
3-0 o 4-0
Material
Silk, monofilament
Gore-Tex, Vicryl
Silk
Silk
Silk
KNOTS AND KNOT TYING Suture security is the ability of the knot and material to maintain tissue approximation during the healing process. Failure is generally the result of untying owing to knot slippage or breakage. Since the knot strength is always less than the tensile strength of the material, when force is applied, the site of disruption is always the knot (Worsfield 1975).
77
SECTION 1
SUTURING TECHNIQUES Different suturing techniques may employ either periosteal or nonperiosteal suture placement.
Circumferential director loop
Interrupted
Mattress-vertical/horizontal
Intrapapillary
Papillary Sling
Continuos
Vertical mattress
Locking
78
SECTION 1
The mattress is especially intesresting in GBR procedures. Mattress sutures are used for greater flap security and control; they permit more precise flap placement , especially when combined with periosteal stabilization. They also allow for good papillary Stabilization and placement. The vertical mattress (Non periosteal) suture is recommended for use with bone regeneration procedures because it permits maximum tissue closure while avoiding suture contact with the implant material, preventing wicking. They are left for 14-21 days (Mejias, 1983) and therefore requires a suitable material (Nylon, e-PTFE) that is biologically inert. Recommended suture in guided bone regeneration: Vertical mattress suture coronally reinforced with a simple suture.
79
CHAPTER 6
USEFUL RESOURCES
WHAT ELSE ... Before saying goodbye, we would like to share with you some valuable resources that you may find useful. This ebook will also be available in the interactive version as an eBook. This means that it will have embedded videos, animations and much more. These resources are very useful to explain concepts and other procedures, that are sometimes difficult to understand with text only. This eBook “Guided Bone Regeneration In Implant Dentistry”, will be available in July 2016. Follow this link to pre-order the ebook, or https://itunes.apple.com/us/ just click in the illustration on the right. CLICK ABOVE TO GO TO THE INTERACTIVE VERSION 81
Oralsurgerytube.com is the best platform to learn more about implant dentistry and regenerative procedures.
ORALSURGERYTUBE PAGE
If you use this code “Periospot” you´ll have access to a basic account and a great discount (30%) on the Premium account. http://wwwwww.oralsurgerytube.com/ index.php? Click here to visit Oralsurgerytube. controller=home
82
Other interesting ebooks Immediate implants ebook
Immediate loading ebook
This ebooks is about immediate implants with immediate restoration. It includes videos, surgeries, illustrations, 3D images and animations. Also included digital impressions and socket shield topic.
Introduction to immediate loading protocols with digital impressions and digital workflow. It includes surgery videos, animations and 3D images. Also included digital impressions and socket shield topic.
Download here
Download here
Connective Tissue Graft Ebooks
10 Tips about aesthetic implant dentistry
This ebook is one of the most succesful piece of content created for Periospot. More than 3.000 downloads and for free.
More than 5.000 downloads of this free ebook endorses it as a quick and useful guide about aesthetic implant dentistry.
Don´t miss it! Download here
Download here
83
Authors Francisco Teixeira Barbosa Francisco is a dentist, passionate about implant dentistry, music and social media. Periospot co-founder. He also loves to share is free time with his four kids, Nuno, Luis, Nicolás, Olivia and his wife, Maria. “Its never too late to learn” email:
[email protected]
Francisco Teixeira Barbosa
@cisco_research
@tuminha_dds
Francisco Teixeira Barbosa
Authors Francisco Carroquino Cuevas Francisco is a periodontist passionate about implantology, oral surgery and aesthetic dentistry. He works in Melilla and Madrid. He enjoys collaborating with dentists colleagues in different jobs. He loves basketball , football and fitness. ‘Family and friends is first; but odontology is like my family’. Email:
[email protected]
Kurro ca
@KurroCa
@kurroca
Francisco Carroquino Cuevas
Kurro Ca
Collaborators: Víctor Serrano Sánchez. Víctor is a 5th grade dentistry student at Universidad Complutense of Madrid, and he´s mad about periodontics, surgery and implant dentistry. He is also a new technologies enthusiast. He collaborates with the Medicine Department of the Medicine faculty (UCM). He loves reading, and sharing his free time with his family and friends, although his girlfriend, Iris says that his real love is his dog: Black Jack. Email:
[email protected]
Victor Serrano Sanchéz
@vic_skyline
@Vic_skyline
João Botto Botto is an oral implantologist who has his practice in Lisbon. He also enjoys being a wine-taster and and a very skillful surfer. email:
[email protected]
We enjoy very much creating new useful content. help us to improve it with this short survey!!!!!!!!
Yes, I want to help you! (Take the survey) https://es.surveymonkey.com/r/YMMNWS8
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