This presentation reviews common functional and esthetic problems associated with extraction of teeth and current methods and surgical techniques to minimize loss of bone and soft tissue
2. Dr. Scott K. Smith
1986 Pennsylvania State University B.S. Biochemistry
1990 University of Maryland D.D.S.
1992 University of Maryland Certificate in Periodontics
3. Experience
• 20 years of Regeneration experience
• Lectured for Collagenex for 5 years
• Lectured for BioHorizon on Regenerative
Materials and Implant Surgery
• Lectured for Astra Tech
• Guest on the Wellness Hour
4.
5.
6.
7.
8. Today’s Goals
• Anatomy of Bone and related Structures
• Biology of Healing
• Consequences of extractions, trauma and
disease on Anatomical Structures
• Methods Materials and Techniques for
Regeneration
• Treatment Planning Skills
• K.I.S.S.
9. Mandibular and
Maxillary Bone
• Composed of Compact and Cancellous
• Alveolar bone is specialized bone that
supports teeth via ligamentous insertions.
• 67% Inorganic ad 33% Organic
• Cell Types: Osteoblasts, Osteoclasts,
Osteocyte
16. BMP (Bone Morphogenetic Protein)
1. What is BMP
: Protein extractors from bone could induce
the local formation of new cartilage and bone
when implanted at non-bony site(Dr. Urist)
Ectopic bone formation
: He called that protein extract BMP
(bone morphogenic protein)
: Group of growth factors also known as cytokines
17. PDGF and TGF-B
• PDGF - Mitogenesis of Mesenchymal Stem
cells and endothelial cells
• TGF-B - Chemotaxis of Osteoblast
precursors, bone matrix formation by
osteoblasts
19. Osteoblast Cell
• Derived from Mesenchymal stem cells
• Responsible for Bone Matrix synthesis and
mineralization
20. Osteocyte Cells
• Osteoblasts that become incorporated
within newly formed osteoid
• Osteocytes maintain contact with
Osteoblasts on surface of bone via
canaliculi.
22. Source of Bone Cells
• Mesenchymal stem cells
– Source of chondrocyte
– Source of osteoblast and osteocyte
– Source of cells in the periosteum and perichondrium
• Hematopoietic stem cells
30. Consequences of
Extraction
• Loss of Functional Support
• Interference with Phonetics
• Compromised Esthetics
• Plaque and Food Accumulation
31.
32. Socket Healing
•
Blood clot forms with Coagulation of Red and
White Blood Cells
•
Replacement of Clot with Granulation tissue 4-5
days
•
Replacement of Granulation tissue by Connective
Tissue 14-16 day process
•
Apical and lateral walls mineralize 10 weeks and
complete fill in 15 weeks
•
Epithelialization of the socket occurs 24-35 days
later
36. Bone Healing and Soft
Tissue Changes
•2/3 rds of the hard and soft tissue changes occur
in the first 3 months.
•50% of crestal width to be lost in a 12-month
period
•2/3 of which (3.8 mm; 30%) occurred in first
twelve weeks
Schropp, et.al
37. Percent of Volume Loss
• Horizontal Loss - 22-63%
• Vertical Loss - 11-22%
Wong
Clin Oral Impl Res:14;2012
44. Guided Bone
Regeneration
• Regeneration of bone through space
maintaining, osteoconductive, inductive and
biologics to encourage osteoblasts to reestablish dominate tissue at the exclusion
of connective tissue.
47. Mechanism of Bone Formation
• Osteogenesis
• OsteoInduction
• OsteoConduction
48. OsteoGenesis
• Bone formation by living or autogenous
osteoblasts
• Formation of bone even without
Mesenchymal Cells
49. OsteoInduction
• Process of Stimulating Osteogenesis
• Transformation of Undifferentiated
Mesenchymal cells into Osteoblasts
• Ability of Graft material to induce
Osteogenesis and bone
• BMP instrumental in this process
50. Bowers et al - New
Attachment
Concept of Regeneration
Originated with DFDBA
developing bone under
skin of Rabbits
51. OsteoConduction
• New bone by “creeping substitution”
• Bone graft material is scaffold to promote
and allow vessel in growth
• Bone formation by margin of host bone
57. Socket Preservation Healing
•
Iasella - FDBA with Collagen membranes
nonmolar areas - 15% more bone but still loss of
coronal buccal bone
•
Lekovic -Resorbable membrane vs. Nothing - Less
buccal bone resorption 0.38 vs 4.5mm. Vertical
height loss comparable
•
Araujo Lindhe - Is graft material Necessary? Found
althought FDBA did not prevent remodeling increased bone density
58. Graft Materials:
• OsteoConductive Material - Scaffold
Xenograft - BioOss
Alloplast - Calcium Sulfate, Biogran, BTCP
•
OsteoInductive Material - Bone Stimulating
Autograft - Local site, Distant site
Allograft - FDBA Cortical or Cortical/Cancellous, DFDBA,
DBA Paste
65. Bone Regeneration
• Extraction Socket
• Fenestrations and Dehiscence
• Ridge Augmentation Prior to Implant
• Implant and Ridge Augmentation
66. Five Categories of Defect
2. Fenestrations
- Class II Fenestration
(Outside Bony Envelop)
67. Five Categories of Defect
3. Dehiscences
- Class II Dehiscense
(Outside Bony Envelop)
68. Five Categories of Defect
1. Extraction wounds
Class I Extraction Sockets
Class II Extraction Sockets
69. Why Do Socket Preservation?
• Enable Implant installation and stability
• Reduce loss of Alveolar Bone Volume
• Reduce need for additional bone grafting
• Improve Esthetic and Phonetic Outcome
70.
71. Atraumatic Extraction
• Eliminate Infection and Irritant
• Preserve Existing Bone and Soft Tissue
• Minimize Loss of Volume with
Augmentation materials
82. Width of Buccal Bone
Maxillary Incisor
In the anterior sites, a vast majority of the
•
buccal bony walls (87.2%) had a width of
≤1mm,
•
•
Only 2.6% of buccal walls were 2mm wide or
greater
Proposed Criterion for Stable Buccal Bony wall
following extraction is 2mm - then MOST sites
will LOSE bone.
In most situations, guided bone regeneration may
be needed to achieve adequate bone contour
around the implant and optimal esthetic
outcome.
83.
84. Graft Material
• Not 4 wall defect
• Reduced Blood Supply and Less MSC
• Reduced Stability and Retention
• Need to use OsteoInductive - I like FDBA
and DBA paste mix
115. Implant Placement and Guided
Bone Regeneration
• Sufficient Bone for Stabilization
• Secure Implant torque (>35N/cm)
• Graft Containment
• Stabilize Site
• Ensure Esthetic Outcome Possible
128. SMARTmembrane™
Features
• Concept : 3D Pre-formed customizing titanium membrane
• Adaptation: Fixture + Height + Membrane + Cap(healing abt)
• Tool : Cover cap driver, Defect guage
Type 1
(Buccal)
Type 2
(Buccal &
Proximal)
Type 3
(Buccal,
Proximal, &
Lingual)
3D
View
Flat View
187
129. Competitors – FT Wing
Designed and developed by:
Dr. Funato & Dr Tonatsuka
Size: 11.5mm(W) x 29mm(L) x 0.2mm (T)
188
130. Competitors – CTi Membrane
Buccal or
Lingual
Buccal- Lingual Proximal
Submerged &
Non-fixed
*Has 6 different shapes and sizes: 30 different types
** Only few types are being used.
189
132. Optimum Pore Size for Ridge
Augmentation
•
Compared Titanium Mesh with Pore size of 0.6mm
and 1.2mm to that of Resorbable Collagen mesh of
1mm size and No pore
•
Macro Mesh of 1.2 best for Total Volume of
Regeneration
•
No pore size prevents most soft tissue ingrowth
with 1.2 titanium next
•
Contaiment of Graft most important criteria
134. Journal Analysis
< Result >
Courtesy by Dr. Lee DH
Optimal Pore size ?
Mesh type
Regeneration
area(mm2)
Soft tissue
Ingrowth (mm2)
Mar rate
(Mineral apposition rate)
Macro mesh
With porous Ø1.2
66.26±13.78
16.96
1.09μm/day
Micro mesh
With porous Ø0.6
52.82±24.75
22.29
-
Resorbable mesh
With Ø1.0
46.76±21.22
23.47
2.41μm/day
Without pore
29.80±9.35
9.41
-
• Bone regeneration : Macro mesh > other comparison group
• Prevent soft tissue ingrowth : Without pore > Macro mesh > other comparison group
• Containment of bone graft is most critical parameter in success bone regeneration
• Cortical perforation did not have any effect on the quantity of bone regeneration.
Result and conclusion,
Need Bone regeneration or reconstruction and Prevent soft tissue ingrowth
therefore Mesh size : Ø1.0 ~ Ø1.2
135. Optimum Pore Size
• For optimum Bone Regeneration and
exclusion of soft tissue need Mesh size of 1.0
- 1.2mm size.
J Oral Maxillofacial Surg 67:1218-1225, 2009
141. SMARTbuilder
3. Choose Height Component - If Implant submerged or want to
gain vertical height use longer one
4. Place Bone Material into defect and over fill
142. SMARTmembrane™
4. Connect the SMARTmembrane on the height through the hole in the middle.
5. Use 1.2 hex driver for healing abutment, use Cap driver for Cover cap.
6. Suture.
202
165. Maximum effect of 3D extrasocket overlay augmentation
Excellent space maintenance
PRF for surgical isolation
2 wall augmentation
Easy circular approximation
by slim healing Abutment
166. PRF for surgical isolation & meticulous circular approximation
Healing after 18ds
Never brush
Never touch
PRF
Healing after 1 month
Postop CT
173. SMARTbuilder Guidelines
• Accurate Membrane size for Defect!
• Bone Material should have Large particle
size - 1mm or so
• Make sure Membrane Secure and Adapted
well to Bone
• No Dead Space - Fill voids with bone
193. Why SMARTbuilder?
• Excellent Mechanical properties:
• Sufficiently Rigid for space maintenance
• Elasticity - Prevents Mucosal Compression
• Stabilizes Bone graft material
194. Conclusion; Why
SMARTbuilder?
• Single implant defect
• Common clinical situation
• Low cost(vs. membrane)
• Easy to use & removal
• Predictable result
195. GBR is Predictable
• Understand Normal Anatomy, Cause of
Defect, and Anticipated Result
• Understand Healing capabilities and
Limitations
• Understand Surgical Concepts
• Utilize Optimum Techniques and Materials
• Continue to Learn and Care!
{"231":"6개월후 CT사진에서 정확하게 13번 부위에서cross section후 모습으로/\n","254":"이상의 증례를 바탕으로 SMARTbuildr는 임상에서 자주 접하게 되는 single implant의 dehiscence defect에서 membrane에 비해 적용과 제거가 쉽고 경제적이며 technique sensitive하지 않는 예지성 있는 결과를 보인다고 결론 지을 수 있겠습니다.\n"}