Large Posterior Mandible 3D Defect..Treatment Part 1

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Posted on By Maurice Salama In Bio-modifiers: BMP-2 / PRGF

Following failure of 2 implants in this area a Large 3D Defect was in need of reconstruction. Additionally bone loss was noted on the buccal aspect of an implant in area of #28. Options and Solutions. Provided Treatment GBR with Tenting Screws Autogenous Bone Chips and BMP-2 with Ti-Mesh. Latest images at 8 weeks followup. Dr. Salama

Panorex at 2 weeks
Tenting Screws

BMP-2 & Autogenous
Ti-Mesh Secured


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44 Comments

It appears from CBCT 2 that there is only an opposing maxillary first molar and the defect is in the # 29-30 area with the great bone loss in the # 29 site.
If the diagnosis of buccal bone loss on implant # 28 is only from the CT scan then it needs to be confirmed clinically (it could be thin bone than is not seen due to the lower resolution of the scan).
Option 1 - Free gingival grafting defect area + # 28 then 2 months later... reconstruct the bone defect and repair # 28. Several alternatives to reconstruct the defect including TiMesh + autograft, TiMesh + rhBMP-2/ACS + MFDBA, Ti reinforced PTFE membrane + autograft/MFDBA
Option 2 – place 2 implants posterior to the defect (# 30 distal, # 31) and repair # 28 implant for an implant bridge. Implant # 30d may need simultaneous GBR repair along the mesial. Free gingival graft and implant repair # 28.


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FGG then particulate bone graft mixture DFDBA / MFDBA / Bovine. Collagen membrane supported by tenting screws.
No implants to be placed in 28-29 region. Biggest concern going forward is jaw fracture.
Place implants 30-31 region.
Restore with hybrid prosthesis supported by milled bar.
Chuck


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Great to be able to see the interaction between to great clinicians and educators. I have and continue to learn much from both of you. I like the ideas of Dr.Misch.
Perhaps as another option, would anyone consider "narrow" diameter implants engaging the lingual plate instead?
Sam


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Another good suggestion by Dr. Schwimmer – tenting screws with a collagen membrane and bone substitute would also be an option. However, I’m not sure about the reluctance to place an implant in the # 29 region. If the augmentation is successful 2 implants could be inserted (# 29, 30) for implant crowns (# 28 is already present). Jaw fracture is not a concern in this case as there is plenty of remaining bone.
I would be concerned that narrow diameter implants would be too lingual for prosthetic restoration in this case. However, we do not know what the relationship is with the opposing occlusion.


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Hi Craig, Your right about the teeth numbers. I personally wouldn't place an implant in the #29 region, because I feel stability of the implant would rely too much on grafted bone. I wouldn't want to risk the potential harm of another implant failure in that region. That is what I meant by risk of fracture.
I realize you have much more experience with this type of case than I do and I prefer to keep it that way:-).
Chuck


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Hi Chuck. You bring up a very good point about managing retreatment cases – minimize risks as the patient has already suffered failure once.


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Beautiful case Maurice! I have a few questions. I don't see any absorbable collagen sponge with the rhBMP-2. Did you use a sponge or just add the BMP to the autograft? There are two tent screws on the buccal. It looks like you placed the mesh over the tent screws but the mesh fixation screws are in the same position as the tent screws? How about a platelet concentrate - I usually place either a non-cross linked collagen membrane or PRP over the mesh before closure. Healing time 6 months? I cant wait to see the results!


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Craig; Thanks for the comments. Yes, we utilized the ACS, cut it into pieces and mixed with 50:50 autogenous bone from ramus and Mineross. Great comment on tent and fixation screws. They are a GREAT GBR system by Neobiotech where they have Fixation screws that fit directly into the Tenting screws. Makes Ti-Mesh fixation MUCH easier. As for PRGF or PRF, I do not mix them with my BMP-2 cases per the Medtronic reps but I do place Pericardium over the Mesh prior to closure. Yes, I am hopeful that we will see good results. All the best Maurice


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just beautiful.what kind of screws are these?it looks like they have internal hex. double screws?why didn't you use a PRF membrane over the Ti-plate?
thanks theo


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Theo, the screws are from Neobiotech GBR kit. Was told by BMP-2 medtronic people NOT to add PRGF or PRF. I did use Pericardium over Mesh prior to closure.
Dr. S


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Beautifull solved the case, Dr.Salama.
Thank you for sharing the pictures and your surgical steps !!
Interesting thaughts about tenting scews(with a hex) under the mesh and two screws for holding the ti-mesh (with a cross). Supose that most blood comes from the big whole in the distal mandible.
Haven't done that until now and I'm getting interested about it.
Looks like implantologists step away from bone blocks and i don't have an explanation.
Christian


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Christian;
The distal area of mandible was source of autogenous bone chips using ACM drill. Could have performed Block graft from ramus as well. It appears that is the MAJOR question moving forward....
thanks for the comments.
Dr. Salama


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Maurice, Beautiful surgery! Can't wait to see the outcome. Do you have plans to augment soft tissue?
Chuck


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Yes, Chuck. At second stage or at implant placement I will perform a Soft Tissue Augmentation. We could argue that it would have been preferable to have done that "prior" to the Augmentation. I felt I could work with the exisiting tissue and come back later and combine the soft tissue work with implant surgery.
thanks Maurice


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Hi Dr. Salama. I was at the partners in synergy course and I thoroughly enjoyed it. What type of soft tissue augmentation are you planning on doing for this case?
Thanks.


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What kind of bone quality are you seeing with type of procedure D-2, D-3? Also, I checked Neo Biotech webiste but did not see any product listing for tenting screws that would stabilize Ti-mesh as well.

Thanks,

Dr. Claiborne


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The bone typically is Type 3 at 6-8 months sometimes type 2. As for Neobiotech GBR kit, it is being posted on XP Neobiotech product page in the next few days.
Dr. Salama


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Sorry for being unclear with my english. What I wanted to say is that blood is needed for bone healing and my narrow mind thaught that the small wholes mesialy are fastly congested by the bloodclot, so the hope for more blood was from the whole where you took the autologous bone. I am very sorry for missunderstanding.
Thanks a lot,
Christian


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nice case dr salama. did you fix mesh on lingual surface? and if we use only xenograft or allograft on this site with mesh,results are very different or not?
thanks, Ali.


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Ali; I did secure lingual at crest with Auto tacs from BH. As for similar results with Allograft mineralized irradiated bone, yes but I prefer to mix with autologous as well. I have heard that BMP-2 and Xenograft does not seem to work well. always mix bone to BMP-2 Infuse 50:50.
That is what I have heard from Misch and Pikos.
Dr. Salama


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A Great case, Dr Salama. All smart GBR devices from Neobiotech was utillized in this case.
I have a few question. 1) How long will you wait for implant placement? 2) What if BMP 2 was not available ?
3) What do you think immediate implant placment for the reduction of healing time? Thank you DS


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Thank you so much for your kind answer


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Dr. Sohn; Great Questions and that is why I love this Forum.
1. I would wait 6-8 months for Implant Placement when utilizing BMP-2 as the bone achieved is typically Type 2-3.
2. If BMP-2 was not available I would have still performed the same procedure so it would NOT change the surgical technique I utilized here.
3. I have used simultaneous implant placement leaving threads exposed at time of GBR which reduces overall treatment time BUT, although often successful, WHEN I do get wound dehiscences or post op Mesh exposure I am left with Exposed Implant surfaces above the bone which is not ideal and more difficult to retreat and manage. This is a RISK-BENEFIT question vs. OVERALL TREATMENT TIME??
Thanks for all the great interaction here.
Dr. Salama


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Dr Salama,

If you achieve Type 3 bone after 6-8mo, and if it presents a situation wherein obtaining primary stability or acceptable stability at that time is not possible, then I wonder what options are available. Would you graft again? and does it revert back to Dr Schwimer's comment about possible 'fracture', rather failure of implant and expensive revisionist dentistry.

The case looks great absolutely, but I'm just trying to see if there are any possible alternative fixed options without grafting!

Thanks
Eswar K.Damodara


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Maurice,
How many of those tenting screws come in the kit and are they re-usable? I would think they would come in handy in other non mesh proceedures. It would be nice to be able to buy them separately.
Chuck


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Chuck; They should be posted on the XP Neobiotech Product page for purchase shortly. They come with 12 of each at different depths for the Tent screws. Yes, you can sterilize them and purchase more screws to replenish the kit if needed. Also, the machining of these screws and drivers are very nice with intimate fit. By the way, have tried their bone Chipper Drills ACM (Image #2) that are sold on the site??
They are great additions to your GBR Armamentarium!
Maurice


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Mo
Nice case. But one example of what will be showcased @ our upcoming Partners in Synergy next June. On family vacation and just caught this case. Unable to access a cbct but assuming adequate trans alveolar bone volume another solution for what appears to be primarily a horizontal deficiency is a sliding ramus block graft. Even though I do fewer autogenous block grafts since 2005 or so, this is one site that i have preference for it As you know I have done a bunch of Ti mesh rhBMP-2 cases over the past 5 years ( 150+) but prefer the autogenous approach over Ti mesh/ particulate for a horizontal deficient post edent mandible site all things being equal. Advantages: 1. Time (5 month reentry) 2.Bone density( D-1 bone) 3. Cost (no BMP fee-- I assume you used a XX size-$900 kit). 4. Very predictable bone for implant placement. Of course the lack of attached tissue would still need to be addressed. Just a different approach.
The need for cbct evaluation is critical as well for this protocol as some patients present with ramus buccal shelf and even symphysis sites-- high risk fracture and therefore would preclude this approach and mandate a Ti mesh/ particulate protocol as you have so nicely demonstrated.


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Hi Mike,
Hope you are enjoying your family vacation! The CT scan was posted previously but it does not appear on the collection of photographs any longer (maybe they can repost it). The osseous defect from the failed implants is in the # 29-30 area and it appears to be a “three-dimensional” defect rather than classic medial resorption (horizontal deficiency) seen with tooth loss. I think that is why a particulate graft was chosen in this case over a block technique. A block could be used here but you would probably need some particulate graft and a membrane to help reconstruct the ridge contour – however, your suggestion is excellent and highlights the dilemma of moving towards tissue engineering solutions and abandoning proven and reliable graft techniques. In addition to the advantages of autograft blocks you listed I think it is important to point out we have few studies on rhBMP-2 for ridge augmentation and even the existing literature shows inconsistencies in the outcomes. In this case Maurice nicely mixed “old with the new” – particulate autograft and titanium mesh with rhBMP-2. The case may have worked out well without the biologic modifier but the addition of the growth factor should improve the result. I highly recommend your Partners in Synergy program to anyone that want to stay current with clinical trends in this area!


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Mike and Craig; Thanks for the interaction. It is through discussion and sharing of clinical experiences that we develop our knowledge. Yes Mike, as you have asked, I have now reposted one of the original CBCT cross sections at the middle of the deficiency from my original post. I do believe that your approach would certainly have worked as you have shown for many years. It would have saved cost, provided higher density bone and shotened healing time until implant placement. These "newer" bioengineering techniques must be further evaluated over time and in each case we must weigh the risk-time-cost-benefit ratio. That is WHY I believe that our Synergy event in Orlando June 27-30th is so valuable.
Thanks to all you have posted on this Forum.
Maurice S


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Dr.Salama, thanks for sharing such cases. We all learn from these priceless experiences


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Dr Maurice,

Thank you so much for sharing. Excellent clinical judgement and technique as usual. I would like to ask a couple of questions.

1-Literature shows up to 50% exposure rate for Ti mesh. Are there any specific factors you look at before using mesh, in order to avoid exposure (ex. tissue biotype, KG, etc.)

2- How did you manage the lingual flap release?

3-Do you think that this case could be done in the exact same way but without the Biologic modifier?

Thank you,


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Nawwaf;
Many thanks. Here are my responses to your inquiries.
1-Literature shows up to 50% exposure rate for Ti mesh. Are there any specific factors you look at before using mesh, in order to avoid exposure (ex. tissue biotype, KG, etc.)
Yes, this is true. I look for thick KT especially over incision line. If not, presurgical Gingival Graft is best. Also, a Stable Ti-Mesh is extremely important as micromotion can stimulate early exposure.

2- How did you manage the lingual flap release?
I learned this technique from Dr. Mike Pikos. He utilizes finger disection along the Mylohyoid ridge to avaoid any complications with lingual nerve or perforation of flap.

3-Do you think that this case could be done in the exact same way but without the Biologic modifier?
Yes, I do believe if not with BMP-2 it could have been done with PRGF or PRF or no bioactive modifiers. I believe the biostimualtion is helpful for Healing and to avoid complications.

thanks Dr. Salama


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Thank you Dr Salama, this was truly helpful.


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Mo,
Great " blow by blow" documentation. Thanks for sharing. The 2 week healing looks nice. Especially adjacent to the implant in #28 region. I am curious to what is going on near the suture where you appeared to repair a small tear. Is this a potential mesh exposure beginning? If so, what is your plan?
Chuck


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Chuck; Horizontal Goretex suture at that spot. No Mesh peeking through. Normal healing so far....will continue to follow this case with all of you.....good or bad.
Maurice


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Fantastic learning experience!
Chuck


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Mo, great documentation.. would like to be able to see the CBCT.
I too tend to wait longer with particulate and BMP... as cases i have reentered at the 6 month point are too soft.

I also have ben using PRP with collagen membrane over the Mesh and have not had any issues. Yes it is off label for the BMP but it makes sense to me.

Cant wait to see the reentry! great job!


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Hi Murice,
I'm fond of GBR with Implats.
I appreciate the effort done in this case .. Really:
Professional work.
My question is :
- How can we plan for sufficient soft tissue coverage
in this case. !? Is Carl E. Misch "Submucoal Space
technique" with blunt dissection is sufficienf !?
- What about the resultant shallow sulcus after healing !?
- Is the ridge cobtained minimal width of keratized
mucosa, How can i deal !?
- The starting incision line ; preferred to be crestal or just lingual or just buccal !?
- Can I fix the Ti-mesh lingually by fixation screws
rather than the pins of BH !?
- Does adding xenograft to the autogenous collected witg
ACM + Allograft ; as a trial to lessen the resorbability
rate of the graft giving more time for good quality
bone formation ?

Sorry for my many Qs ?
Bassem


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For those interested in the Neobiotech GBR kit that was used in this case go to the below link;
http://www.dentalxp.com/Store/ProductDetails.aspx?ProductId=148

Dr. Salama


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Dr.Maurice
Pls,,,,How can I get BMP-2??? I am from Egypt..I don't know if it is available here


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Sarah; It is sold by Medtronic in the USA.
Not sure it is approved in Egypt.
Dr. Salama


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Looking good!!! Keep the updates coming. Thanx.
Chuck


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Dr Salama,

Amazing follow up, healing looks fantastic. I have however noticed that the second cover screw has loosened from the tent screw.

Did you secure the mesh by other fixation screws or tacks, or was it just with these 2 tent screws? And if not, would loosening of the cover screw and its impact on mesh movement worry you?

Thank you so much.

Regards,


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Wahib; Good question. I do not think the second screw is loose. Just was never completely seated. I did utilize additional tacks at the periphery to further secure the mesh. I do believe anything loose can be a negative on regenerative results. Will be re-entering to place implants in a few weeks. We will see shortly how all turned out. Thanks for the input and discussion. Dr. Salama


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