Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page1
Preserves boneEnhances aestheticsPrevent socket collapse and tooth migrationPreserves site for implantsReduces complications for future implant placementImproves the patient’s psychological state
• Preserves and maintains bone
The Goodacre Study– 5 year retrospective study looked at Crown &
Bridge– Caries
Single crowns 1%FPD abutments 17%
– Periodontal InvolvementSingle crowns <1%FPD abutments 4%
Survival of abutment teeth connected to aRemovable Partial Denture
– 3 years 60% survival– 10 years 35% survival!
The average denture wearer has 38% or lesschewing efficiency of a fully dentate person.
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page2
Endodontically treated teeth are POORabutment risks
Bridgework with endodontically treatedabutments have an average of 5 years service
Less than a 2mm ferrule of natural tooth willlead to increased single crown failures after 5years even if an endodontic post is present
Consumer awareness surveys conducted from1999 through 2002 concluded that 63% ofpatients who refused bone grafting andimplant treatment options would haveaccepted had they simply known about boneresorption and the fact that bone grafting anddental implants prevents bone loss fromoccurring.
Neil Park DDS- CDA White Paper
Four Types1. Autograft – patient’ s own bone.2. Allograft – human cadaver bone.3. Xenograft –different species.4. Alloplast – synthetic bone.
also referred to as “Alloplastic grafts”
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page3
Human– Block– Particulate– Reasonable– Mineralized– Conductive
Human BoneAllo-Oss
Xenograft– Harvested from a different species (bovine and
porcine)– Healing time is 4-5 months to be able to place
implants.– Takes up to 2 years to turn over into patient’s own
bone.– Non-invasive with low rejection rates– Nu-Oss product that will be used today.
Xenograft - NuOssBovineSame as Bio-Oss40% less expensiveConductive
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page4
Looks like normal human bone
Human BoneAllo-Oss
Bovine BoneNu-Oss
Alloplast– Synthetic bone ( Cerasorb)– Healing time 4-5 months to be able to place
implants.– Non-invasive with low rejection rates– Good filler when mixed with other bone materials– Least expensive material– 2 years to turn over to patient’s own bone with
some particles never turning over
What do you hydrate particulatewith?– Use sterile water, sterile saline
Not anesthetic solution
– Use the BLOOD from the
freshly curetted extraction site!
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page5
Resorbable– Allograph or Xenograph– Variable length of time until resorption
24 weeks is desirable– Single stage (no second surgery needed)
Nonresorbable– Synthetic
100% PTFE (Teflon)– Require second surgery to remove
Textured Non-Textured
TitaniumReinforced
Silk not recommended– Wicking occurs
Recommended suture types– Wicking does not occur
Chromic gut
PolyglactinPTFE
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page6
3 Cellular Stages of Repair– Osteoclast Stage*– Vascularization Stage*– Osteoblast Stage*
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page7
1.)Osteoclast StageOsteoclasts break bone down. When this
happens, signals are sent to the body to initiate therepair process.
a.) bone surface release bone repair proteinsJust scratching the surface of bone initiates this .Bisphosphonates can inhibit Osteoclast activity
b.) access to bone marrow cellsAdipocytes,Osteoblasts,OsteoclastsMesenchymal cells,Fibroblasts,Macrophages
All of these cells are needed for bone repairMake sure you have some bleeding from the socket!!!!!
2.) Vascular stageRevascularization is critical
– Bone cells are oxygen sensitive
3.) Osteoblast stageMatrixHaversian SystemsWoven to Lamellar bone
1. Clot stabilization– facilitated by graft interconnecting macro and
micropores.2. Revascularization3. Migration of osteoblasts (purple)4. In-growth of woven bone (yellow)
– enhanced by graft scaffolding.5. Graft integration/Lamellar bone formation
BONE GRAFTSREPAIR
How a graft matures…
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page8
Maintain periosteum and blood supply.Clear visualization of surgical site.Easy access for surgical team members.Effortless reflection of the tissues for the surgical
team members.
TISSUE FLAPSCRITERIA
Scalpel penetration contacts bone.Full thickness tissue reflection-
Sharp edge of periosteal elevator faces the bone.Use the thumb to resist the pressure of the periosteal
elevator against the tissue.May require use of curette to relieve the tissue at the
distal aspect of the last tooth.Remove all tissue tags with instrument and/or wet gauze.
TISSUE FLAPSTECHNIQUE
“Establishing non-tension primary closure over a dental implantand/or
bone grafted sites begins with proper Soft Tissue Management”
Soft Tissue Management for Implant Dent: A Clinical Guide Heller, Heller et al. JOI, No. 2/2000
TISSUE FLAPSDESIGN
Maryland AGD AE and Socket Grafting 2015
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Non Tension Primary Closure Benefits:– Shortens soft tissue healing time– Contains graft materials– Reduces infection potential– Less painful healing– Allows tissue expansion with post operative
swelling– Helps maintain blood supply
TISSUE FLAPSDESIGN
The trapezoid design includes a wider tissueattachment at the base of the flap whichimproves the following factors:– Blood supply– Lymphatic drainage– Periosteal integrity
Facilitates non tension vertical closure with bonegrafting
TISSUE FLAPTHE TRAPEZOID DESIGN
Trapezoid shape still applies
Carry incision to the adjacent papilla withlimited attached gingiva to avoid tearing.
INTERDENTAL FLAP DESIGN
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page10
Non tension soft tissue flap closure isessential for a successful surgical result.
Maryland AGD AE and Socket Grafting 2015
Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page11
Restore functionRestore aestheticsPrevent tooth migrationNo destruction of adjacent teethImproves the patient’s psychological state• Preserves and maintains bone
This coversupThe AIM