P105 Predictable Bone Grafting for Site Preparation for Implants and Prosthetics Workshop JAMES GRISDALE, DDS THURSDAY, FEBRUARY 26

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1 P105 Predictable Bone Grafting for Site Preparation for Implants and Prosthetics Workshop JAMES GRISDALE, DDS THURSDAY, FEBRUARY 26 Please complete the speaker evaluation form in the Midwinter Meeting App. DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission has been granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide right to distribute solely as an educational material at the scientific program being presented at the Midwinter Meeting. Permission has been granted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in any form or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Society does not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Society shall not be sued for any claim involving the distribution of this work.

2 Predictable Bone Grafting for Site Preparation for Implants & Prosthetics: Workshop 150 Jim Grisdale, D.D.S., Dip. Prosth., Dip.Perio., M.R.C.D. Presentation Overview Ø Keys to Successful Bone Grafting Ø Why Socket Preservation and Ridge Augmentation Ø Bone Grafting Products Ø Advanced Extraction Therapy Ø Utilization of Membranes Clinical and Biologic Objectives for Ridge Preservation and Augmentation 1

3 Why Socket Preservation and Ridge Augmentation Ø Reduce or eliminate the need for subsequent hard and soft tissue grafting Ø Avoid collapse of soft tissue into defect Ø Most appropriate for patients with thin tissue phenotype because of predisposition to soft and hard tissue loss Why Socket Preservation and Ridge Augmentation Ø Preserve hard and soft tissue anatomy to provide enhanced esthetics and function Ø Maintain a stable osteoinductive/ osteoconductive environment Ø Maximize the supply of osteoprogenitor cells for bone regeneration Bone Grafting Products Definitions to Know Undifferentiated Cells - Also called osteoprogenitor or mesenchymal cells - Differentiate into many different tissue types depending on the signals they receive from their environment Osteoclast - The bone resorbing cell - Eats away the mineral content of bone as part of the remodelling process Osteoblast - The bone growing cell - Deposits new bone mineral onto the extracellular bone matrix at the site Osteocyte - A mature, fully differentiated osteoblast which has been surrounded by mineralized bone matrix 2

4 What s Needed to Regenerate Tissue? Two Mechanisms of Action in Bone Formation Osteoconduction: Bone graft materials acting as a scaffold or matrix for new bone to grow onto. Ø Like coral reef Ø The bigger the site, the more of this effect you need Ø Without osteoconduction, bone would lose the race against soft tissue to fill a site that has lost its bone Osteoinduction: Proteins and growth factors in the graft material stimulate undifferentiated cells at the host site to become osteoblasts and begin forming bone. Ø Only human-based graft materials have this power Ø BMPs (Bone Morphogenic Proteins) induce cells to become bone Ø Other morphogenic proteins induce cells to become other types of tissue Ø Can create bone in a non-bone site (Urist test) Protocol: Placing the Graft Prepare the site - Degranulate - Decorticate Place the graft don t pack material Close - Primary & passive closure - Membrane move it, lose it 3

5 Types of Bone Same Human Autograft Allograft Autogenous Bone holy grail/gold standard Human Donor Bone Different Humans Xenograft Bovine Bone Man : Animal Alloplast Synthetic Man : Synthe5c Allografts Allografts: - Bone from posthumous tissue donors, usually taken from the long bones, and processed for sale by any one of the dozens of tissue banks in the U.S.A. - Bone is processed for use in either Demineralized or Mineralized forms in various particle and package sizes = bone in a bottle A Wide Range of Allograft Bone Graft Materials AlloGraft Cancellous Offers: Ø Ø High osteoconductivity through trabecular bone structure Interconnecting pores to allow for vascular ingrowth Osteoconduc1vity for vascular penetra1on and bone ingrowth AlloGra9 Cancellous AlloGra( Demineralized Cor1cal AlloGra( Mineralized Cor1cal Alloplast Hydroxyapa1te Volume maintenance 9-11;15-16 Mechanical resistance Osteoinduc1ve poten1al 1-4 4

6 A Wide Range of Allograft Bone Graft Materials Ø AlloGraft Demineralized Cortical Offers: Ø Ø Optimized osteoinductive potential Rapid bone regeneration AlloGra( Cancellous AlloGra9 Demineralized Cor5cal AlloGra( Mineralized Cor1cal Alloplast Hydroxyapa1te Osteoconduc1vity for vascular penetra1on and bone ingrowth Volume maintenance Mechanical resistance Osteoinduc1ve poten1al A Wide Range of Allograft Bone Graft Materials Ø AlloGraft Mineralized Cortical Offers: Ø Dense bone graft material for mechanical resistance Ø Volume maintenance of the graft material AlloGra( Cancellous AlloGra( Demineralized Cor1cal AlloGra9 Mineralized Cor5cal Alloplast Hydroxyapa1te Osteoconduc1vity for vascular penetra1on and bone ingrowth Volume maintenance 9-11;15-16 Mechanical resistance Osteoinduc1ve poten1al 1-4 A Wide Range of Bone Graft Materials Ø Alloplasts Offer: Ø Fully synthetic material Ø Homogeneous composite Osteoconduc1vity for vascular penetra1on and bone ingrowth Volume maintenance 9-11;15-16 Mechanical resistance Osteoinduc1ve poten1al 1-4 AlloGra( Cancellous AlloGra( DGC AlloGra( GC Alloplast 5

7 Alloplasts Alloplasts: Man-made, synthetic graft materials consisting of calcium, acrylic, or glass. Also graft materials derived from other substances like coral. Ø Calcium-like materials: Include Osteograf/LD and Osteograf/D (hydroxyapatite), Osteogen (amorphous tricalcium phosphate), Capset (calcium sulphate), and HA powders Ø Acrylics: Include HTR, Bioplant Ø Glasses (calcium silicate): Include PerioGlass and Biogran Ø Corals: Rarely used anymore due to extreme porosity & sharp edges irritating tissue, algae-base Algipore used currently in Europe with some success Surgical Technique for Socket Defects Advanced Extraction Therapy An Innovative Procedure To Improve Your Oldest Technique 6

8 Types of Defects Ø 5 wall defect (extraction site) Ø 4 wall defect (loss of one wall, e.g., facial) Ø 2 or 3 wall defect (loss of two or three walls, e.g., facial and lingual, crater, intrabony defect) Ø 1 wall defect (loss of four walls, e.g., edentulous, resorbed ridge) Patient Consultation Discuss Immediate Advantages Ø Significantly less bleeding Ø Reduced risk of infection Ø Less chance for a dry socket Patient Consultation Discuss Long Term Advantages Ø Ridge preservation Ø Better fitting prosthesis Ø Easier and better oral hygiene 7

9 Barrier Membranes Definition: A device used in GBR and GTR to exclude soft tissue cells from growing into an area in which another more slowly growing selected tissue type such as bone is desired. Membrane Design Criteria for GBR of the Alveolar Ridge Membrane Requirements: Ø Biocompatibility Ø Suitable occlusive properties Ø Space-making properties Ø Tissue integration ability to attach or integrate into surrounding tissue Ø Clinical manageability Barrier Membrane Types Resorbable Ø Synthetic polymers - Lactide/glycolide - Polylactic acid blended with citric acid ester Ø Natural biomaterials - Collagen Non-Resorbable Ø e-ptfe (expanded Polytetrafluoroethylene) Ø n-ptfe (non porous Polytetrafluoroethylene 8

10 #5 Straight Round Scalpel Handle 15C Scalpel Blade #2 College Pliers 9

11 Crile-Wood Needle Holder, 15cm/6 Grisdale Periosteal Elevator CP-12 Periodontal Probe 10

12 Grisdale Bone Condenser 1/3 Buser Modified Periodontal Chisel PR-3 Prichard Periosteal 11

13 #16 Kramer-Nevins Scissors 13/14 Columbia University Curette PR 1/2 Prichard Surgical Curette 12

14 #3 Goldstein Flexi-Thin XTS Composite Instrument Kramer-Nevins Tissue Pliers 1x2 Curved 13