Large Posterior Mandible 3D Defect..Treatment Part 2

471 Rating(s).


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 months followup, CBCT and 2nd stage surgery. Thoughts? Discussion. Options? Dr. Salama

Re-entry 8 months
Re-entry occlusal view

Tenting Screw Removed
Mesh Removal


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23 Comments

Amazing Result Dr. Salama. Is it my imagination or did you also manage to get bone over the labial of the mesial implant? Remarkable achievement!!!
Sam


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Beautifully executed case Maurice. Did you find this mesh was easier to remove than other types? What was the quality of the regenerated bone? Thank you for documenting and sharing this case.


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Craig; Thanks. Yes, this mesh was well integrated but easier to remove. A thin layer Periosteum was embedded in the mesh on both side so I carefully peeled the periosteum away and then removed the mesh. As for the bone it was dense, mostly Type 2 with some areas of Type 1. This by far the best BMP-2 case I have had, 100% regeneration of the space created with the most dense bone at 8 months.
The only thing I did differently here was to utilize autogenous bone chips 50-50 with the BMP-2 and not Mineross?? Not sure but perhaps BMP-2 responds best with autogenous vital bone rather than allograft or xenograft?? What are your thoughts?
Thanks again Maurice


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Amazing result Dr. Salama. Did you use a membrane or PRGF on top of the titanium mesh?
Cheers


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Amazing result and very nice documentation.
I share the inquiry about the quality of bone. I saw many cases for you so far in managing singnificant defects that manged with Ti mesh, tinting screws and PRGF with particulate allogenic bones etc. were equally amazing. In general what is your Criteria or indication to use BMP2 ? Why for this particular case, as the cost of the material is considrable?
Omar


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its amazing Maurice.thanks for sharing, do you think that using allografts or xenografts without BMP could have similar results?


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Maurice. Simply amazing. I have know not experience with BMP-2. I dont how to get it here in Spain. Same question as Omar. What is your criteria to use BMP-2? Thx for sharing. I am very interested in this kind of cases. Best regards.Ramón


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Ramon and Omar; Thanks for the question. I would utilize BMP-2 and bone graft particulate 50:50 in Type 3 Defects with a large Vertical and Horizontal deficiency. I utilize this as an effort to avoid autogenous block harvest and a secondary donor site.
regards Maurice


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It's great increased .Maurice, anyway you used additional site to get autogenous bone,didn't you?


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Yes, Viktor. I used a simple ACM bone chipper drill to harvest autogenous particulate corticocancellous chips.
It allowed me to shape the mesh to the 3D contours I envisioned. Viktor, please continue your posts as well. regards
Maurice


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Amazing work Dr Maurice!! I have a few questions:)
1. Which area did you harvest the bone chips?
2. How is the bone scraper(osteogenics) in comparison to your ACM drill ?
3. What is your experience with Zimmer Trabecular implants so far.... and the early loading theory (I know that you were not planning to load it in this case)
4.How do you like the TXT Cytoplast membrane compared to the real titanium mesh with screws? I have had good results with the TXT cytoplast as long as the suturing is tight, has a tension free flap, slides good and can be exposed in the mouth... please give me your opinion....could this case be done by using a Cytoplast TXT membrane?
5. Roughly, what do you think the cost is for the reconstruction phase? BMP-2, TI mesh..

Thank you :) Delia


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Please describe how you achieved a tension free flap in the posterior mandible? Usually this is difficult due to anatomy of region. Any thoughts that can make this more predictable and safer in this region? Any good references, videos or excellent courses you suggest that address this particular question about flap design and management for posterior mandibular sites that can make this a predictable and safe procedure?
THx in advance


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Giuseppe;
Dr. Pikos does a great job describing this area inlcuding specifically flap management and tension free closure in a 5 part video series here on XP. Go to the link;
http://www.dentalxp.com/video/autogenous-bone-graft-1-flap-management-97858.aspx?locale=


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Hello Maurice,

Quality of bone formed the framework looks really wonderful was the dream and consumption for anyone looking surgeon. Great case and if possible show us the final rehabilitation. Congratulations.

Sandro Valente


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Thank Sandro....will expose implants and perform Soft tissue augmentation simultaneously, then restore the case. Thanks Dr. S


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I aslo see that BMP2 get better result with autogenous bone. Great result!


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Bone at implant placement. High houndsfield units. Type 1 Bone

3D CBCT
3D cross section


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One can use all the products in the world, but it all comes down to skill and flap management techniques. My compliments Dr Salama. 3D reconstruction at its finest, a masterpiece.

Very interesting to note the better results you experience with BMP in combination with Auto bone.

Where do you stand in regards to using vertical incisions with Ti mesh? Do you try to avoid? 1 or 2?

And how important is it to release the lingual flap?

Best,

Ehab


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Thank you Ehab. Yes, I try to avoid a vertical incision in proximity to my mesh. I agree about tissue and flap management.


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Soft Tissue stage

Uncovering Bed Prep
FGG


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6 Years post op

PA at 6 yrs
Soft Tissue & Implants


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Great hard and soft tissue management with admirable 6 year result. Thank you for sharing!
Snjezana


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Amazing result Maurice ....this is to prove how much GBR techniques is taking place of other block graft techniques ..
I think that regardless of using BMP, Ti mesh or PTFE reinforced meshes, Cytoplast membrane ,PRF ....etc....still the flap management ,tension free watertight closure is the key of success ,and this cannot be surely accomplished without correct lingual flap release...
Hats off Maurice ....we always learn from you


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