Maryland AGD AE and Socket Grafting 2015

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1 The Goodacre Study 5 year retrospective study looked at Crown & Bridge Caries Single crowns 1% FPD abutments 17% Periodontal Involvement Single crowns <1% FPD abutments 4% Preserves bone Enhances aesthetics Prevent socket collapse and tooth migration Preserves site for implants Reduces complications for future implant placement Improves the patient s psychological state Preserves and maintains bone Survival of abutment teeth connected to a Removable Partial Denture 3 years 60% survival 10 years 35% survival! The average denture wearer has 38% or less chewing efficiency of a fully dentate person. Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page1

2 Endodontically treated teeth are POOR abutment risks Bridgework with endodontically treated abutments have an average of 5 years service Less than a 2mm ferrule of natural tooth will lead to increased single crown failures after 5 years even if an endodontic post is present Consumer awareness surveys conducted from 1999 through 2002 concluded that 63% of patients who refused bone grafting and implant treatment options would have accepted had they simply known about bone resorption and the fact that bone grafting and dental implants prevents bone loss from occurring. Neil Park DDS- CDA White Paper Four Types 1. Autograft patient s own bone. 2. Allograft human cadaver bone. 3. Xenograft different species. 4. Alloplast synthetic bone. also referred to as Alloplastic grafts Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page2

3 Human Block Particulate Reasonable Mineralized Conductive Xenograft Harvested from a different species (bovine and porcine) Healing time is 4-5 months to be able to place implants. Takes up to 2 years to turn over into patient s own bone. Non-invasive with low rejection rates Nu-Oss product that will be used today. Human Bone Allo-Oss Xenograft - NuOss Bovine Same as Bio-Oss 40% less expensive Conductive Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page3

4 Looks like normal human bone Human Bone Allo-Oss Bovine Bone Nu-Oss Alloplast Synthetic bone ( Cerasorb) Healing time 4-5 months to be able to place implants. Non-invasive with low rejection rates Good filler when mixed with other bone materials Least expensive material 2 years to turn over to patient s own bone with some particles never turning over What do you hydrate particulate with? Use sterile water, sterile saline Not anesthetic solution Use the BLOOD from the freshly curetted extraction site! Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page4

5 Nonresorbable Synthetic 100% PTFE (Teflon) Require second surgery to remove Textured Non- Textured Titanium Reinforced Resorbable Allograph or Xenograph Variable length of time until resorption 24 weeks is desirable Single stage (no second surgery needed) Silk not recommended Wicking occurs Recommended suture types Wicking does not occur Chromic gut Polyglactin PTFE Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page5

6 3 Cellular Stages of Repair Osteoclast Stage* Vascularization Stage* Osteoblast Stage* Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page6

7 BONE GRAFTS REPAIR 1.)Osteoclast Stage Osteoclasts break bone down. When this happens, signals are sent to the body to initiate the repair process. a.) bone surface release bone repair proteins Just scratching the surface of bone initiates this. Bisphosphonates can inhibit Osteoclast activity b.) access to bone marrow cells Adipocytes,Osteoblasts,Osteoclasts Mesenchymal cells,fibroblasts,macrophages All of these cells are needed for bone repair Make sure you have some bleeding from the socket!!!!! 1. Clot stabilization facilitated by graft interconnecting macro and micropores. 2. Revascularization 3. Migration of osteoblasts (purple) 4. In-growth of woven bone (yellow) enhanced by graft scaffolding. 5. Graft integration/lamellar bone formation How a graft matures 2.) Vascular stage Revascularization is critical Bone cells are oxygen sensitive 3.) Osteoblast stage Matrix Haversian Systems Woven to Lamellar bone Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page7

8 TISSUE FLAPS TECHNIQUE Scalpel penetration contacts bone. Full thickness tissue reflection- Sharp edge of periosteal elevator faces the bone. Use the thumb to resist the pressure of the periosteal elevator against the tissue. May require use of curette to relieve the tissue at the distal aspect of the last tooth. Remove all tissue tags with instrument and/or wet gauze. TISSUE FLAPS CRITERIA Maintain periosteum and blood supply. Clear visualization of surgical site. Easy access for surgical team members. Effortless reflection of the tissues for the surgical team members. TISSUE FLAPS DESIGN Establishing non-tension primary closure over a dental implant and/or bone grafted sites begins with proper Soft Tissue Management Soft Tissue Management for Implant Dent: A Clinical Guide Heller, Heller et al. JOI, No. 2/2000 Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page8

9 TISSUE FLAPS DESIGN Non Tension Primary Closure Benefits: Shortens soft tissue healing time Contains graft materials Reduces infection potential Less painful healing Allows tissue expansion with post operative swelling Helps maintain blood supply INTERDENTAL FLAP DESIGN Trapezoid shape still applies Carry incision to the adjacent papilla with limited attached gingiva to avoid tearing. TISSUE FLAP THE TRAPEZOID DESIGN The trapezoid design includes a wider tissue attachment at the base of the flap which improves the following factors: Blood supply Lymphatic drainage Periosteal integrity Facilitates non tension vertical closure with bone grafting Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page9

10 Non tension soft tissue flap closure is essential for a successful surgical result. Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page10

11 Restore function Restore aesthetics Prevent tooth migration No destruction of adjacent teeth Improves the patient s psychological state Preserves and maintains bone This covers up The AIM Advanced Implant Mentoring Rob D Orazio DDS Day 1 Morning 1 Page11

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