11/4/13. Ultrasonically Fabricated Barriers in GBR. Ultrasonically Fabricated Barriers in GBR

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1 Kevin G. Murphy, DDS, MS Associate Professor of Periodontics Baltimore College of Dentistry University of Maryland Private Practice, Baltimore, MD THE USE OF ULTRASONICALLY FABRICATED BARRIERS FOR ENHANCED OUTCOMES IN GUIDED BONE REGENERATION With the exception of cropping and rotational processes, images of clinical procedures performed by the author have not been altered in any way. Dr. Murphy receives no federal funding for this presentation. Therefore, in contrast to Videos of clinical procedures may have brightness levels altered to compensate for intra- oral the our elected officials in Washington, Dr. Murphy will proceed to give this presentation lighting. No other alterations have been made to these files. with or without a final budget. Dr. Murphy has received honorarium in the past from the manufacturers of products presented in this presentation. Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 1

2 Ultrasonically Fabricated Barriers in GBR Barriers (foil) made from biodegradable material (50:50 poly D, L- lactide acid) PDLLA Able to physically mold barrier using both thermoplastic and ultrasonic energies Biodegradation with minimal inflammation Ultrasonic fixation of materials in prepared boreholes by changing the aggregation state from stable to molten using ultrasonic energies delivered by a sonotrode Sonotrode SonicWelder Rx Waterbath Surgical tray 2

3 Foils Alveolar Protectors Pins Gerhard Iglhaut Shell Technique Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 3

4 Swiss School of Engineering for Wood studies use of ultrasonics to join wood Creaholic SA, Switzerland studies use of ultrasound to join porous materials Creaholic spin- off WoodWelding SA is founded WoodWelding develops technology for use in bone WoodWelding licenses technology to KLS Martin for craniofacial use WoodWelding licenses to SpinalWeld for orthopedic applications Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites Characteristics of polymeric barriers Poly (a- hydroxy acids) Combinations of polymers : copolymers Crystaline polymers tend to be stiff and brittle; amorphous polymers softer Plasticizers or introduction of softer polymers into matrix will make barrier more ductile Thermoplastic and ultrasonic properties Degradation of poly(a- hydroxy) acids Polymer chains are broken into smaller chains through hydrolysis Smaller chains then are enzymatically degraded by macrophages and multi- nucleated giant cells End products degraded via Kreb s cycle Problems with the degradation of poly(α- hydroxy)acids Localized low- grade inflammatory response with an early decrease in oxygen tension is related to speed of degradation Decrease in oxygen tension results in localized acidosis if poor vascularity Decrease in oxygen tension is related to degradation kinetics 4

5 Factors effecting polymer degradation Native degradation rates and proportions of polymers Molecular weight, crystallinity of polymer Surface area Pore size Subcutaneous vs. oral environment Polymer degradation timing Polymer Biodegradation (m) Poly (L-lactide) [PLA] Poly (DL-lactide) [P(D,L)LA] Poly (glycolide) [PGA] :50 (DL-lactide:glycolide) 2 85:15 (DL-lactide:glycolide) 5 90:10 (DL- lactide:capralactone) 2 Ultrasonically Fabricated Barrier GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 5

6 Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 6

7 Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites Sinus lift and lateral augmentation 54 yo female Lost of upper left premolar and molar teeth secondary to decay Desires replacement with crowns fixed on implants Sinus lift and later augmentation 7

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10 Restorative Dentistry by Dr. Denny Byrne Maxillary premolar area undercuts 59 yo female Locally advanced periodontal disease resulted in severe alveolar bone loss Needs lateral augmentation and sinus lift procedures 1 0

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12 Restorative Dentistry by Dr. Denny Byrne Mandibular posterior lateral augmentation 39 yo female Partially edentulous Significant lingual undercuts Needs lateral augmentation for best prosthetic alignment 1 2

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14 Restorative Dentistry by Dr. Denny Byrne Maxillary anterior lateral augmentation 49 yo female History of failed #8 implant Past history of active periodontal disease Generalized recession Mobility Fearful of second implant procedure Patient refuses orthontia 1 4

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17 Provisional Restorations by Dr. Sahar Damghani Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 1 7

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19 Large maxillary alveolar defects Place particulate graft from palatal or lingual aspect Lift unsecured side of foil to place graft Slightly over pack, then compress top of foil Weld last tack after graft is placed Smooth edges as needed, especially lingual concavities Cover with barrier or Alloderm if mucosal tissues thin 34 yo male Early Onset Periodontal Disease with advanced alveolar bone loss Full rehabilitation required Vertical and lateral augmentation of alveolar bone necessary before implant placement Sinus augmentation contraindicated 1. Debride 2. Place apical anchors 3. Adapt wire frame intra-orally 4. Remove wire frame from mouth 5. Place foil on frame, immerse both in water bath 6. Remove frame from foil and weld shaped foil to anchors 1 9

20 5 months Right Premolar Right Canine 2 0

21 Mandibular posterior vertical augmentation 63 male Partially edentulous Loss of posterior mandibular teeth Very thin alveolar ridge Loss of vertical bone height precludes implant placement 2 1

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25 Maxillary posterior vertical augmentation 72 yo female Two failed sinus lift procedures Adhesions of mucosal tissues in sinus precludes lateral window approach Loss of vertical alveolar height Vertical augmentation required 2 5

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28 Maxillary anterior vertical augmentation 37 male Partially edentulous Loss of palatal wall secondary to prior apical surgery Endodontic failures #7 and #9 High smile line 2 8

29 Provisional restoration by Dr. Andrew Swenda 2 9

30 Ultrasonically Fabricated Barriers in GBR What is it? The Concept Biodegradable barriers The basics Histologic evidence The shell technique for lateral augmentation Extra-oral frame technique for vertical augmentation Alveolar protector for single sites 3 0

31 Alveolar Protector 15mm 2.5 mm 7 mm Localized lateral augmentation 56 yo female History of failed apical surgery on #8 and 9 Loss of labial plate Labial undercut Esthetics are chief concern 3 1

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33 Localized augmentation secondary to root resorption 62 female Prior subepithelial connective graft #11 Extreme subgingival root resorption Lack of buccal plate Loss of vertical bone height precludes implant placement 3 3

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35 6 months CBCT immediately after Alveolar Protector placement 3 5

36 Localized lack of buccal plate due to failing endo 42 yo female History of failed apico Generalized root shortening secondary to orthodontic therapy as young adult Very thin alveolar ridge Loss of vertical bone height precludes implant placement 3 6

37 Pre-treament Day of surgery 5 months 3 7

38 Ultrasonically Fabricated Barriers in GBR Advantages Disadvantages Very good alternative to small to moderate sized blocks and Ti mesh After learning curve: easy, fast method to provide space for graft material Bioabsorbable no need for second surgery Cost is comparable to TR- PTFE Collagen based barriers for smaller Reasons for complications common to all barriers development of methods to mitigate complications (Iglhaut) Initial investment will deter some users Lack of Evidenced Based Data Minimal Human and Animal Histology Documentation of resorption kinetics 3 8