Autogenous Bone Block. Is it still warranted?

415 Rating(s).


Posted on By Maurice Salama In Bone Grafting

A young patient with a large anterior defect. No buccal plate. So many options, here selected autogenous block grafting at the time of 3rd molar removal. Is it still warranted as a procedure? Is it superior to GBR? What say the group? HNY Dr. Salama

Block secured
Particulate Bone added

PRGF added to graft
Fibrin added


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40 Comments

Harvest at time of 3rd molar removal

Piezo cuts after tooth removal
After block harvest


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CBCT sections at 4 months

CBCT sagital
CBCT axial


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PA images

Block secured
implant PA


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Minimally invasive screw removal

stab incision
screw removal


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Implant placement

Implant placement
Minimally Invasive Implant Sx Guided


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Tissue Molding...

Impression
Tissue Molding


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Restorative phase

Emergence profile
Final at Placement


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Nice! What kind of Abutment is that?


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Not sure...PEEK


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very nice,perfect Mr. Salama.


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Thank you.


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Outstanding Maurice! Happy new year to you too. The more autogenous I do, the more I realize it has huge advantages over other techniques involving biomaterials, where healing and bone quality have no comparison to autogenous. Do you think using PRGF makes a difference here? Regards!


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PRGF helps with soft tissue healing and keeping participate bone together.


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Very nice work! What’s the alternative? Igen membranes, allograft bone grafts?


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Many options, GBT, IGen etc.


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Mo,

Are you asking block vs khoury plate? Autogenous block/plate will always have a place...

Cheeers,

Richard


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Richard; Yes, which do you prefer? Plate or Block and WHY?? regards Mo


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HNY Mo!
IMHO, blocks still deserve it´s place on oral implantology. Khoury´s fans prefer thin plates but I still trust on block graft like the one you show here.
No matter the bulk we use, sometimes we need a CTG to help with the final volume.
Thanks for posting
Regards
Jorge


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Jorge; I agree, very often additional CTG is needed to preserve bone and esthetics...regards Mo


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Mo, Jorge! I agree with you two! CTG is mandatory in most of the augmentation cases.
Let me ask you ask a question; In an augmented area, (Central incisor) Do you prefer 3mm of bone in the buccal side and 1.5 mm of soft tissue, or you rather have 1.5mm of bone and 3mm of soft tissue (In the buccal side)? I assume that on the crystal we have more than 2.5 mm of some tissue.

I give you my answer, I prefer 1.5mm bone and 3mm soft tissue. "Soft tissue is the hard guy, hard tissue is the soft/weak guy".

Thoughts??

Jose Mompell


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Wow...I have been saying that for years.... Very provocative. Regards Mo


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Beautiful case Maurice! Minimal overhead costs, minimal morbidity, shorter healing time than GBR, dense bone quality for implant placement and predictable - definitely still warranted! The intraoral block graft has a well documented history with high implant survival rates (96 - 100%). Khoury plate method also works very well but it requires additional steps and more clinical time. I would also caution that it can be more technique sensitive (however, block bone grafts in general are an advanced procedure anyway).


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Craig; Thanks, I feel the same regarding these procedures and struggle often to decide which way to go? Autogenous Bone is still a significant portion of my Regenerative practice. The big questions that linger are long term resorption with Blocks vs. Plates? What say you? many thanks again. Maurice


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Maurice, as I am sure you have found over the years, less invasive procedures are appreciated by our patients. However, I don’t want to compromise the outcome to avoid some “minor” morbidity. I look for ways to use local bone blocks using the recipient site as the donor site (trephine core block, tuberosity block). If not available I would use the ramus as a remote donor site for the maxilla (and local donor site for the posterior mandible). I am not aware of a comparison of resorption for Khoury plates vs. blocks. I reviewed the literature and found the vast majority of cortical intraoral block resorption is 0 – 25%. The “outlier” is a study by Cordaro et al, 2002 – 42% volume loss in vertical augmentation of 9 sites measured with a periodontal probe (yes a perio probe!). Unfortunately this skewed study gets referenced the most. Keep in mind the graft resorption is typically measured from the incorporation phase (placement to preimplant healing). The graft does not continue to resorb thereafter as it is becoming vital bone. Studies that have looked at block resorption show most resorption early and minimal change after incorporation (and the implants stimulate the augmented bone to provide an impetus for further remodeling and bone maintenance). Cortical grafts resorb less than corticocancellous grafts. There is one outlier study on resorption by Sbordone et al, 2014 on corticocancellous iliac bone grafts but I am suspect of their research methods and their data doesn't make sense clinically. When I teach in the graduate perio and OMFS clinics I am amazed that blocks aren't used that much - I am amazed as using autograft blocks has served as such a reliable method for bone augmentation over the years.


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Craig; I agree wholeheartedly. I have found the same clinically. Thanks for your thorough comment and review. I am have gravitated towards your clinical views over the past few years....


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Maurice! What a topic!!
As many of you know, I really like the "Split Bone Block Technique" (Bone Plates) In where we use the bone plate as an "Autogenous Revascularizable Membrane", this so called membrane will protect the particulate bone from resorption (It will help to his fast vascularization) And as you pointed I think that, although bone blocks may still having its place in oral implanvology, bone core biopsies show a higher amount of vital bone when using Bone Plates rather than pure autogenous bone blocks.
This % is more similar when pure bone blocks are place within the bone frame. Therefore, I prefer in most of the cases Bone Plates to "Classic" Bone Blocks

Great topic for discussion!!

Jose Mompell


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Jose, as previously mentioned I understand the biologic rationale of the Khoury plate. It most likely results in faster revascularization as the cortical block requires revascularization along the existing haversian system. We still only allow 4 months healing in either case. I am not aware of any specific histologic study that compared cortical blocks to Khoury plate but I would not be surprised if there was more vital bone with the split bone (keep in mind that the biopsy is taken at implant placement so this is not the biologic end point – the cortical graft will continue to remodel via creeping substitution). However, is vital bone % clinically significant? The success rates of cortical block incorporation are very high in the literature as well as implant survival (96 – 100%). How much vital bone do you really need? Same argument with the sinus graft – low vital bone % (ig. ABBM) still results in high implant survival. I think is you are a skilled and experienced clinician the Khoury plate approach is a great tool.


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Mo,

To Answer your question, I cannot say I prefer one over the other. IMHO- I utilize the one I feel best fits the reconstructive and restorative situation- Craig so nicely has provided the literature review as he eloquently does - So as I initially said Autogenous block/plate will always have a place

Cheers,



Richard


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Now another question as Craig said, "how much vital bone do we need?" as we hear often from implant manufacturers how great their surface treatments are BUT how much BIC "bone to implant contact" is required for successful osseointegration?"


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And that is the question for sure.... A study should not be difficult to do. What say you all? Dr. Salama


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Craig,
Great comment, as you perfectly explained in your MUST SEE presentations, nowadays is not a matter on how much vital bone we get. Once we achieved a 96-98% success on the integration, we need to look to other aspects.
Both techniques may have their indications. Nevertheless, I also strongly believe that, in any of them (Although I have not a big experience on pure bone blocks) Tunnel approach can play a very important role.
I know that some colleagues would say that open approaches, with a tension-free closure work perfectly well, and it’s true. I think that no incisions give us great advantages.
Once again thanks for taking your time to comment!

José Mompell


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Jose, I think tunneling techniques will gain momentum with biomaterials that predictably form bone in this application. This falls into the less invasive approach and offers biologic advantages (less risk of graft exposure). It may limit how much you can augment but shorter and narrower implant can be used to overcome the limitations. I enjoy your perspective!


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Bioengineering and user friendly regen materials are needed for the Tunnel Approach to become significant. But the future is in that direction. Great discussions. Regards Mo


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Skill must increase dramatically to pursue this method.... Few have these skills IMHO limiting it's effectiveness. Dr. S


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Great result Mo and great discussion. Craig I remember the first time we met at Xp when I lecture on the palatal block and you on the BMPs and the discussion we had about autogenous bone still being the gold standard. There is no doubt it still remains the same today. I am still convinced and my use of other materials and the unpredictability of it even when I get perfect healing reinforces my belief. My own experience which we will publish one day is when using palatal blocks as solid versus Khoury and the Khoury so far wins hands down. Our 8 year data on the solid we had 8 out of 10 which did not appear to have any bone on the buccal of the implant as opposed to the Khoury that were not 8 years yet so im waiting for them to get to 8 years before I publish the difference but all of them have excellent buccal bone. The issue for me is the creeping substitution and whether or not it actually takes place or not and this is not clear. I believe it is more a revascularisation of the block but the lacunae remain empty which is the difference with Khoury whose history is full of vital bone. I have put a case on the forum showing the history after 4 months and it is definitely what I want to see. The other issue with solid blocks is they can come loose when using larger diameter drills or as you seat a tapered implant. This is not an issue with the khoury plates. Having used both over the years I would not revert to the solid block.

4 months post op


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Howie; Great review if your findings. Must publish the data. How did you find that the blocks continued to resorb and some implant dehiscence over time? CBCT or clinical findings during reentry? Would you say one technique is more challenging than the other? Possible complications with each method? Great discussion amongst the best in the world.... Wow.


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Amazing discussion right here ONLY at DENTALXP!! Thnx to all of you. Mo


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Congrats on a great case Dr Salama, and a great discussion, always learning from you and from all the Dentalxp community. The amount of BIC needed is an interesting question to investigate, I am curious of what would be your study design. Would love to work on like topic that.

Regards,
Ernest


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Ernest; Thank you. We do not know but 58-68% BIC range has been attributed to successful clinical osseointegration. Dr. Salama


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Mo, I enjoyed very much about the discussion about Block vs Khoury. Also know the position of the Khoury´s fans that prefer the live-bone to insert implants. Keep the Forum with challenge topics is fun and full of science to learn.
Regards
Jorge


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