Ridge preservation copy

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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

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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"}
  • Ridge preservation copy

    1. 1. Advanced Bone Preservation and Regeneration Scott K. Smith, D.D.S. September 21,2013 A HiOssen Course
    2. 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. 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. 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. 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. 6. Alveolar Bone
    7. 7. Alveolar Bone Need Teeth to have Alveolar Bone
    8. 8. Edentulous Bone
    9. 9. Misch Bone Density
    10. 10. Factors for Bone Formation Bone Cells Signals Matrix
    11. 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. 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. 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. 14. Osteoblast Osteoclast Organic matrix Osteocyte Inorganic matrix
    15. 15. Osteoblast Cell • Derived from Mesenchymal stem cells • Responsible for Bone Matrix synthesis and mineralization
    16. 16. Osteocyte Cells • Osteoblasts that become incorporated within newly formed osteoid • Osteocytes maintain contact with Osteoblasts on surface of bone via canaliculi.
    17. 17. Osteoclast Cell • Responsible for osteoid dissolution • Large multinucleated cells similar to macrophages
    18. 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. 19. Source of Bone Cells
    20. 20. Matrix • Ground Substance in newly developing bone • Cartilage to Bone • Graft Materials
    21. 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. 22. Matrix > Graft and Healing
    23. 23. Concept of GBR SIGNALING MOLECULE (PDGF, BMP) TIME APPROPRIATE ENVIRONMENT CELLS (Osteoblasts) SCAFFOLDS (Bone Graft Material) REGENERATIO N OF BONE
    24. 24. Extraction Consequences
    25. 25. Consequences of Extraction • Loss of Functional Support • Interference with Phonetics • Compromised Esthetics • Plaque and Food Accumulation
    26. 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. 27. Factors that Affect Resorption Thin Buccal Bone Gingival BioType
    28. 28. Loss of Bundle Bone Without Grafting
    29. 29. Modifying Factors • Endodontic Infection • Periodontal Infection, Recession • Trauma • Teeth Relationship - Malposition • Risk Factors - Diabetes, Smoking, “PPP”
    30. 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. 31. Percent of Volume Loss • Horizontal Loss - 22-63% • Vertical Loss - 11-22% Wong Clin Oral Impl Res:14;2012
    32. 32. Vertical Loss
    33. 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. 34. What’s Alternative? Guided Bone Regeneration
    35. 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. 36. Guided Bone Regeneration
    37. 37. Principles of Guided Regeneration • Sterile Enviornment • Tissue Exclusion • Graft Containment • Stable Clot
    38. 38. Mechanism of Bone Formation • Osteogenesis • OsteoInduction • OsteoConduction
    39. 39. OsteoGenesis • Bone formation by living or autogenous osteoblasts • Formation of bone even without Mesenchymal Cells
    40. 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. 41. Bowers et al - New Attachment Concept of Regeneration Originated with DFDBA developing bone under skin of Rabbits
    42. 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. 43. Bone Defects • Closed - contained - Extraction socket • One Wall - Dehiscence, Fenestration • Multiple Wall Defects - Horizontal Defect • Vertical Defect
    44. 44. Socket Preservation Studies: • Bone Augmentation Will Reduce Bone Dimensional Changes - Depending on Technique and Material Van der Weijden, 2010
    45. 45. Socket Preservation Studies: • Osteoconductive Materials Do NOT accelerate bone healing, BUT ALLOWS for better preservation of Ridge Volume Pagni, 2012
    46. 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. 47. Socket Preservation Studies: • Resorbable Collagen Membranes covering Extraction sites revealed Adequate Bone Formation for Implant placement at 12 weeks. Iasella
    48. 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. 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. 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. 51. Resorbable Membranes
    52. 52. *Growth Factors • Platlet Rich Protein (PRP) • Emdogain (PDGF) • Gem 21 (PRGF) • BMP - 2 (Infuse) • Bone Marrow Derived Stem Cells (osteocel)
    53. 53. Bone Regeneration • Extraction Socket • Fenestrations and Dehiscence • Ridge Augmentation Prior to Implant • Implant and Ridge Augmentation
    54. 54. Five Categories of Defect 2. Fenestrations - Class II Fenestration (Outside Bony Envelop)
    55. 55. Five Categories of Defect 3. Dehiscences - Class II Dehiscense (Outside Bony Envelop)
    56. 56. Five Categories of Defect 1. Extraction wounds Class I Extraction Sockets Class II Extraction Sockets
    57. 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. 58. Atraumatic Extraction • Eliminate Infection and Irritant • Preserve Existing Bone and Soft Tissue • Minimize Loss of Volume with Augmentation materials
    59. 59. Atraumatic Extraction Requirements • PDL incision • Periotomes • Extraction Forceps • Socket Degranulation • Socket Inspection
    60. 60. Periotome
    61. 61. Extraction Morphology • Intact Bony Socket • Buccal Bone Loss • Multiple Walls of Bone Loss - Ridge Augmentation
    62. 62. Intact Buccal Plate -Materials
    63. 63. Soft Tissue Preservation Pontic Space Retained
    64. 64. Good Two Week PO
    65. 65. QuickTime™ and a decompressor are needed to see this picture.
    66. 66. Fenestration Defects
    67. 67. Buccal Concavity
    68. 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. 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. 70. FDBA/DFDBA Paste Collagen Membrane Collagen Membrane
    71. 71. Graft Containment • Resorbable Membrane OK • Trim to cover entire buccal defect and tuck around healing abutment or under palatal flap
    72. 72. Periosteal Releasing Incision Coronally Position Tissue Interrupteds
    73. 73. Socket AND Ridge Augmentation
    74. 74. Mandibular anterior Bone Loss
    75. 75. FDBA Graft postioned
    76. 76. alloderm Material Sutured or Tacked to Place
    77. 77. Fantastic Bone
    78. 78. Marvelous Closure
    79. 79. Previous Extraction No Augmentation
    80. 80. Adaptation and Suture Continuous Sling Suture
    81. 81. and 12b blades • 15c Instrumentation • Rounded Blade Holders • Pritchard Periosteal Elevator • Orban Knife • Addison Tissue Forceps • Castroviejo Needle Holder
    82. 82. Armamentarium
    83. 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. 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. 85. Complications • Infection - Swelling, Pain after 3 days • Flap Retraction • Soft tissue Slough • Excessive Bleeding post op • Nerve Damage • Sinus Perforation
    86. 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. 87. Space Maintenance
    88. 88. FDBA - Cortical and Cancelous Bone
    89. 89. Six Months Later
    90. 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. 91. Goals?
    92. 92. MidCrestal Incision Preserve the Keratinized Tissue
    93. 93. Extraction and Evaluation
    94. 94. Buccal Bone Loss
    95. 95. DeCortication
    96. 96. FDBA
    97. 97. Suturing - Periosteal Releasing Incision
    98. 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. 99. QuickTime™ and a H.264 decompressor are needed to see this picture.
    100. 100. SMARTbuilder
    101. 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. 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. 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. 104. 190
    105. 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. 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. 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. 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. 109. Components • Healing Cap or Cover • SMARTbuilder Mesh • Height • Fixture
    110. 110. SMARTbuilder • • 3-D Customized Preformed Mesh Side and Bottom pores smaller for graft containment. • • Main pore 1.0mm Smooth edges (!)
    111. 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. 112. ™ 1. Check the defect and determine the type of the SMARTmembrane ™ 198
    113. 113. SMARTmembrane™ Place the Height on the fixture already placed bone grafting. 200
    114. 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. 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. 116. Indications for SMARTbuilder • Fenestration defects • Dehiscence defects • Immediate Extraction moat defects
    117. 117. SMARTmembrane™ 204
    118. 118. Types of Defects Classification of dehiscence defect < 1 wall augmentation> < 2 wall augmentation> < 3 wall augmentation>
    119. 119. Dental model < 1 wall augmentation> < 2 wall augmentation> < 3 wall augmentation>
    120. 120. Dental model < 2 wall augmentation >
    121. 121. Dental model < 3 wall augmentation >
    122. 122. Multiple Membranes
    123. 123. A B C D
    124. 124. SMARTbuilder > Case 1 A B C
    125. 125. SMARTbuilder > Case 1 A B C
    126. 126. SMARTbuilder > Case 2 • UJS (M/64) • #4 Extraction d/t Crown Fx. ( 2 months ago)
    127. 127. SMARTbuilder > A B C D
    128. 128. SMARTbuilder > Case 2
    129. 129. SMARTbuilder > Case 2 POD 24 weeks 2nd Stage surgery
    130. 130. SMARTbuilder > Case 2 Before After
    131. 131. SMARTbuilder > Case 2
    132. 132. SMARTbuilder indication (I) Case presentation
    133. 133. SMARTbuilder indication (I) Extrasocket overlay augmentation with Nonsubmerged GBR Preoperative view(#6)
    134. 134. Buccal bone envelope defect
    135. 135. Vertical augmentation Intrasocket graft Extrasocket overlay graft
    136. 136. Selection Height and 3D titanium mesh 2 wall augmentation
    137. 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. 138. PRF for surgical isolation & meticulous circular approximation Healing after 18ds Never brush Never touch PRF Healing after 1 month Postop CT
    139. 139. SMARTbuilder removal technique a. Minimal invasive sulcus incision
    140. 140. SMARTbuilder removal technique Tissue integration b. Pouch technique
    141. 141. Reposition of transmucosal area 4 weeks later
    142. 142. Final Prosthesis 4 ms later 1 year later
    143. 143. 6 ms 15ds postop. CT (#6) Incredible GBR
    144. 144. 1year postop. CT (#6) Incredible GBR
    145. 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. 146. SMARTbuilder indication (II) Case presentation
    147. 147. Preoperative intraoral view (post ext. 4ms) Horizontal deficiency at labial side (#12) Implantation & Sinus lifting Labial bone deficiency
    148. 148. Selection of 3D titanium mesh 1 wall augmentation • Bone Graft for labial augmentation
    149. 149. 2 months later Good nonsubmerged healing of GBR
    150. 150. 2nd stage surgery after 4 months Excellent tissue integration
    151. 151. Good bone regeneration Before After (4 ms later) Good space maintenance at labioincisal area
    152. 152. 6 ms later postop. CT (#12) 6 ms later final prosthesis
    153. 153. 7 ms later postop. CT (#12) Preop. view Postop. view
    154. 154. Preoperative intraoral view Horizontal & Vertical bone deficiency Palatal bone deficiency
    155. 155. Labial & Palatal & Vertical bone augmentation 3 wall augmentation type
    156. 156. 3 wall augmentation type PRF for surgical isolation
    157. 157. PRF for surgical isolation & meticulous circular approximation Postop CT
    158. 158. 6 weeks later Never touch Never brush
    159. 159. Excellent Space maintenance Horizontal augmentation Vertical augmentation
    160. 160. Surgical isolation by PRF PO 1 week
    161. 161. 4 months later(GBR)
    162. 162. Limitation of SMARTbulder 1. Fenestration wound
    163. 163. Limitations of SMARTbuilder • Extensive Palatal Defects • Extensive Ridge Augmentation without implant Stabilization
    164. 164. Limitation of SMARTbuilder 1.Fenestration
    165. 165. Why SMARTbuilder? • Excellent Mechanical properties: • Sufficiently Rigid for space maintenance • Elasticity - Prevents Mucosal Compression • Stabilizes Bone graft material
    166. 166. Conclusion; Why SMARTbuilder? • Single implant defect • Common clinical situation • Low cost(vs. membrane) • Easy to use & removal • Predictable result
    167. 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. 168. The End

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