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Maryland AGD AE and Socket Grafting 2015 Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page1 Preserves bone Enhances aesthetics Prevent socket collapse and tooth migration Preserves site for implants Reduces complications for future implant placement Improves 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 Involvement Single crowns <1% FPD abutments 4% Survival of abutment teeth connected to a Removable Partial Denture 3 years 60% survival 10 years 35% survival! The average denture wearer has 38% or less chewing efficiency of a fully dentate person.
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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

Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page9

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

Maryland AGD AE and Socket Grafting 2015

Advanced Implant Mentoring Rob D’Orazio DDS Day 1 – Morning 1 Page12


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