GBR using Titanium reinforced membrane on a teenager with a fractured root

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Posted on By Howard Gluckman In Bone Grafting

A 16 year old female patient presented with a large buccal swelling and draining sinus. There was a 9mm buccal probing depth suggestive of a vertical root fracture. Instead of just extraction we decided to do an immediate bone augmentation using a titanium reinforced membrane and xenograft in order for the bone to be able to be stable in the long term. As we had a minimum of 2-3 years to wait before the implant is placed this technique was considered the best and most stable long term option. Autogenous bone would not have been an option as it would have resorbed if it had not had an implant placed after 4 months. WE will leave the membrane in place as long as possible but will remove it if it starts to perforate the soft tissue. When she is 19 she should be ready for the implant and we should have a good bone base in which to place our implant.

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26 Comments

Howard, I like the approach. I would have done the same, but perhaps with a resorbable membrane, two layers.
You´ll have a great bone formation and as you pointed out, an excellent place to put an implant.
Good job!!
Regards,
Jorge


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Jorge thanks for the kind comments. I definitely wouldn't use reservable membrane for 2 reasons. The first is that the results are very unpredictable and we will most likely have to redraft in 3-4 years time. The second is aI want something that is going to give the graft some stability. A reservable membrane will not do this for us so we will have to use tenting screws. The membrane also needs to be there for a long time so I am happier with this as if there are no complications then the bone in 3-4 years will be unbelievable compared to questionable when using reservable membranes. Thanks for the post


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Nice surgery, soft and clean. I would have also used a resorbable membrane, maybe a harder one like the Zimmer curv. About the grafting material, I don't find consistent and good quality bone using a xenograft. On a future implant site I would much prefer to use an allograft. I would limit xenografts to immediate implant+GBR cases.

What is your experience with xenografts? What kind of bone do you find afterwards ?

Thanks for a great video


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http://forum.dentalxp.com/case/details/severe-bony-deffect-treated-allograft-g/4502


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Andoni I disagree on both aspects firstly reservable membranes are not great anywhere and there success is a crap shoot at best. The second is that I want a less reservable material that will not be eaten away like an allograft. I want a more stable material for this long term grafting. I don't use allografts in many places especially not grafts but that is just my preference. Each has their preference. But I think in this case I want non reservable material everywhere to stand the test of time


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Howard,
fantastic execution: very clean and didactic surgery.
What suture did you use hold the gingival graft? I suppose they are resorbable can you send the brand of them?
Dr. Song just uses sticky bone: your tecnique is quite more complex. What are the main issue and goals on the one you show here?.
Thanks Howard, really super.
Armand0


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Thanks Armando. The suture we use is a 6/0 monofilament reservable suture called serafast. It is great to work with an resorbs in about 3-4 months. So it holds well and does not lose its senile strength.
With regards to sticky bone alone no matter who puts it there without any membrane he is dreaming if they think that bone will form without some kind of barrier and stabiliser as we have used in this case. There is absolutely zero data for using sticky bone alone and if you look at everything that gets posted on it you will never see a case open and showing healthy bone or even a CBCT showing a cross section of the healed and healthy new bone. All the show are periodicals. IMHO the sticky bone alone technique is nothing but a sales hype that has absolutely no grounding in science. Just my opinion


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Sounds valuable opinion to me.
I agree on your point of view. I didn't see any convincing result yet. But I'm patient enough to wait.
Thanks fo reply.
Armando


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couldn't agree more on the sticky bone matter Doctor Howie..Just a marketing propaganda with no solid post operative results to show that it really works


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Hi Howie,

Stunning as usual. Love the sling sutures for the palatal pedicle, very smart.

I want to ask you:
1-What is the suture technique you used after making the 2 vertical mattresses on the crest? modified horizontal mattress?

2-I have struggled to get this sticky bone consistency, could you describe your protocol?

Also did the long wait time for the implant influence your choice of barrier? If this was a more conventional case, would you have used a cross linked collagen may be?

Thanks as always my friend,

Ehab


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Ehab her age definitely played a role in the membrane choice. I do not like collagen at all so No it would never have been my choice. I would either do it this way or perhaps a block graft at a later stage. Maybe a tuberosity punch as well may have worked well.


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Rehab thanks for the kind words. The suture a normal horizontal mattress inverting suture. Sticky bone is fairly simple to use. I use Choukrons technique of Aprf and Iprf so it works well. Song has a simpler system but I don't use it. So the norm is making the pdf cutting it up and then adding the bone and some aprf liquid. then add the IPRF liquid and within a minute you have sticky bone. Watch my video on Facebook on IPRF it shows how


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Howard

Very nice clean reconstruction I look forward to the next phase of implant placement.I have had a problem achieving the proper consistancy of the Sticky bone and I have not been able to find an answer to two questions regarding the protocol. First the spin time/ RPM setting and second which collection tube is used? I watched your facebook video so I now have the answer to my first question but is the color of the cap for the IPRF gold,yellow or orange? I have tried the yellow top tubes( used in the PRP protocol that have the ACD/anticoagulant) but those did not give me the proper consistency. Please be so kind as to inform me of the proper tube to employ. Thank you in advance


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Howard that is state of the art surgery! So many concepts put together and executed perfectly.
My question is:
For the GBR with Ti membrane we see other master clinicians like yourself utilising a two stage protocol with extraction of the tooth and GBR 4-6 weeks later to allow soft tissue quality improvement (i.e. Grunder, etc). Do you feel that the VIP CTG and the PRF eliminate the risk for soft tissue dehiscence on this compromised by inflammation facial flap?

Thank you for sharing this great video.

Yiannis


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Howie; By the time you release and flip over the palatal pedicle how much "pedicle" blood supply is retained? Do you think a free CTG would not work as well? There are NO studies comparing one to the other? Just thinking simplicity as well as thinning out the palatal flap of the Regen site? Mo


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Mo I think in this case I did cut the base a little thin however in other ones with a wide base I do believe that it will still retain a lot of its vascularity. This technique in my hands is far easier than doing a free graft which then requires 2 sets of sutures which can be tricky as well whereas this one pulls into place beautifully. I do however do a FGG in cases where I have a denture and the patient cannot go without it as the rotated palatal flap will increase the palatal tissue thickness which will result in poor fit and retention of the denture


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Yiannis I would normally go for the 2 stage protocol my self as it is more predictable. However this patient flew in from another part of the country so we did all the procedures in one to reduce the need for further trips to my city. The rotated flap will definitely give me the protection I need for this to close without any major problems at all.


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hi Jerome.
The colours of the caps are orange and they are different to the normal ones as they do not have any anticoagulant in them so you will not get any success with them. You need try another orange tube without anything in them. Then with the correct spin mode you will get the success you need.


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Great Case Dr. Gluckman.
What tacking system are you using for your membrane?
Thank you
A. Ntounis


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Hi Athanasios. Thanks for the kid words. I am suing the cytoplast mini screw system which are very short screws that turn in very quickly and have amazing retention. IM not sure of the exact name


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Howard, great surgery and Music, enjoyed this presentation with a beer !!!!.

You have used a Ti membrane, great choice, which is very stable, so is it necessary to use sticky bone under that. Regards, Ashok.


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Ashok a good point and the answer is probably no. However the addition of the I-PRF may (and I say may as there is no scientific data) enhance my healing. But I also do it because the handling properties are so amazing with it. I do not believe either that sticky bone alone is good enough for augmentation purposes as described by a number of practitioners on multimedia sites and in their lectures.


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Great case and presentation Dr Howard. I'd like to ask you about the restoration for the next 3-4 years by the time she'll have the implant restored. Will you continue with the one presented on the video?
Simon Milbauer


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Thank you Simon. She will get a metal acrylic bridge as a provisional with a resin cement for the next few years. We need something strong and that is well cemented. Thereafter we will have individual crowns


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Nice surgery, Dr Howard. Totally agreed with your management. You are using Titanium reinforced d-PTFE membrane, will you consider using Titanium Mesh in such similar cases? Any specific reasons you are choosing PTFE membrane over titanium membrane? Thanks.


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Thank you very much. Yes there was a very distinct reason for the PTFE membrane. And that is the bacterial contamination or lack thereof if there is any exposure of the membrane whereas the titanium itself does accumulate bacteria and if exposed needs to be removed as soon as possible. This membrane even with early exposure will only need to be removed at 6 weeks which gives enough time for consolidation of the graft. Thank you for your question


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