Autogenous bone definitely still the gold standard Histology to show the success

Here I have taken histology of the case. this clearly shows the unbelievable bone growth in 4 months and the creation of bone with lacunae filled with osteocytes, this is essential for the bone to be able to appreciate the pressure that the implant is taking and this is what will prevent the bone from resorbing over time.

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Solid proof on microscopic level.....

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Dear Howie Sir., Thanks for a beautiful case. May i use your histopath image for a postgraduate lecture with mentioning your credentials on the slide with your name ? Thanks

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This is the Pre-op situation of the case showing poor implant placement as well as poor soft tissue development. There was no bone over the buccal of the implants at all

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Great work and result Howard. You really got more. How much vertical you gained after this procedure. Regards.

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Probably about 3mm

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Howie, as you know I love autogenous and Khoury technique. And I´m especially big fan of this technique in your hands. It looks great!
There were two implants with bone and soft tissue deficiency.
Have you prepared soft tissue before hard tissue augmentation?
Thank you for sharing and inspiration!
Best regards
Snjezana

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Bravo Bravo Bravo....above and beyond. You covered the space between plates with A-PRF fibrin ONLY? or added Collagen membrane? What is bone density at 4 months? Do you utilize the same incision design at uncovering? Did you require additional bone grafting and if so what would you utilize? This is immenase and spectacular. Thanks my friend. regards Mo

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Thanks MO Always great to get a compliment from your teacher. The bone between the plates is pure autogenous bone chip harvested with a safe scraper. I then place PRF over the bone about 4 membranes. Nothing more. No other collagen membrane at all as it will reduce blood supply to the bone. When opening I use a very similar incision but only one release to get the screws out. I did not need any further bone augmentation as I had between 2-4mm on the buccal of the bone. I will do further work on the soft tissue at a later stage. The bone is a type 3-4 and I use osseodensification but it will firm up further over time. The histological also gives a hint as to the quality of bone which in this case is exceptional.
I hope I have answered everything.
regards
H

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Thanks Sjnez. always a compliment coming from you. To answer your question I never pre-prepare the soft tissue. This is a Buser technique which I do not follow. When you do soft tissue grafting you create more scarring of the tissue which is not very vascular. I worry about wound closure and vascularization of the bone graft from here. I have no science behind it as I don't think there is for one or the other rather a feel good situation which unfortunately a lot of our techniques revolve around.

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Sorry Sjnez. I lied. I checked the soft tissue work before and I did do a vestibuloplasty with some laser frenectomy to remove a lot of the muscle pull at the time of the implant removal. See the photos below

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Howie, you are absolutely correct. Autologous bone is the gold standard (Marshall Urist and others). Adding foo foo dust from a bottle requires luck and making a"wish" when it is placed. Your thinking is well received. Hope others view your case, read and observe the histology. In most cases, autologous bone is free and results last. There is a lot of histology to support your thinking. Any complaints, file them with me. Bill Becker

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Thanks for the comments Bill. It is awesome to be on this XP Platform and have two people comment on your case that helped mould my thinking when I was a registrar in Perio in the 90's. you are a legend along with the Salamas and Dave Garber in South Africa. I will definitely Italy refer them onto you there are too many who have lost their way.

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Hey Dr Becker

I am a Veterinarian in Tucson ( about 10 minutes from your practice ) doing surgery for 45 years +

Send me your e mail or stop by I will be happy to show you or send you some major documented maxillary and mandibular reconstruction with complete histological work up utilizing Foo Foo dust. I really don't think we have lost our way, some of us have to be more creative

Thanks, Hope to hear from you soon

Rocco

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Rocco you cannot compare animals to humans in the results that you get. Animals work way better. Humans are totally unpredictable.

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Howard

Amazing Surgery and Thanks for the input.
"Animals work way better. Humans are totally unpredictable."

Im curious, how would you know that?

Rocco

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`simple. Most of our trials of materials and methods are tripled on dogs and work extremely well in that model. As soon as they go to humans they don't work nearly as well. Well known phenomenon in dentistry

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Howard

Also Interesting. Can you direct me to that information. I would like to learn about this...

Thanks again

Rocco

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Hi Dr. Rocco, good to hear about that. Can you please share what kind of Bottle Bone (Foo, Foo dust, lol) you use to get that kind of result. Regards.

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Dr Ashock

Great to hear from you.

Please send me your e mail.and I can send you a power point presentation of a mandibular reconstruct with Equine block, particulate, and PRF. Complete Histo also

Beautiful documented case

R

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Thanks Dr.Rocco, Regards.


e - mail : ashokv2000@gmail.com

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Absolutely spectacular!

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Great work Dr. Gluckman! Did you employ a rotated palatal pedicle flap? Thanks

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Thanks Warren. No not in this case as we would need too much tissue to be able to manage to manage this. what we did do was make sure that we had a perfectly passive flap as well as use tension relieving sutures to take the stress off the wound margin

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Unbelievable case!

Ioannis

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Howie Could you use allograft plates with autogenous bone chips as well

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you can but you will not get the same result. Once you add any synthetic material it changes the healing potential of the area. I do not mix material in any way at all

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thanks my friend

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Hi Howie,

Another masterpiece !! Yet one has become used to seeing these kinds of results from your hands my friend :) congratulations to you and to your patient for finding you as her surgeon.
One question, reading your comments to Snjezana regarding prepping soft tissue. I too find that FGG for example will lead to more scarred tissue that has less vascularity. But what do you do in those cases with limited/no vestibule depth pre-op? Or ones that have extremely thin tissue that might simply lead to dehiscence of the block?

Thank you,
Ehab

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Thanks for the Kind words Ehab. most of these cases we are doing single or maximum 4 teeth and there is generally enough soft tissue with good periosteal release to allow the closure. Secondly in thin gingival morphotyeps we know that you can do block augmentations without any hassle. The reason for that is the rapid revascularisation of the blocks which will give good blood supply to the soft tissue and hence you can comfortably use any blocks in thin tissue morphotypes

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Here are some slides to look at (6)

Equine Block, Particulate, and PRF at 6 months

Rocco

Pre

Uncover @ 6 Months

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Rocco this is not great histology,. look at mine and then compare the two. the one that you show has zero osteocytes at all and that is the point of my argument. Osteocytes are critical to long term stability of the graft. Yours has zero. some small amounts of bone around the periphery is not what I want. I don't think this is comparing apples with apples

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Howard
Very interesting

Although I disagree. It got me thinking about this a lot.
If you don't mind I am going to send both studies to a couple friends of mine to get there input on the bone quality. They are both osteopathologists.

Thanks for the comment

Rocco

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This may be of some interest?

Alveolar ridge regeneration w Equine spongy bone: A clinical, histological, and Immunohistochemical case series

5 patients. Not a long term studies which we really need. However, interesting

If you would like some material on side by side ( Equine vs Autologous blocks ) comparison in the maxillae let me know

Rocco

Test / Control

Control / Test Histo

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Surgical Site

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Rocco; Please summarize your histo analysis and what you feel one can expect from similar Xenograft materials? Thanks Dr. S

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Dr Salama

" The product looks like it is performing the way it is intended. The histopathology sections of bone and Xenograft are of excellent quality."

Roy Pool DVM,PhD ( Professor ) Department of Pathobiology
Texas A & M University.

I asked Roy to summarize the case when presented. I would hope and expect that similar results would occur in Humans. I am aware of some work with EQ in people with listed very good response.

In my humble opinion if excellent surgical protocol is followed and addition a biomaterial is added to the mix excellent results can be experienced.

So, to answer your question I would expect similar to excellent results with Equine Xenograft in people.

Research in the Dog, Sheep, etc. direct the approach to new techniques, and materials used in your every day procedures. We must be similiar in many ways?

I am a clinician with just an opinion...

Thanks

Rocco

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Slide Orientation

Orientation

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Rocco why do you think that the animal results will be the same as humans.

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Thanks for Howie for this fantastic post and topic. While sufficient quantity can be achieved with bone substitutes, the two chief questions remain the quality of bone and its stability over time. Your case and beautiful histology certainly in support of this time-proven and evidence based method. Harvesting and placement of autogenous bone is certainly very technique sensitive and requires lots of attention to its handling. But the results, as I have documented over 20 years, is superb. I'll be sharing some cases of its use in the posterior maxilla in the upcoming DentalXP summit.

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Thanks Hamid. totally agree and look forward to seeing your results.

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Amazing results. You make this very technique sensitive procedure look so easy. And time after time showing fabulous results. Regards Naheed

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Howie,

Amazing case and execution as usual. Can you tell me what is your thought process when choosing the screw length for stabilization of the plates? Also do you trim an excess of the screw on the sharp end?

Best,
Michel

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Thanks Mike, I will choose one that is the correct width of the ridge so generally will be around 8-10mm. but then it also depends on the thickness of the ridges so you have to calculate each one in each case and then make a case for it

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Thank you master Howie, it makes sense!
Looking forward for the progress of this case.

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What evidence supports the comparison to humans again?

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Howie. First and foremost this is one the most AWESOME CLINICAL CASES of ridge repair I have ever seen. Then you add the BEAUTIFUL HISTOLOGY and it becomes nothing short of breathtaking. Congratulations for sure! With that said I wish to put this into perspective from my many years of observations relative to bone repair long term. Why should we expect this bone to remain or behave any better long term than that of new bone from within an extraction socket? Bone repair in an ecxtraction socket is Histologically spectacular at 4 months:

https://www.ncbi.nlm.nih.gov/m/pubmed/6950085

but we know it continues to resorb thereafter year by year.
Yes Autogenous bone may be the gold standard for bone repair BUT it is only bundle bone that stands the true test of longevity over a lifetime.
GREST DISCUSSION! Best regards to all. Chuck.

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Thanks Chuck. While doing my research there is very little evidence that the autogenous bone dissaperars after placement even the thick blocks in fact there is a new article by Verdugo in 2017 that shows stable implants and bone after many years of function.
Autogenous bone block grafting provides facial implant tissue stability long-term.
Verdugo F1, Uribarri A2, D'Addona A3.
Clin Implant Dent Relat Res. 2017 Jun;19(3):478-485.
But to answer your questions about the Khoury technique. the answer is simple. The stability of the alveolar bone not the bundle bone is dependent on the presence of oseocytes. These are absolutely necessary to perceive any pressure being exerted on the bone. This is why my histology is so important. It allows us to see the total viability of this bone. No dead material at all. This is the bone block which is dead but its only 1mm thick. Once the osteocytes are there the bone knows its being loaded so it remains as it becomes denser and the trabecular will continue to be relaid in the the directions of the force that the bone is under

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Howie; How do you manage the "curvature of the graft"?? Just amazing as I continue to marvel at what you did. Thanks Mo

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Thanks Mo. This is not something I worry about when doing a single or two teeth it is more when doing the anterior 4 when there us a curve. In these cases I will use 2 plates and meet them in the middle as seen in the pics below. With single or two teeth I rely on the soft tissue to get the final contour.

This one was a Kerf and then bent into position but still screwed

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So beautiful case Howie, Congratulations!

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Thanks Juan

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Just beautiful Howie. Comments covered almost all my questions. Thanks for sharing your superb work. Just wanted to know your experience with khoury technique in ant mandible in cases that only cortical dense bone is available snd there is no Spongy bone available for blood supply!

Bests
Omid

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Thanks Omid. I must say that I find autogenous the best bone for both anterior and posterior mandible. remember there are vessels and there are haversian systems so the bone does get nourishment. The reason cells go there is a cytokine gradient which signals the cells to come to this area. and the endothelial cells follow this network as well. I have done many anterior mandible cases and I get great results. the other reason why autogenous works for me is that the anterior mandible has very thin soft tissue so non reservable membranes often expose here in my experience. What would you do normally in these areas.

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That is an amazing case performed by a master .... I totally agree with you Howie that khoury concept is absolutely the most predictable and reproducible technique for real 3D bone augmentation, mainly in cases of combined vertical and horizontal deficiency .....and it works every every time with least complications. Thanks Howie for sharing your knowledge...participants in the XP mastership program are lucky to have a superb educator like you. hope to see you soon.

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thanks my friend much appreciated. I look forward to seeing you all soon.
kind regards from a Cold South Africa

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This is just so good. Look forward to your Advanced Bone Workshop at Dentalxp in June!!

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Howie. Great case, as usual..! Sorry, I did't see it on time. About differences between animals and humans: the difference is in the 2 immune systems. Not the same. This is why results in animals are still better. You may find many explanations in the Osteo-immunology science, which is growing very fast since the first publication in 2000... Cheers my friend.!

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Thanks my friend. Appreciate your input

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