Session 4 A Alveolar Bone Regeneration - Ridge Only ...smile.uthscsa.edu/ImplantologyCont/AlveolarBoneRegeneration.pdfSession 4 A Alveolar Bone Regeneration - Ridge Only - SonicWeld

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  Disable Norton AV, Norton Firewall   Set Power mode to presentation   Set Laptop to max resolution of

projector   Check Slide Show options   Projector on, connect   Fn/7 to duplicate

23% 74% Defect Fill

2.75 mm

4.26 mm CAG

2.24 mm

4.94 mm Reduction in PD

OFD (control

)

Emdogain®

(test)

Parameter

ALVEOLAR AUGMENTATION FACILITATED BY PARTICULATE BONE GRAFTS

Kevin G. Murphy, DDS, MS Associate Professor of Periodontics Private Practice, Baltimore, MD

How  would  you  treat  these  cases?   Methods  of  Ridge  Augmentation  

  Distraction  

  Autogenous  Block  

  Allograft  Block  

  Ridge  Expansion  

  GBR  using  Particulate  Graft  

  Hybrid  

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Augmentation  Treatment  Modalities  

•  Distraction  Osteogenesis  •  Block  Autografts  •  Block  Allograft  •  Ridge  Expansion  •  Guided  Bone  Regeneration  with  Barrier  

and  Particulate  Graft  •  Hybrid  

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GBR  Treatment  Modalities  

•  Distraction  Osteogenesis  •  Block  Autografts  •  Block  Allograft  •  Ridge  Expansion  •  Guided  Bone  Regeneration  with  Barrier  

and  Particulate  Graft  •  Hybrid  

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Dr. G.

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Augmentation  Treatment  Modalities  

•  Distraction  Osteogenesis  •  Block  Autografts  •  Block  Allograft  •  Ridge  Expansion  •  Guided  Bone  Regeneration  with  barrier  

and  particulate  graft  •  Hybrid  

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Augmentation  Treatment  Modalities  

•  Distraction  Osteogenesis  •  Block  Autografts  •  Block  Allograft  •  Ridge  Expansion  •  Guided  Bone  Regeneration  with  Barrier  

and  Particulate  Graft  •  Hybrid  

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Augmentation  Treatment  Modalities  

•  Distraction  Osteogenesis  •  Block  Autografts  •  Block  Allograft  •  Ridge  Expansion  •  Guided  Bone  Regeneration  with  Barrier  and  Particulate  Graft  

•  Hybrid  

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GBR with Particulate Grafts What is the histologic evidence?

 –  Schenk et al, IJOMI 1994 –  Simion et al, IJPRD 1994 –  Jovanovic et al, IJPRD 1995 –  Jensen et al, IJPRD 1995 –  Renvert et al, COIR 1996 –  Simion et al, COIR 1999 –  Araujo et al, JCP 2002

 –  Dahlin et al, COIR 1998 –  Fugazzotto P, IJPRD 2003 –  Canullo et al, IJPRD 2006

EB Systematic Review Cochrane Collaboration 2006

  Very few RCTs compare the efficacy of

 different trials - therefore meta-analysis could not be performed   Both GBR and DO result in vertical

GBR with Particulate Grafts What is the clinical evidence?

 –  Buser et al, IJPRD 1993, 1995 –  Nevins et al, IJPRD 1998 –  Fugazzotto et al, IJPRD 1997 –  Brocard et al, 2000

 –  Tinti et al, IJPRD 1996 – Autogeneous –  Simion et, IJPRD 1998 – DFDBA + Autogenous –  Tinti et al, IJPRD 1998 – DFDBA + Autogenous –  Simion et al, COIR 2001 – Autogenous + TR –  Canullo et al, IJPRD 2006 – Bio-Oss + TR

Amount of lateral augmentation rarely defined, but most studies demonstrated implant survival rates of >96%

Vertical augmentation ranged from 3 – 5 mm

Comparisons

Block Block Particulate

Graft Morbidity + +++ +

Cost Assume barrier use

$$$ $ $$

Complications Complete failure of

[8.5 %] 0 - 30 % 0 – 30 %

Graft unknown 7 – 40 % 1 – 2 mm

Efficacy ++

+++ ++ / +++

Clinical Evidence

+ ++ ++++

Schwartz-Arad & Levin, JP 2005; Machtei, JP 2001; Arx & Buser, COIR 2006; Keith et al, IJPRD 2006

Complications  associated  with  GBR  

  Failure  to  maintain  graft  volume    Use  of  reinforced  non-­‐resorbable  barriers    Use  of  graft  “binder”  –  PRP  

  Flap  necrosis    Tension-­‐free  closure  techniques     Incision  designs  

 Alteration  of  the  gingival  form  

Patterns of Neo-vascularization of

1

10

100

Day 1 Day 3 Day 7 Day 10 Day 14

% Area of Flap Capillary Circulation

Extravascular DiffusionNo Diffusion

(Caffesse et al)

   Vascular stasis and edema   Intracapillary diffusion   Wound contracture   Vasconstrictive influences

– – Epinephrine

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Why  do  flaps  open-­‐up?  Wound  contracture  vs  angiogenesis       Poor  adaptation  of  wound  margins    Excessive    compression  from  sutures    Lack  of  multi-­‐layer  closure    Indiscriminate  use  of  vasoconstrictors   Mechanical  trauma    Flap  design  inconsistent  with    

revascularization   Buser, 1994 Buser, 1994

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Is this outcome

predictable?

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Incision  designs  based  upon  microvasculature  Kleinheinz  et  al  2005  

  Cast  perfusion  studies  on  cadaver  material  

  Crestal  area  of  the  edentulous  alveolar  ridge  is  covered  by  an  avascular  zone  with  no  anastomoses  crossing  the  alveolar  ridge  

 Main  arteries  run  posterior  to  anterior  in  vestibule  

Effect of incision location on flap necrosis in GBR Park and Wang 2007

  Related  flap  necrosis  to  flap  thickness  

  “Offset”  or  paracrestal  incisions  more  likely  to  fail  than  crestal  

  Tissue  thickness  should  be  >3mm  at  incision  site  

Buser

Multi-layer closure

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GBR  with  particulate  grafts  ideally  suited:  

 When  complex  flap  manipulation  required  

 Contained  defects  

 Lateral  augmentation  

 Moderate  vertical  augmentation  

GBR  facilitates  complex  flap  manipulation  

Contained  Defects  

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Lateral  Augmentation  

Hur et al JP 2010

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Vertical  Augmentation  

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Types  of  resorbable  barriers  

  Polymer  based  

  Collagen  based  

  CaSO4    

What  material  is  the  best?  e-­‐PTFE  is  the  gold  standard  

  Longest  history  of  use    Largest  number  of  documented  cases  

  Safety  

 Retrievable  

 Morbidity  with  second  stage  surgery  

  Complications  

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Why  use  bioabsorbable  barriers?    

• No  retrieval  

• Period  for  risk  of  complications  is  shorter  

•  Incidence  of  complications  similar  to  inert  barrier    

• Performance  is  similar  

•  Ease  of  use  

McGinnis et al - 1998 Resorbable vs. non-resorbable

barriers in calvaria defects

  Surgically created calvaria defects in dogs

  15mm critical size defects   Vicryl, fascia lata, BioMend, Millipore, e-PTFE barriers

  Millipore and e-PTFE perform best

e-PTFE vs. Resolut in GBR   e-PTFE vs. Resolut vs. control   No bone grafts   Histologic evaluation at 3.5 months   nonspacemaking dehiscence type defects in 6 dogs   Threads covered with e-PTFE, but not with Resolut or controls

e-PTFE vs. Resolut

  e-PTFE with DFDBA vs. Resolut with DFDBA vs. Resolut alone in non-spacemaking defects in dogs   Histologic evaluation at 3 months   Both barriers demonstrated bone fill   e-PTFE had greater bone-implant contact and volume of bone fill

Dahlin et al - 1998 e-PTFE to tissue interface

  3mm tall cover screws on implants counter-sunk in healing extraction sites   Harvested at 7 months   Thin layer of connective tissue (CT) between barrier and screw   CT may be related to micromovement   Bone formation in the membrane

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Polymeric barriers in GBR   e-PTFE alone results in better healing   Grafts are usually necessary to provide space   Bioabsorbables must maintain shape long enough for regeneration to occur   Bioabsorbables must be stiff enough to maintain shape if no graft is used   Increase stiffness decreases adaptability and impairs soft tissue coverage

Stiffness

Adaptability

Barrier exposure

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slide

Alteration  of  the  gingival  form  after  GBR  

  Buccal  flap  is  frequently  released  to  provide  passive  adaptation  

  Buccal  crestal  bone  is  first  to  resorb  

 MGJ  will  frequently  shift  towards  palatal  –  lingual  

  Less  tissue  volume  on  buccal  -­‐  labial  

  Lack  of  bound  tissue  on  buccal  -­‐  labial  

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Hybridization  of  GBR  techniques  

  Combination  of  split-­‐ridge  with  particulate  graft    Expanded  buccal  –  labial  plate  holds  graft  material    Barrier  promotes  survival  of  expanded  buccal  plate    Rotated  buccal  plate  supports  moderate  vertical  augmentation  

  Vestibular  pouch    Pouch  approach  eliminates  crestal  incision  liability    Remote  vertical  incisions  facilitate  moderate  access    MGJ  not  significantly  altered    

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GBR  with  particulate  grafts  

 Positive  surgical  outcomes  are  related  to  ideal  flap  management  

  Incision  design  and  the  passivity  of  flap  closure  greatly  impact  flap  survival  

 Maintenance  of  graft  volume  can  be  achieved  with  reinforced  barriers  or  graft  binders  

 Hybridizing  techniques  will  decrease  the  risk  of  surgical  failures  

 Alteration  of  the  gingival  form  is  common  with  GBR  procedures  

 Augmentation  or  modification  of  the  gingival  tissues  is  a  commonly  required