In Memory of Professor Per-Ingvar Brånemark

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In Memory of Professor Per-Ingvar Brånemark

Today millions of men and women can smile with pride thanks to Professor Brånemark − what a legacy. Upon hearing the news of his passing, I felt a great loss both professionally and personally. My sincere condolences go out to the Brånemark family. Although we are saddened, we must celebrate this exceptional man for his innovative mind and his tireless work that forever changed the course of dentistry worldwide. Professor Brånemark literally ushered in the age of “Implant Dentistry” by legitimizing the once maligned therapy through scientific studies that accurately documented the benefits of “Osseointegration” in oral rehabilitation. I first met Professor Brånemark at an oral surgery symposium in Canada in the late 1990’s where he gave a presentation in the morning and I followed with a presentation in the afternoon. I was beyond honored and my wish was to meet Professor Brånemark and get a photograph with him if possible. We briefly shook hands, but nothing more. A few years later, our paths crossed at an author’s dinner hosted by Quintessence publishing. I did not expect Professor Brånemark to remember me, but he did. He asked me and my wife to join him at his table. He said he wanted to make up for not having any time to talk in Canada. And so I learned – not only a brilliant doctor and accomplished researcher, but a true gentleman as well. In short order, he began to quiz my knowledge regarding the science and clinical applications of osseointegration. He corrected me when I used the term “Implant” instead of “fixture” and that implants were synonymous with tissue grafts. I shared with him how osseointegration had allowed me to help so many suffering patients and how this work had profoundly added purpose to my life. I was inspired by both Professor Brånemark’s genius and his humbleness. I believe that his spirit will forever guide those who continue to apply his scientific innovations. His ground-breaking work will live on for generations and for that we are all deeply grateful.

Anthony G. Sclar OMFS

Miami, Florida

 

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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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Achieving Successful Bone Grafts

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Achieving predictable results with intra-oral bone grafting and oral soft tissue grafting procedures requires advanced training and experience.

To begin with, the implant surgeon must fully comprehend:

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