Bone Grafting for Socket Preservation Dr. Karl R. Koerner Normal extraction facial bone loss. Excessive force. Commonly the thickness of facial bone. Hussain, A. et al. Ridge preservation comparing a nonresorbable PTFE membrane to a resorbable collagen membrane: a clinical and histologic study in humans. Implant Dentistry. 25(1):128-134, 2016. Why a barrier membrane? Prevent epithelium and connective tissue from migrating into the grafted site, Facilitating repopulation of the bone graft with progenitor cells from adjacent bone. Retzepi M and Donos N. Guided bone regeneration: Biological principle and therapeutic applications. Clin Oral Implants Res. 2010:21(6):567-576. Greenstein, et al. Utilization of d-ptfe barriers for post-extraction bone regeneration in preparation for dental implants. Compendium 2015:36(7), pp.465-472. July/August. 1
How long does it take a bone graft to not need protection any more to not need a barrier membrane any more to become osteoid? Minimum 3-4 weeks. How can socket grafts fail?? Bone graft material comes out. No membrane. Inadequate membrane. Closure opens up after surgery. Membrane lost from patient non-compliance. Stays in but is contaminated and does not become osteoid. Stays particulate. Disappears or loses volume from lack of nutrients, inadequate blood supply. The problem. Part of the solution. Too many choices for socket grafts? 1. 2 week post-op. BioGide, Ossix Plus Cytoplast (PTFE) BioXclude Epiguide Laminar bone Osteogen Plugs BioGide, Ossix Plus, other collagens Cytoplast (PTFE) BioXclude Epiguide Laminar bone Osteogen Plugs If nearly closed (within 3-4 mm) can use collagen membrane. If open more than that, PTFE more predictable. 1 month post-op. 2
Socket healing: About 4 days: The blood clot is replaced with granulation tissue. 21-28 days: Granulation tissue is converted to connective tissue. Osteoblasts initiate bone formation by secreting osteoid as several specific proteins. o Osteoid (fibers and ground substance) is a precursor to bone. o Osteoid tissue organizes and mineralized to become woven bone. o Osteoid doesn t need a protective membrane. About three months: the socket is filled with woven bone. About four months: Mineralizes to become lamellar bone. For the next year: Lamellar bone continues to mineralize. In a favorable situation, an implant can be placed in about four months. Types of bone grafting materials: Autogenous (from the patient) Allograft (from another person). Advantage: rapid turnover 4 months. Mineralized (cortical, cancellous, or mixed)* Osteoconductive. Demineralized (may have osteoinductive capability due to bone morphogenic proteins) Mixed mineralized and demineralized. Has advantages of both. * cortical bone alone will take longer to turnover. 6 months Xenograft (from a species other than human). Bovine. Usually takes longer. 6 months Alloplast (synthetic). HA, TCP, bioactive glass, or polymer. Usually take longer. > 6 months Where to use which bone graft: For future implant. Want to do the implant ASAP. 1. Mineralized allograft cancellous, cortical OR blend of cancelous/cortical 2. Demineralized Allograft or blend of demineralized + mineralized 3. DBM (demineralized bone matrix) 4. Tricalcium phosphate (TCP). Blend of TCP and other products For pontic site. Peri-implantitis repair. Not going back in. Bovine bone Resorbable HA Peri-implantitis repair? By 2020, 2-4 million implants will be placed annually in the U.S. 2-3% will be lost before prosthetic loading. Then, 2-3% with fixed prostheses will fail over 5 years. One author estimates there is an 8.5% occurrence of peri-implantitis over 5 years. Requiring continued need for bone grafting. Dentistry Today 2015; April; 15:43; CE 184; 1-16 Types of bone barrier membrane materials: Resorbable Usually tucked under periosteum on buccal and lingual More predictable if have primary closure Many types can be successful without primary closure, especially if only open 3-4 mm. Bovine collagen, bovine pericardium Allograft collagen, allograft pericardium AlloDerm, Fascia (thicker 0.8-1.0 mm) pericardium (strong, double layer collagen) Laminar bone BioXclude (amnion/chorion) Polyglycolic acid (EpiGuide) 3
Xenograft collagen membranes. Non-resorbable e-ptfe. Effective but can become infected after about 4-6 weeks if exposed. d-ptfe. Advantages: Need not be submerged. Don t need primary closure. Don t need periosteal release. Can remain open the width of the socket. 4 week removal. Could be as long as 6. Assures the presence of keratinized tissue. Disadvantages: Needs to be removed. Should not touch an adjacent tooth. Can blunt papillae in anterior thin phenotype cases. One month post-op. One month post-op. 4
Greenstein G and Carpentieri, JR. Utilization of d-ptfe barriers For post-extraction bone Regeneration in preparation For dental implants. Compendium. 36:7 465-472. July/Aug. 2015 3 weeks postop 4 weeks postop 8 weeks postop Left: Gap created by teasing out an incision made in the periosteum. bone April 13, 2017. Ridge augmentation in preparation for an implant. Bone graft: Allograft putty (demineralized bone and mineralized cortical chips). Membrane: PTFE. White lines: Proposed incisions. PTFE (Teflon) membrane (rough side up). 3 months postop Above: Periosteal release done by the instructor (not required when using PTFE). The double envelope flaps help achieve partial closure. Right: Fenistrations to provide nutrients for the bone graft. Pre-op Bone graft. PGA sutures placed. Follow-up with patient and suture removal in 14 days. Membrane removal in one month. Optional: PTFE with titanium strip when trying to re-create buccal fullness. PTFE tucked 4 mm under the lingual flap then bone graft material placed on the buccal side of the ridge. membrane brought over the top and placed over the bone graft on the facial side (without touching the adjacent teeth). Amoxicillin starting preop. 500 mg, 2 stat then 1 tid for 6 days. Post op instructions: Follow up visits. Antibiotic. Peridex applied to the site bid for six weeks Avoid chewing in this area for 6 weeks. PTFE membrane removed in 1 month. Call surgeon if problems. 5
Adjunctive bone grafting supplies and techniques for more difficult cases. 2 week post-op. PRF Need IV blood draw Gem 21 Osteohealth $249 (0.5cc) Infuse Medtronic $950 (1 kit) Emdogain Straumann $165 (1 pack) Both 4 week post-op. Granulates in as keratinized tissue. Blood draw Spin down Fibrin clot Use in bone graft and as a membrane. Socket Preservation vs. Ridge Augmentation 7953 (Socket Preservation) Graft IS placed same day as extraction Includes graft material but not membrane 7950 (Ridge Augmentation) Graft IS NOT placed same day as extraction Includes graft material but not membrane Barrier Membrane Codes 4266 resorbable 4267 non-resorbable (includes removal usually about 3-4 weeks later) 6
Easy Fix (when not open more than 2-3 mm) Bridge pontic site with provisional. Smashed ½ of a Colla-Plug. For smaller areas of non-closure (2-3 mm). Bone graft (Resorbable HA). HYBRID: OsteoGen Plugs All-inclusive: bone graft and membrane. Easy to use molds to the socket. For socket grafts - must have buccal plate present. Requires a minimally invasive extraction For future implant or pontic site. Routine use by general dentists. Calcium phosphate-based (synthetic) graft -- intermixed with Type I bovine collagen. $50 cost per socket Immediate post-extraction. 7
7 weeks post-extraction. 3 months post-extraction. OsteoGen Plugs Takes 3-5 months to be able to place an implant. Deliver to the socket dry and let hydrate with blood. - Increase blood supply if needed by decorticating the socket lamina dura (#2 round bur or equivalent) Four months post-op. What is it? 1. Collagenous, made from placenta. 2. Amnion/chorion layers. 3. Has growth factors and other substances that enhance healing. 4. Doesn t just protect the bone graft. It impregnates and becomes part of it. 5. Bioactive and anti-bacterial 8
Can place double layer, can fold on itself. Tuck 1-2 mm under soft tissue. Suture over top. 2 week and 4 week postop checks. Patient: No acidic foods (soda, Gator Aid, citrus drinks, etc.), no Peridex. Rather, milk, water. Don t brush, saline rinses 3-4/day. 9