MBCP. Clinical Cases Synthetic resorbable bone graft. In partnership with

Transcription

1 MBCP Clinical Cases Synthetic resorbable bone graft In partnership with

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3 Dr Xavier Struillou President of the French Society of Periodontics and Oral Implantology Dr Christian VERNER Scientific President of the French Society of Periodontics and Oral Implantology The French Society of Periodontics and Oral Implantology, as a scientific association, supports industry companies developing innovative products. This active partnership allows us to present the bone substitution material SBS 60/40 (MBCP ) proposed by the Expanscience Laboratoires. They represent, today, biomaterials of reference, validated by international publications, for the treatment of intra-bone lesions in periodontics and pre and peri-implant placements. Dr Xavier Struillou The Laboratoires Expanscience are partners participating in the French Society of Periodontics and Oral Implantology, with their different products and their wish to advance the quality of periodontal and implant treatments. Following the non-surgical phase, deep sockets require surgical access in order to efficiently treat periodontal and peri-implantary diseases, but also to reduce and recreate a structure of support tissue. The biphasic synthetic bone substitutes have a large number of advantages, at both level of resorption kinetics and tissue integration. Here you will find cases treated during periodontal diseases as well as implantary ones. Dr Christian VERNER Brochure created in collaboration with: Dr Solenn HOURDIN Dental surgeon Dentistry and Oral Surgery Department Rennes Dr Bruno SALSOU Dental surgeon Toulon Dr Bernard BARTHET Dental surgeon Agen Dr Yves ESTRABAUD Dental surgeon Angers Dr Jacques HASSID Dental surgeon Colmar SBS 60/40 is the trademark of Expanscience Laboratoires, referring to MBCP. MBCP is the trademark of Biomatlante. MBCP and SBS 60/40 are manufactured by Biomatlante. 1

4 Maxillary sinus floor augmentation: tooth 26 Lateral Sinus augmentation with implant placement / 4 / 6 2

5 sinus lift sinus lift 3

6 Dr. Solenn Hourdin / Dentistry and Oral Surgery Department Periodontics Section - Rennes Maxillary sinus floor augmentation: tooth 26 This 46-year-old man, in good general health, would like to replace his 26 by maintaining the integrity of the adjacent teeth. Pre-surgery examination The 26 was extracted 3 years ago Treatment decision The residual bone volume subsinus is of 3 mm. This height indicates a sinus lift and an implant placement in 1 sitting. Surgery Preparation Making a bone window in piezosurgery. The horizontal crown incision is located at 6-7 mm from the top of the alveolar crest in order to maintain the support of the filling material. The preserved alveolar ridge will provide more efficient support for the biomaterial than a membrane. The Schneider membrane is delicately raised with a manual sinus curette. The bone flap remains on the membrane and is placed at a 90º angle. The membrane remains intact thanks to the Valsalva manoeuvre. Filling/implant placement Subsinus filling with 1 dose of SBS 60/40 (MBCP ) granules 0.5-1mm 0.5 cc. The implant is placed if cross-movement stability is established. As the periosteum is of good quality, no membrane is placed on the lateral opening. 4

7 Immediate check-up This type of implant is perfectly adapted in its emergence profile for restoring a molar and for strengthening primary stability. In this protocol, it is essential to establish the primary stability of the implant in order to be able to associate the filling to the implant placement. X-ray taken immediately post-surgery of the implant 4.8 WN/8 SLA Straumann. Follow-up after 4 months Images of peri-implantary tissue healing The impression, on this implant displaying a juxta-gingival plate, can be made with a transfer clip. A conventional impression tray will hence be used. Construction of the fixed sealed supra implantary prosthesis 4 months after surgery. Conclusion/ practitioner s commentaries The biomaterial and the immediate placement of the implant avoid a new pneumatisation connected to intrasinus pressure. The biomaterial allows a three-dimensional stabilisation of the blood clot and osteogenic progression. The main indication for synthetic biomaterials for bone substitution is sinus augmentation. References: Del Fabro M., Testori T., Francetti L., Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent 2004; 24:

8 Dr Bruno Salsou / Toulon Lateral Sinus augmentation with implant placement After cavity problems, a 25-year-old patient has lost the 15 and the 16. The retroalveolary X-ray shows a significant sinus volume which prevents the immediate placement of implants to replace the missing teeth. Pre-surgery examination Treatment decision Therefore, the decision is taken to perform a sinus lift. X-ray showing the size of the sinus Surgery Opening the bone flap through piezosurgery. Placing filling material SBS 60/40 (MBCP ), granules of 1-2 mm diameter with the packaging syringe. 6

9 Opening the bone flap through piezosurgery. Placing filling material SBS 60/40 (MBCP ), granules of 1-2 mm diameter with the syringe. Immediate check-up Panoramic X-ray showing the bone gain obtained following the sinus lift sector 1. Follow-up after 6 months Placement of two Straumann implants. RN Standard Plus of 4.1mm diameter and 10 mm length. Conclusion/ practitioner s commentaries The very granular consistency of the material allows an easier placement and avoids a dispersion of the SBS 60/40 (MBCP ) granules. The stability of the material also optimises bone healing. 7

10 Alveolar regeneration with implants placement Intrabony Defect: Tooth 43 Intrabony Defect: Tooth 21 Class III Furcation Tooth 36 Peri-Implant Defect Alveolar regeneration with implants placement Dehiscience and fenestration: Tooth 46 Mini-invasive approach: periodontal debridement with infrabony defect /10 /12 /14 /16 /18 /20 /22 /24 8

11 defect filling defect filling 9

12 Dr Bernard Barthet / Agen Alveolar regeneration with implants placement 64-year old patient, referred by a general practitioner for an abscess in the posterior sector of the right maxillary. Pre-surgery examination X-ray showing endodontic and periodontal lesions on 14, 15, 16 Treatment decision Extraction, curettage, filling and placement of a membrane. Surgery A partial-thickness flap was repositioned in order to completely cover the alveolar. Check-up after 6 months X-ray and clinical examination. 10

13 2nd surgery Reopening Pre-prosthetic X-ray Control X-rays prior to preparing the prosthesis. After 6 months, placement of three conical implants and the prosthesis. Conclusion/ practitioner s commentaries Good density allowing good primary wedging. 11

14 Dr. Xavier Struillou / Nantes Intrabony Defect: Tooth year-old patient, with severe generalised chronic periodontitis. Initial non-surgical treatment undertaken. At the 3rd month re-evaluation meeting: Persistence of a deep socket (8mm) in mesial surface of the 43 and presence of a fistula. Persistent pain at that level. Strict plaque control. Pre-surgery examination Treatment decision Debridement surgery and filling of the lesion. Retro-alveolar X-ray: presence of an intra-bony lesion on mesial surface of 43. Surgery Persistence of a lingual and mesial wall. Destruction of the vestibular wall. Large and open defect but offering good material support. HA/ß TCP filling: SBS 60/40 (MBCP ). 12

15 Immediate check-up The X-ray shows the complete filling of the lesion. After 15 days, the soft tissues are barely inflamed and the fistula is closed. 15 days at suture removal. Follow-up 1 year 2 years 2 years Conclusion/ practitioner s commentaries The bone filling is very suitable for this lesion, which was fairly favorable from an anatomical point of view, as it provided good support for the materials in the defect. 13

16 Dr. Xavier Struillou / Nantes Intrabony Defect: Tooth year-old patient Severe generalised aggressive periodontitis Non-surgical treatment undertaken Strict plaque control (plaque index < 25%) Pre-surgery examination Clinical and X-Ray exams Deep lesion (almost up to the apex of 21). Circumferential. Catheterization V P Bleeding during catheterization at the level of deep sites. No pre-surgical mobility. Vital tooth. Treatment decision Aesthetic access flap with papillary preservation and filling of intra-bony lesions. Surgery Incisions and peeling with preserved papilla. Lesions debridement. Scaling and root capping. Note the persistence of the sub-gingival tartar at the level of the defect. Filling of defects. Hermetical sutures in order to protect the material. 14

17 Follow-up at 3 and 6 months Healing 3 months 3 months 6 months No infectious events. No mobility but light extrusion of 21. A 2 mm recession on 21.. Follow-up at 18 months No bleeding during catheterisazion. No mobility. No infectious event. V P Catheterization X-ray assessment Initial 3 months 9 months 1 year 18 months Results consolidation. Conclusion/ practitioner s commentaries Interesting filling of the lesion on 21, allowing to keep the tooth on the arch, although in the beginning of the treatment it seemed strongly compromised. Nevertheless, the 21 remains a tooth that presents a reserved prognosis in the long run, given the context of aggressive periodontitis. 15

18 Dr. Bruno Salsou / Toulon Class III Furcation Tooth year-old patient with significant mobility of the 36. The retroalveolary X-ray shows a furcation of level 3, which makes it impossible to save the tooth. Pre-surgery examination Furcation of the 36 Treatment decision It was decided to extract the tooth and perform a bone filling in order to allow the placement of the implant. Surgery 1 3 Clinical situation. 2 Extraction alveolar. Broken tooth extracted. 16

19 4 6 Syringe with SBS 60/40 (MBCP ) filling material, granules of 0.5-1mm diameter. 5 Filling material SBS 60/40 (MBCP ) soaked with blood. Alveolar 36 filled with SBS 60/40 (MBCP ). 7 8 Protection of filling with PRF membranes. Repositioning of flap and silk suture 3/0 Follow-up at 6 months The control X-ray shows significant bone gain. The placement of the implant can take place under the best conditions. Conclusion/ practitioner s commentaries The syringe of SBS 60/40 (MBCP ) facilitates the handling and the setting-up of the material. The conglomerate created with the blood clot keeps the material in the alveolar, which is absolutely necessary for good bone healing. 17

20 Dr. Bruno Salsou / Toulon Peri-implant defect 47-year-old patient, no medical antecedent. The 2 teeth have been pulpless for several years and cannot be saved for intrinsic dental reasons (fractures). The patient does not want removable prosthesis nor bridge. The 21 and 22 incisors have been extracted. The plan is to replace them with 2 crowns on 2 implants. A temporary removable prosthesis has been placed after 4 months. Pre-surgery examination Clinical view after bone and gum healing. Pre-implantary X-ray Cross-section based on the cone beam examination and implantary simulation showing the lack of cervical facial bone. Three-dimensional simulation of the positioning of implants (Nobelguide software) confirming the lack of facial bone. Treatment decision The retroalveolary and three-dimensional X-rays show a bone loss which does not allow the placement of 2 implants under favourable conditions. It has been therefore decided to place the implants together with a guided bone regeneration technique. 18

21 Surgery The implants (Nobel speedy replace 4/13 mm) are in place. The primary stability is correct (insertion torque 35N/cm). As predicted, the turns are partially visible. The bone defect is visible. SBS 60/40 (MBCP ) granules of 0.5-1mm diameter are used to cover the exposed area. An Ez Cure membrane is then placed in double layer. The area is then sutured after repositioning the flap without tension. The site is therefore hermetically closed. Follow-up at 6 months After 6 months, the heads of the implants are cleared. The 3D X-ray allows us to assess the bone gain. The prosthetic phase can therefore start under good conditions. X-ray to identify the heads of the implants. Three-dimensional X-ray. Pre-prosthetic clinical view after clearing heads of implants. Conclusion/ practitioner s commentaries This technique makes it possible to overcome a lack of bone volume and to place implants under correct conditions. In addition, the execution of the filling during the same surgical sitting as the placement of the implants simplifies the procedure for the patient. It is, however, important to be able to guarantee good primary stability at the level of implants. Large bone deformities must be treated by other techniques. 19

22 Dr. Jaques Hassid / Colmar Alveolar Regeneration with implants placement After cavity problems on 15 and 16, those teeth have to be extracted. An implantary treatment is planned in order to rehabilitate unilateral edentulism of the maxillary, because the patient does not want prosthesis. Pre-surgery examination Clinical view and X-ray prior to extraction. Treatment decision It was decided to first extract those teeth and execute a filling with SBS 60/40 (MBCP ) granules of 0.5-1mm diameter. Surgery Extraction of the remaining roots and placement in the alveolar of SBS 60/40 (MBCP ) filling biomaterial. Closure of the extraction site edges 20

23 Follow-up at 6 months After 5 months of healing, an X-ray was taken in order to plan the follow-up treatment. Pre-surgery clinical view showing good gum healing. 2nd surgery Pre-surgery view of bone site, we notice some visible SBS 60/40 (MBCP ) granules Clinical view of the implantary osteotomy. Pre-surgery clinical view of three implants (Thommen Element 4.5/8mm, 5/8mm, 5/8mm). The flap is repositioned through a lock-stitch suture. Follow-up at 3 months after the 2nd operation Follow-up at 6 months after the 2nd operation After a healing period of 6 months, the prosthetic treatment is executed. X-ray. Conclusion/ practitioner s commentaries During extraction and placement of filling material, it is necessary to wait for at least 4 months in order to obtain sufficient bone density to place implants. Thanks to this type of biomaterial, the residual bone volume is maintained by avoiding bone resorption of alveolar walls. References: Araujo MG et Lindhe J, Journal of clinical Periodontology

24 Dr. Christian Verner / Nantes Dehiscience and fenestration: Tooth year old patient affected by a periimplantitis around 46. The presence of pathogens harvested by PCR rt confirms it. Pre-surgery examination Clinical view and X-ray Microbiological examination. Treatment decision Non-surgery therapy with ultrasound and adapted air polishing, followed by surgical debridement of the lesion and of the implant by using a bone substitute SBS 60/40 (MBCP ) around the implant in order to retain periimplantary tissues and favour tissue colonisation and then integration. Surgery Intra-sulcular incision, keeping the majority of the papilla in order to facilitate the recovery of the area at the end of the intervention. Removal of granulation tissue of the lesion with dissection on internal socket walls. Ultrasound debridement of the implant followed by light bone plastic surgery with the piezosurgery system on the internal part of the bone walls. Air polishing adapted to the implant. Disinfection. Placement of bone graft material without condensation. Suture after displacement of the flap for a maximum of coaptation and support. 22

25 Surgery Flap and surgical decontamination. Placement of SBS 60/40 (MBCP ) biomaterials. Follow-up at 6 months The socket has disappeared, the turns are again osteointegrated. Conclusion/ practitioner s commentaries The adherence of soft tissues and the structure of hard tissues are stable in time without any inflammation. Strict care will ensure durability. 23

26 Dr. Christian Verner / Nantes Mini-invasive approach: periodontal debridement with infrabony defect Infra-bony defect of 33 in a 48-year old patient. Pre-surgery examination X-ray Treatment decision Mini-invasive surgical debridement. Placement of SBS 60/40 (MBCP ). Surgery Displacement for maximum recovery. 24

27 Follow-up at 6 months Pre-surgical X-ray. X-ray at 6 months. The socket is stabilised. The bone level is satisfactory; even if the remodelling is still in process. Conclusion/ practitioner s commentaries The mini-invasive flaps make the interventions be possible for: more efficient through very precise access to the lesion, better functioning for better attachment, more aesthetic. 25

28 The MBCP product range Synthetic resorbable bone graft Class III medical device Manufactured by Biomatlante MBCP Biphasic Micro-Macroporous 60% hydroxyapatite 40% beta tricalcium phosphate Global porosity 70%: 1/3 micropores < 10 μm 2/3 macropores μm 2 granulometries Putty Synthetic Bone Graft Micro-particles and polymer 60% hydroxyapatite 40% beta tricalcium phosphate Product Characteristics 100% synthetic bone graft No risk of pathogen transmission linked to the product Progressive and total resorbability Eventual replacement by functional natural bone Biocompatibility Chemical nature close to natural bone Stable and soluble Optimal biphasic formula: Hydroxyapatite Stability, maintain the created volume Beta tricalcium phosphate Solubility Crystal precipitation of biological apatite Osteoconduction Guided bone reconstruction inside the substitute Porosity controlled in the manufacturing phase Common indications Periodontal bone filling Augmentation of the alveolar crest Filling of cystic cavities Filling of peri-implantary defects Possible augmentation of the bone volume of an autograft Sinus Augmentation Characteristics of Putty moldable and filling of small cavities 26 Common contra-indications The MBCP bone substitutes must be used only under low load, only as bone substitutes without mechanical properties. Any use with strong mechanical strength is not recommended. For more information please refer to the corresponding instructions for use Other conditions presenting a conta-indication also include: osteomyelitis, implantation on necrotic site, degenerative bone diseases, intraarticular implants, opening of meninx, persons under treatment based on corticoids or acting upon the phosphor-calcium metabolism.

29 Preparing MBCP MBCP Single-use tubes Biphasic ceramic granules 60% hydroxyapatite 40% beta tricalcium phosphate Make sure you are applying an adequate aseptic technique. Remove the tube from its sterile package in an aseptic manner. Prior to use, MBCP must be hydrated with saline solution in order to avoid osmotic shock; for this purpose, place the desired quantity of product in a cup and proceed to hydration. MBCP can also be mixed with autologous blood after hydration with saline solution. The resulting mix must have the aspect and the consistency of a paste. The material adheres to the spatula and must be easy to handle and shape on site. MBCP syringes for single use Biphasic ceramic granules 60% hydroxyapatite 40% beta tricalcium phosphate Remove the syringe from its sterile package in an aseptic manner. Prior to use, MBCP must be hydrated with saline solution in order to avoid osmotic shock. MBCP may also be mixed with autologous blood, but always after hydration with saline solution. Place the extremity of the syringe in contact with the liquid. Pull the piston. Suck up the liquid via the filter cap. The level of the liquid must slightly exceed that of the MBCP granules. Push the piston in order to evacuate the excess liquid. Remove the filter cap, then place the granules directly in the surgery site with the help of the syringe. MBCP 1 procedure tubes/ syringes After hydration with saline solution and, if applicable, addition of autologous blood, place the MBCP granules in the site with the help of a spatula, a sterile amalgam tray or directly with the syringe. Because of its crystalline porous structure, the material must not be squashed or compressed in order to maintain sufficient space in between the granules, essential for the good diffusion of biological fluids. For defects larger than 2 cc, the addition of autologous bone favours bone reshaping through osteoinductive cells. MBCP must be placed without being crushed. Restart the operation, if necessary, without squashing nor pressing. Then reposition the flap and hermetically stitch up the cut. 1 - Fellah B, Gauthier O et al. Osteogenicity of biphasic calcium phosphate ceramics and bone autograft in a goat model. Biomaterials 29 (2008): gamme MBCP

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32 Biomatlante 5 Rue Edouard Belin ZA Les Quatre Nations Vigneux de Bretagne France C MD1