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This presentation reviews common functional and esthetic problems associated with extraction of teeth and current methods and surgical techniques to minimize loss of bone and soft tissue

This presentation reviews common functional and esthetic problems associated with extraction of teeth and current methods and surgical techniques to minimize loss of bone and soft tissue

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  • {"231":"6개월후 CT사진에서 정확하게 13번 부위에서cross section후 모습으로/\n","254":"이상의 증례를 바탕으로 SMARTbuildr는 임상에서 자주 접하게 되는 single implant의 dehiscence defect에서 membrane에 비해 적용과 제거가 쉽고 경제적이며 technique sensitive하지 않는 예지성 있는 결과를 보인다고 결론 지을 수 있겠습니다.\n"}

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  • 1. Advanced Bone Preservation and Regeneration Scott K. Smith, D.D.S. September 21,2013 A HiOssen Course
  • 2. Dr. Scott K. Smith 1986 Pennsylvania State University B.S. Biochemistry 1990 University of Maryland D.D.S. 1992 University of Maryland Certificate in Periodontics
  • 3. Experience • 20 years of Regeneration experience • Lectured for Collagenex for 5 years • Lectured for BioHorizon on Regenerative Materials and Implant Surgery • Lectured for Astra Tech • Guest on the Wellness Hour
  • 4. Today’s Goals • Anatomy of Bone and related Structures • Biology of Healing • Consequences of extractions, trauma and disease on Anatomical Structures • Methods Materials and Techniques for Regeneration • Treatment Planning Skills • K.I.S.S.
  • 5. Mandibular and Maxillary Bone • Composed of Compact and Cancellous • Alveolar bone is specialized bone that supports teeth via ligamentous insertions. • 67% Inorganic ad 33% Organic • Cell Types: Osteoblasts, Osteoclasts, Osteocyte
  • 6. Alveolar Bone
  • 7. Alveolar Bone Need Teeth to have Alveolar Bone
  • 8. Edentulous Bone
  • 9. Misch Bone Density
  • 10. Factors for Bone Formation Bone Cells Signals Matrix
  • 11. Signals • BMP (Bone Morphogenic Proteins) • TGF-B (Transforming growth factor) • PDGF (Platelet Derived Growth Factor) • Insulin-like growth factor • Epidermal and Fibroblast Growth Factor • Tumor Necrosis Growth Factor
  • 12. BMP (Bone Morphogenetic Protein) 1. What is BMP : Protein extractors from bone could induce the local formation of new cartilage and bone when implanted at non-bony site(Dr. Urist) Ectopic bone formation : He called that protein extract BMP (bone morphogenic protein) : Group of growth factors also known as cytokines
  • 13. PDGF and TGF-B • PDGF - Mitogenesis of Mesenchymal Stem cells and endothelial cells • TGF-B - Chemotaxis of Osteoblast precursors, bone matrix formation by osteoblasts
  • 14. Osteoblast Osteoclast Organic matrix Osteocyte Inorganic matrix
  • 15. Osteoblast Cell • Derived from Mesenchymal stem cells • Responsible for Bone Matrix synthesis and mineralization
  • 16. Osteocyte Cells • Osteoblasts that become incorporated within newly formed osteoid • Osteocytes maintain contact with Osteoblasts on surface of bone via canaliculi.
  • 17. Osteoclast Cell • Responsible for osteoid dissolution • Large multinucleated cells similar to macrophages
  • 18. Source of Bone Cells • Mesenchymal stem cells – Source of chondrocyte – Source of osteoblast and osteocyte – Source of cells in the periosteum and perichondrium • Hematopoietic stem cells
  • 19. Source of Bone Cells
  • 20. Matrix • Ground Substance in newly developing bone • Cartilage to Bone • Graft Materials
  • 21. Bone Graft Materials – • Autogenous material Particulated marrow and cancellous bone(PMCB) – Block bone – • Allogenic material Demineralized freeze-dried bone allograft(DFDBA – Freeze-dried bone allograft(FDBA) – Solvent dehydrated with gamma irradiated bone(ICB) – • Xenogenic material Non-organic bovine bone(Bio-oss) – Bovine bone powder(BBP) • Alloplastic material Hydroxyapatite(Calcitite, Osteogen) – – – – – – Beta tricalcium phosphate(Cerasorb) Bioactive glass ceramics(Biogran, Perioglass) Calcium carbonate(Biocoral) Polymer(Bioplant HTR polymer) BCP: Biphasic Calcium Phosphate(Bone ceramic, MBCP)
  • 22. Matrix > Graft and Healing
  • 23. Concept of GBR SIGNALING MOLECULE (PDGF, BMP) TIME APPROPRIATE ENVIRONMENT CELLS (Osteoblasts) SCAFFOLDS (Bone Graft Material) REGENERATIO N OF BONE
  • 24. Extraction Consequences
  • 25. Consequences of Extraction • Loss of Functional Support • Interference with Phonetics • Compromised Esthetics • Plaque and Food Accumulation
  • 26. Socket Healing • Blood clot forms with Coagulation of Red and White Blood Cells • Replacement of Clot with Granulation tissue 4-5 days • Replacement of Granulation tissue by Connective Tissue 14-16 day process • Apical and lateral walls mineralize 10 weeks and complete fill in 15 weeks • Epithelialization of the socket occurs 24-35 days later
  • 27. Factors that Affect Resorption Thin Buccal Bone Gingival BioType
  • 28. Loss of Bundle Bone Without Grafting
  • 29. Modifying Factors • Endodontic Infection • Periodontal Infection, Recession • Trauma • Teeth Relationship - Malposition • Risk Factors - Diabetes, Smoking, “PPP”
  • 30. Bone Healing and Soft Tissue Changes •2/3 rds of the hard and soft tissue changes occur in the first 3 months. •50% of crestal width to be lost in a 12-month period •2/3 of which (3.8 mm; 30%) occurred in first twelve weeks Schropp, et.al
  • 31. Percent of Volume Loss • Horizontal Loss - 22-63% • Vertical Loss - 11-22% Wong Clin Oral Impl Res:14;2012
  • 32. Vertical Loss
  • 33. Six Month Radiographic Metanalysis Study • Average Width Loss 3.87mm • Average Height Loss 1.67mm Van Der Weijden clin oral impl res: 22; 2011
  • 34. What’s Alternative? Guided Bone Regeneration
  • 35. Guided Bone Regeneration • Regeneration of bone through space maintaining, osteoconductive, inductive and biologics to encourage osteoblasts to reestablish dominate tissue at the exclusion of connective tissue.
  • 36. Guided Bone Regeneration
  • 37. Principles of Guided Regeneration • Sterile Enviornment • Tissue Exclusion • Graft Containment • Stable Clot
  • 38. Mechanism of Bone Formation • Osteogenesis • OsteoInduction • OsteoConduction
  • 39. OsteoGenesis • Bone formation by living or autogenous osteoblasts • Formation of bone even without Mesenchymal Cells
  • 40. OsteoInduction • Process of Stimulating Osteogenesis • Transformation of Undifferentiated Mesenchymal cells into Osteoblasts • Ability of Graft material to induce Osteogenesis and bone • BMP instrumental in this process
  • 41. Bowers et al - New Attachment Concept of Regeneration Originated with DFDBA developing bone under skin of Rabbits
  • 42. OsteoConduction • New bone by “creeping substitution” • Bone graft material is scaffold to promote and allow vessel in growth • Bone formation by margin of host bone
  • 43. Bone Defects • Closed - contained - Extraction socket • One Wall - Dehiscence, Fenestration • Multiple Wall Defects - Horizontal Defect • Vertical Defect
  • 44. Socket Preservation Studies: • Bone Augmentation Will Reduce Bone Dimensional Changes - Depending on Technique and Material Van der Weijden, 2010
  • 45. Socket Preservation Studies: • Osteoconductive Materials Do NOT accelerate bone healing, BUT ALLOWS for better preservation of Ridge Volume Pagni, 2012
  • 46. Socket Preservation Studies: • Nonabsorbable ePTFE membranes showed no Volume change of Alveolar Ridge after Six Months Vs. Significant Changes in Control Lekovic, 1997
  • 47. Socket Preservation Studies: • Resorbable Collagen Membranes covering Extraction sites revealed Adequate Bone Formation for Implant placement at 12 weeks. Iasella
  • 48. Socket Preservation Healing • Iasella - FDBA with Collagen membranes nonmolar areas - 15% more bone but still loss of coronal buccal bone • Lekovic -Resorbable membrane vs. Nothing - Less buccal bone resorption 0.38 vs 4.5mm. Vertical height loss comparable • Araujo Lindhe - Is graft material Necessary? Found althought FDBA did not prevent remodeling increased bone density
  • 49. Graft Materials: • OsteoConductive Material - Scaffold Xenograft - BioOss Alloplast - Calcium Sulfate, Biogran, BTCP • OsteoInductive Material - Bone Stimulating Autograft - Local site, Distant site Allograft - FDBA Cortical or Cortical/Cancellous, DFDBA, DBA Paste
  • 50. Occlusive Materials • Collagen Matrix Light - Gelfoam, Collacote • Collagen Matrix Durable • Soft Tissue Graft - auto or allograft • Nonabsorbable Matrix - ePTFE • Other - Periacryl • Titanium membrane
  • 51. Resorbable Membranes
  • 52. *Growth Factors • Platlet Rich Protein (PRP) • Emdogain (PDGF) • Gem 21 (PRGF) • BMP - 2 (Infuse) • Bone Marrow Derived Stem Cells (osteocel)
  • 53. Bone Regeneration • Extraction Socket • Fenestrations and Dehiscence • Ridge Augmentation Prior to Implant • Implant and Ridge Augmentation
  • 54. Five Categories of Defect 2. Fenestrations - Class II Fenestration (Outside Bony Envelop)
  • 55. Five Categories of Defect 3. Dehiscences - Class II Dehiscense (Outside Bony Envelop)
  • 56. Five Categories of Defect 1. Extraction wounds Class I Extraction Sockets Class II Extraction Sockets
  • 57. Why Do Socket Preservation? • Enable Implant installation and stability • Reduce loss of Alveolar Bone Volume • Reduce need for additional bone grafting • Improve Esthetic and Phonetic Outcome
  • 58. Atraumatic Extraction • Eliminate Infection and Irritant • Preserve Existing Bone and Soft Tissue • Minimize Loss of Volume with Augmentation materials
  • 59. Atraumatic Extraction Requirements • PDL incision • Periotomes • Extraction Forceps • Socket Degranulation • Socket Inspection
  • 60. Periotome
  • 61. Extraction Morphology • Intact Bony Socket • Buccal Bone Loss • Multiple Walls of Bone Loss - Ridge Augmentation
  • 62. Intact Buccal Plate -Materials
  • 63. Soft Tissue Preservation Pontic Space Retained
  • 64. Good Two Week PO
  • 65. QuickTime™ and a decompressor are needed to see this picture.
  • 66. Fenestration Defects
  • 67. Buccal Concavity
  • 68. Width of Buccal Bone Maxillary Incisor In the anterior sites, a vast majority of the • buccal bony walls (87.2%) had a width of ≤1mm, • • Only 2.6% of buccal walls were 2mm wide or greater Proposed Criterion for Stable Buccal Bony wall following extraction is 2mm - then MOST sites will LOSE bone. In most situations, guided bone regeneration may be needed to achieve adequate bone contour around the implant and optimal esthetic outcome.
  • 69. Graft Material • Not 4 wall defect • Reduced Blood Supply and Less MSC • Reduced Stability and Retention • Need to use OsteoInductive - I like FDBA and DBA paste mix
  • 70. FDBA/DFDBA Paste Collagen Membrane Collagen Membrane
  • 71. Graft Containment • Resorbable Membrane OK • Trim to cover entire buccal defect and tuck around healing abutment or under palatal flap
  • 72. Periosteal Releasing Incision Coronally Position Tissue Interrupteds
  • 73. Socket AND Ridge Augmentation
  • 74. Mandibular anterior Bone Loss
  • 75. FDBA Graft postioned
  • 76. alloderm Material Sutured or Tacked to Place
  • 77. Fantastic Bone
  • 78. Marvelous Closure
  • 79. Previous Extraction No Augmentation
  • 80. Adaptation and Suture Continuous Sling Suture
  • 81. and 12b blades • 15c Instrumentation • Rounded Blade Holders • Pritchard Periosteal Elevator • Orban Knife • Addison Tissue Forceps • Castroviejo Needle Holder
  • 82. Armamentarium
  • 83. Post-Op Medications • • • • • • Amoxicillin 50mg t.i.d. x 21 OR Clindamycin 300mg t.i.d. x 21 Lodine 400mg t.i.d. x 21 Chlorhexidine Rinse *Vicodin 7.5/300 q.i.d. prn x 12 *Medrol Pak
  • 84. Post Op Follow up • Two week Suture Removal • Patient Resumes Normal Brushing and Diet • Six weeks later Xray • Implant Placement TBD after Xray
  • 85. Complications • Infection - Swelling, Pain after 3 days • Flap Retraction • Soft tissue Slough • Excessive Bleeding post op • Nerve Damage • Sinus Perforation
  • 86. Materials for Ridge Augmentation • OsteoInductive Graft (BMP-2, Osteocel) • Membrane - Collagen, Teflon, Allograft, Titanium mesh • Tack Membrane (?) • Suture - 4-O or 5-O Vicryl, PGA
  • 87. Space Maintenance
  • 88. FDBA - Cortical and Cancelous Bone
  • 89. Six Months Later
  • 90. Implant Placement and Guided Bone Regeneration • Sufficient Bone for Stabilization • Secure Implant torque (>35N/cm) • Graft Containment • Stabilize Site • Ensure Esthetic Outcome Possible
  • 91. Goals?
  • 92. MidCrestal Incision Preserve the Keratinized Tissue
  • 93. Extraction and Evaluation
  • 94. Buccal Bone Loss
  • 95. DeCortication
  • 96. FDBA
  • 97. Suturing - Periosteal Releasing Incision
  • 98. Ridge Augmentation • Flap Design • • • • • • • Incision 15c and 12b Consider Blood Supply - Vertical Insion? Flap Elevation Cortical Perforation Periosteal Releasing Membrane Trimming and Graft Placement Suturing - Interupted, continuous, mattress
  • 99. QuickTime™ and a H.264 decompressor are needed to see this picture.
  • 100. SMARTbuilder
  • 101. SMARTmembrane™ Features • Concept : 3D Pre-formed customizing titanium membrane • Adaptation: Fixture + Height + Membrane + Cap(healing abt) • Tool : Cover cap driver, Defect guage Type 1 (Buccal) Type 2 (Buccal & Proximal) Type 3 (Buccal, Proximal, & Lingual) 3D View Flat View 187
  • 102. Competitors – FT Wing Designed and developed by: Dr. Funato & Dr Tonatsuka Size: 11.5mm(W) x 29mm(L) x 0.2mm (T) 188
  • 103. Competitors – CTi Membrane Buccal or Lingual Buccal- Lingual Proximal Submerged & Non-fixed *Has 6 different shapes and sizes: 30 different types ** Only few types are being used. 189
  • 104. 190
  • 105. Optimum Pore Size for Ridge Augmentation • Compared Titanium Mesh with Pore size of 0.6mm and 1.2mm to that of Resorbable Collagen mesh of 1mm size and No pore • Macro Mesh of 1.2 best for Total Volume of Regeneration • No pore size prevents most soft tissue ingrowth with 1.2 titanium next • Contaiment of Graft most important criteria
  • 106. Journal Analysis Courtesy by Dr. Lee DH  Optimal Pore size ? Specimen : •Macro porous Ø1.2 (titanium) •Micro porous Ø0.6 (titanium) •Resorbable mesh Ø1.0 (poliactic aid) •Any containment (titanium) Each side of cube size is 10mm. Where, tibia bone of Hound dog 1,2,4 week sacrificed R&M Biometrics image analysis SW FIGURE 6. Microsection revealing bone formation with microporous mesh. 10mm 10mm FIGURE 5. Microsection revealing bone formation with macro porous mesh. 1-face open of cube FIGURE 7. Microsection revealing bone formation FIGURE 8. Microsection revealing minimal bone with resorbable mesh formation in the site without any containment. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofacial Surg 67:1218-1225, 2009
  • 107. Journal Analysis < Result > Courtesy by Dr. Lee DH  Optimal Pore size ? Mesh type Regeneration area(mm2) Soft tissue Ingrowth (mm2) Mar rate (Mineral apposition rate) Macro mesh With porous Ø1.2 66.26±13.78 16.96 1.09μm/day Micro mesh With porous Ø0.6 52.82±24.75 22.29 - Resorbable mesh With Ø1.0 46.76±21.22 23.47 2.41μm/day Without pore 29.80±9.35 9.41 - • Bone regeneration : Macro mesh > other comparison group • Prevent soft tissue ingrowth : Without pore > Macro mesh > other comparison group • Containment of bone graft is most critical parameter in success bone regeneration • Cortical perforation did not have any effect on the quantity of bone regeneration. Result and conclusion, Need Bone regeneration or reconstruction and Prevent soft tissue ingrowth therefore Mesh size : Ø1.0 ~ Ø1.2
  • 108. Optimum Pore Size • For optimum Bone Regeneration and exclusion of soft tissue need Mesh size of 1.0 - 1.2mm size. J Oral Maxillofacial Surg 67:1218-1225, 2009
  • 109. Components • Healing Cap or Cover • SMARTbuilder Mesh • Height • Fixture
  • 110. SMARTbuilder • • 3-D Customized Preformed Mesh Side and Bottom pores smaller for graft containment. • • Main pore 1.0mm Smooth edges (!)
  • 111. SMARTbuilder • Type of Defect: 1 wall, 2 wall, 3 wall • Content Specification: Height, Healing abutment, caps • Assemble: Fixture + Height +Membrane + Cap • Requires Cover Cap Driver
  • 112. ™ 1. Check the defect and determine the type of the SMARTmembrane ™ 198
  • 113. SMARTmembrane™ Place the Height on the fixture already placed bone grafting. 200
  • 114. SMARTbuilder 3. Choose Height Component - If Implant submerged or want to gain vertical height use longer one 4. Place Bone Material into defect and over fill
  • 115. SMARTmembrane™ 4. Connect the SMARTmembrane on the height through the hole in the middle. 5. Use 1.2 hex driver for healing abutment, use Cap driver for Cover cap. 6. Suture. 202
  • 116. Indications for SMARTbuilder • Fenestration defects • Dehiscence defects • Immediate Extraction moat defects
  • 117. SMARTmembrane™ 204
  • 118. Types of Defects Classification of dehiscence defect < 1 wall augmentation> < 2 wall augmentation> < 3 wall augmentation>
  • 119. Dental model < 1 wall augmentation> < 2 wall augmentation> < 3 wall augmentation>
  • 120. Dental model < 2 wall augmentation >
  • 121. Dental model < 3 wall augmentation >
  • 122. Multiple Membranes
  • 123. A B C D
  • 124. SMARTbuilder > Case 1 A B C
  • 125. SMARTbuilder > Case 1 A B C
  • 126. SMARTbuilder > Case 2 • UJS (M/64) • #4 Extraction d/t Crown Fx. ( 2 months ago)
  • 127. SMARTbuilder > A B C D
  • 128. SMARTbuilder > Case 2
  • 129. SMARTbuilder > Case 2 POD 24 weeks 2nd Stage surgery
  • 130. SMARTbuilder > Case 2 Before After
  • 131. SMARTbuilder > Case 2
  • 132. SMARTbuilder indication (I) Case presentation
  • 133. SMARTbuilder indication (I) Extrasocket overlay augmentation with Nonsubmerged GBR Preoperative view(#6)
  • 134. Buccal bone envelope defect
  • 135. Vertical augmentation Intrasocket graft Extrasocket overlay graft
  • 136. Selection Height and 3D titanium mesh 2 wall augmentation
  • 137. Maximum effect of 3D extrasocket overlay augmentation Excellent space maintenance PRF for surgical isolation 2 wall augmentation Easy circular approximation by slim healing Abutment
  • 138. PRF for surgical isolation & meticulous circular approximation Healing after 18ds Never brush Never touch PRF Healing after 1 month Postop CT
  • 139. SMARTbuilder removal technique a. Minimal invasive sulcus incision
  • 140. SMARTbuilder removal technique Tissue integration b. Pouch technique
  • 141. Reposition of transmucosal area 4 weeks later
  • 142. Final Prosthesis 4 ms later 1 year later
  • 143. 6 ms 15ds postop. CT (#6) Incredible GBR
  • 144. 1year postop. CT (#6) Incredible GBR
  • 145. SMARTbuilder Guidelines • Accurate Membrane size for Defect! • Bone Material should have Large particle size - 1mm or so • Make sure Membrane Secure and Adapted well to Bone • No Dead Space - Fill voids with bone
  • 146. SMARTbuilder indication (II) Case presentation
  • 147. Preoperative intraoral view (post ext. 4ms) Horizontal deficiency at labial side (#12) Implantation & Sinus lifting Labial bone deficiency
  • 148. Selection of 3D titanium mesh 1 wall augmentation • Bone Graft for labial augmentation
  • 149. 2 months later Good nonsubmerged healing of GBR
  • 150. 2nd stage surgery after 4 months Excellent tissue integration
  • 151. Good bone regeneration Before After (4 ms later) Good space maintenance at labioincisal area
  • 152. 6 ms later postop. CT (#12) 6 ms later final prosthesis
  • 153. 7 ms later postop. CT (#12) Preop. view Postop. view
  • 154. Preoperative intraoral view Horizontal & Vertical bone deficiency Palatal bone deficiency
  • 155. Labial & Palatal & Vertical bone augmentation 3 wall augmentation type
  • 156. 3 wall augmentation type PRF for surgical isolation
  • 157. PRF for surgical isolation & meticulous circular approximation Postop CT
  • 158. 6 weeks later Never touch Never brush
  • 159. Excellent Space maintenance Horizontal augmentation Vertical augmentation
  • 160. Surgical isolation by PRF PO 1 week
  • 161. 4 months later(GBR)
  • 162. Limitation of SMARTbulder 1. Fenestration wound
  • 163. Limitations of SMARTbuilder • Extensive Palatal Defects • Extensive Ridge Augmentation without implant Stabilization
  • 164. Limitation of SMARTbuilder 1.Fenestration
  • 165. Why SMARTbuilder? • Excellent Mechanical properties: • Sufficiently Rigid for space maintenance • Elasticity - Prevents Mucosal Compression • Stabilizes Bone graft material
  • 166. Conclusion; Why SMARTbuilder? • Single implant defect • Common clinical situation • Low cost(vs. membrane) • Easy to use & removal • Predictable result
  • 167. GBR is Predictable • Understand Normal Anatomy, Cause of Defect, and Anticipated Result • Understand Healing capabilities and Limitations • Understand Surgical Concepts • Utilize Optimum Techniques and Materials • Continue to Learn and Care!
  • 168. The End