Crestal Bone Loss management through a GBR approach

310 Rating(s).


Posted on By Maurice Salama In Bone Grafting

Following Crestal Bone Loss around the osseointegrated implants after Ridge Expansion & successful Sinus Lift augmentation at 6 months uncovering, we decided to attempt 3D GBR and maintain the implants utilizing PRGF, Allograft and D-PTFE membrane. Uncovering displays substantial bone gain after 5 months re-entry. Thoughts? Dr. Salama

At PTFE membrane removal
Preop of implants with crestal bone loss

PTFE secured to one implant
Bone Graft Sticky Bone complex


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37 Comments

GBR at 5 months

Uneventful healing at 5 months
At flap reflection


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GBR at 5 months

Occlusal view
at membrane removal


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GBR at 5 months

at membrane removal
occlusal view at membrane removal


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Before & After

Before
After


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where did you get the d-ptfe membrane from and where did you tack it down?


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Kevin; The membrane is from Salvin Regenerative. Taked it distally with pins and occlusally with cover screws of implants. Hope to see you at Dentalxp Regen Summit at NYU this August. regards Dr. Salama


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what type of bone did you use? mineralized cortical for slow resorption time since osseointegratin already established and more a countour graft?? or which bone did you use??


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Before & After PA

PA Before
PA After


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Before & After

1st Sx
sn Sx uncovering


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Nothing to add...great management, amazing result.
Thank you for sharing
Snjezana


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Great management and result!
Thanks for sharing
All the best
Enzo


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May I ask why you think that the implants lost bone?
Regards,
gerald


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Gerald; really not sure. Only thing is stress to bone from expansion??


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Maurice,
That is very honest and honorable for you to say that. Most make excuses.
Regards,
gerald


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Gerald; Thank you. I make a commitment to do the best I can and be honest with what I see...regards Maurice


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Great result! It would be interesting to se X-RAYS in couple years. Gregory


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Yes, Gregory....after loading. You will DEFINITELY see slight crestal remodelling around implant connection but a CBCT would show robust thickness 360 degrees around the implant....I would hope. See you in NYC in August. Maurice


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I was the first to register at 3am. I hope to get a prize for that!!!)))


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You do!! warmest regards Maurice


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What is the Osstell reading after the GBR?
Thank you!


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Avg. 72


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Wow what an amazing result Dr Salama!! I’m a dentist in the Uk and have booked onto your course in May, am really looking forward to the course. Can you just comment on the cover screws and how you secure the membrane on the implants. Do you make a little incision over the implants to allow the cover screw to be secured? The reason I ask is that the manufacturers always recommend not piercing the membrane , accidentally , etc with sutures etc. And is there a chance of the cover screw loosening while secured over the membrane? Thanks for your great website dental xp and look forward to meeting you in May. Kindest regards Peter Zeltmann


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Hans; Thank you and I look forward to seeing you in London for the Hands-on course. Yes, I pierce the d-PTFE with a explorer tip and secure with cover screws at 12-15Ncm more than enough to prevent loosening. There are other systems that apply washers over the implants to increase vertical regen...obviously not needed here. And other systems that incorporate ti-mesh secured to the implants....like I-Gen from Megagen IDS. regards Dr. Salama


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Thank you


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These are very challenging cases. Great result. I see key factors in play here: Proper space maintenance with membrane, adequate membrane stability with cover screws and tacks, Platelet rich GF, and what appears to be thick soft tissue. Good long-term success expected when peri-implantitis is not a contributing factor in bone loss. Well done Mo.


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Thanks Hamid; This will be a big part of case discussions with you as MODERATOR at the Dentalxp-NYU Regeneration Summit at NYU this August 2018. Thanks again. Mo


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MO great as always. One question here. What was your decision making process to leave the implants high and do the vertical augmentation versus placing them bone level, possibly less risk and then replacing the soft tissue with pink porcelain. AN interesting discussion to ahve for sure. Great case and superb management, of that there is no doubt.


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Howie, thanks. It was NOT by design to leave implants out of bone....look at Part 1 of case....the implants were originally placed at bone level and then resorption took place.
Regards Mo


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My apologies Mo. I only read the full text. This is a common occurrence with a ridge split case and Salah explanation is a good one. However I always place my implants at least 2mm below the crest on ALL ridge split cases to take the split into account. The other issue for me is one we discussed in Brazil and that is the thickness of the ridge you split. Far too often we split a ridge that is needs to be split and then grafted before an implant is placed so the shrinkage can take place and we put the implants at the correct level. This is why I only split a 5mm ridge and go for other GBR techniques when there is less bone


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Howie; No split here only expansion with Versah burs using protocols assigned. The ridge width was as you suggest roughly 5mm, implant sizes were 3.7, 4.2 and 5mm diameter so you know ridge was wide enough....2mm subcrestal is that routine or only for split/expansion cases. regards Mo


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Howie, at the same time I agree and don´t agree.
Originally I learned split crest technique from Ernst Fuchs 15 years ago. If the procedure is done flap less and the buccal bone, periosteum and attached gingiva are moved together the achieved results are stabile and complications minimal. I used to perform this technique for years this way and have really nice and long term stabile results.
Recently I started to perform ridge split with full flap and veneer grafting, and I`ve seen some complications.
I hope Armin Nedjat is going to join this discussion and provide us with some evidence based data.
Cheers
Snjezana


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these cases need post op CBCT to show me that they have been successful and that there is buccal bone. I see too many with zero buccal bone


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Howie, no chance in this particular case - this patient comes regularly for follow up but trying to be pregnant and avoiding x rays. But I`ll definitely take CBCT for an other case done with the same protocol.
Cheers
Snjezana


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Sjnez mine have been the same for both techniques. For me its more about ridge thickness and I see consistent results with 5mm ridges and the minute we reduce the width thats when we see problems. most people try and split very narrow ridges, as well as ones with only cortical bone. Its a technique I use sparingly.


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Agree.


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I agree with both Howie and Snjezana...I think very often very narrow ridges are split with ONLY cortical bone remaining and with the periosteum removed via an open flap....these FAIL....IMHO and it happens FAST....bone resorption and loss of crestal height!!! Thanks Mo


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Great Results Maurice. Very clean surgery. My question is that why you decided to fix the PTfE membranes with cover screws! .usually in vertical augmentation we want to provide predictable space at the crestal area and puting cover screws push the membrane down at the platform area and can cause less bone formation there. I wanted to know your opinion about it? And that do you always use this approach?

Always learn from you my friend

Regards


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