Concern about Bone Graft Success

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The patient was in crisis and needed treatment. My student wondered how to handle this patient. The situation was a tough one. The patient needed a bone graft at #5 site, but there was loss of periodontal attachment on the adjacent canine.

Tooth #5 max right first premolar was fractured, decayed, with loose crown-post and significant bone loss. The implant surgeon was concerned about esthetic facial soft tissue loss after extraction and was unsure about the bone graft working due to loss of attachment on the adjacent canine tooth. The patient was in crisis and needed immediate treatment.

 

My Advice:

 

I have treated this type of situation on several occasions with good and sometimes excellent success. My advice is to do the following:

1. Extract failed tooth #5 using an open flap approach with a cosmetically concealed distal releasing incision. This will provide access for complete debridement and disinfection of the site by removal of granulation tissue, thereby reducing the risk of post grafting infection.

2. Although detoxification of the exposed root surfaces is necessary using citric acid or Straumann Pref Gel, maintenance of the PDL or remnants of the PDL in the unexposed portions of the adjacent canine tooth is important.

3. I would graft this site using Straumann Emdogain to coat the distal canine root surfaces and a particulate graft of Bio-Oss with autogenous bone harvested from the local area or preferably cancellous marrow harvested from the maxillary tuberosity. I would adapt a non-cross linked membrane such as BioGuide to isolate and protect the graft. Use of PRP in these cases provides the advantage of stabilization of the graft and the technical advantage of allowing you to sculpt the graft with a high degree of precision and “Glue” the barrier membrane in place eliminating the need for sutures or tacks. If you do not have access to PRP, you can collect blood from the local area using a syringe at the surgical site. This is facilitated by minimizing vasoconstrictor in the local anesthetic.

4. You could also consider using Gem21S growth factor enhanced matrix to graft the area. The Gem21S product provides recombinant platelet derived growth factor at a concentration 1,000 times higher than the patient’s own blood. Studies demonstrate 3 times greater bone fill in periodontal defects grafted with Gem21S.  Although off label, mixing the Gem21S with a slow substitution graft material that provides long term structural stability such as Bio-Oss is an approach that has been very successful in compromised sites such as the case you are faced with.

5. After securing the barrier membrane over the graft complex, I would then rotate and secure a VIP-CT palatal pedicle flap over the grafted site and achieve primary closure. This flap provides a vascularized periosteal-connective tissue flap that not only provides additional circulation to the area but also provides a large volume of soft tissue cover and the required mesenchymal cell pool required for maintenance of the graft volume during the remodeling phase of bone graft healing.

6. Allow up to 4-6 months healing time before reentry for implant placement or 3 months if conventional dental restoration is planned.

 

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Dr. Sclar is in South Africa for the International Team for Implantology (ITI) Congress

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Dr. Anthony G. Sclar and Dr. Steven E. Eckert will be presenting the South Africa ITI Congress program titled 60 Years! Yesterday, Today and Tomorrow, at Vodacom World, Midrand, Johannesburg on July 26-27, 2013.

The International Team for Implantology (ITI) is a unique network that unites professionals around the world from every field of implant dentistry and related tissue regeneration. As an independent academic association, it actively promotes networking and exchange among its membership. Established in 1980, the ITI has become one of the largest independent academic organizations in implant dentistry and the related field of tissue regeneration.

Dr. Anthony G. Sclar has attended the International Team for Implantology (ITI) Congress multiple times and has been asked to present on numerous occasions. As an ITI Fellow, Education Committee member, Consensus Conference participant, and ITI Treatment Guide contributor, he has been immersed in this invaluable organization and recommends all ITI Congresses as well worth attending.

Friday July 26, 2013
Opening Remarks
(Gerrit Wyma)
Session 1: Current Knowledge
What we know, is the literature credible? (Steve Eckert)
Biology of hard and soft tissue wound healing and grafting (Anthony Sclar)
Session 2: The Healthy Compromised Implant

Risk factors related to esthetic implant complications (Anthony Sclar)
Prosthetic complications: tips and tricks (Steve Eckert)
Session 3: Poster and Case Presentations (competition)
Session 4: Controversial Issues
Prosthetic decisions: where, how many and which materials. Metal vs. ceramic abutments and super-structures, abutment selection, screw vs. cement retained, implants connected to teeth, how many implants are needed? (Steve Eckert)
Does alveolar ridge preservation provide functional and esthetic benefits? (Anthony Sclar)

Saturday July 27, 2013
Session 5: Peri-Implantitis, Current Status

Peri-implantitis: Prevalence, diagnosis and prognosis (Steve Eckert)
Peri-implantitis: Risk factors, clinical and surgical protocols for management (Anthony Sclar)
Session 6: Treatment Planning
“All on 4 or More” Immediate function procedures: Current clinical protocols and literature support (Anthony Sclar)
Digital Prosthetics, ready for prime time? (Steve Eckert)
Session 7: Emerging Technologies
The role of tissue engineering in reconstructive and esthetic implant dentistry (Anthony Sclar)
The future of implant dentistry (Steve Eckert)
Closing Remarks (Paul van Zyl)

 

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Preparation of the Periimplant Soft Tissue Envelope…what every dental implant surgeon should know

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At the Sclar Center for Empowered Dental Implant Learning, my students frequently ask:

How do I know when soft tissue augmentation is indicated around dental implants or at sites with deficient alveolar ridges requiring bone grafting?

How should the procedures be sequenced?

 

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All-on-4® Full Arch Immediate Function Revisited

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Over five years ago, I became highly interested in helping patients who came to me crying because no one was offering them hope of an easy, fully functional solution for their terminal dentitions. Just as heart-tugging were the desires of those who were already suffering from full edentulism.

Many implant surgeons were and many continue to be skeptical about the efficacy of full arch immediate function fixed restorations supported by angled implants, but I decided to learn about them, do them, and stay in conversation with colleagues who were and are doing them.

I am happy to report we are seeing very few complications among our patients, many of whom are now five years post-operative, and these patients are reporting continued high satisfaction with quality of life improvements consistent with that reported in the literature.

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In Demand: The IDR Protocol

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In Demand: The IDR Protocol

At our ISTM 2013 comprehensive implant surgery training meeting (Feb. 1-5, 2013), we will devote the first afternoon Regenerative Technologies Forum to learning about the relatively new Immediate Dentoalveolar Restoration (IDR) protocol. Presenting on this topic will be the three Brazilian clinicians and researchers who developed the protocol. They are in demand worldwide as speakers so we are honored to have them join us at our fifteenth annual training meeting on Miami Beach.

Until recently, tooth replacement at compromised sites in the esthetic zone, required long-term treatment with possible undesirable complications in the tissue architecture. The Immediate Dentoalveolar Restoration (IDR), which advocates minimally invasive flapless procedures, is a viable and reproducible alternative.

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Avoid Dental Implant Complications with Cone Beam-CT Technology

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I believe Cone Beam-CT technology and treatment planning software have the greatest potential for helping doctors avoid or reduce the frequency of implant complications. Our in office I-Cat cone beam CT (Imaging Sciences International) scanner allows us to evaluate the patient’s anatomy in 3D and accurately identify the location and course of vital structures such as the inferior alveolar nerve. In addition, dental pathology not seen on plain films occasionally becomes readily apparent with this technology.

When combined with a scan guide derived from a diagnostic wax up that duplicates the proposed final implant restoration, we are able to perform 3D treatment planning as we evaluate all of the restorative and surgical information on the screen. We can then convert the scan guide into a conventional surgical guide to prepare our sites for implant placement or to guide our 3D hard tissue site development procedures.

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