Beta-Tricalcium Phosphate
Brands:
1.Synthograft
2.Cerasorb
3.Graftek
Completely unique and synthetic, GEM 21S® is an innovative combination of
a bioactive protein (highly purified recombinant human platelet derived
growth factor, rhPDGF-BB) and a biocompatible osteoconductive matrix
(beta-tricalcium phosphate, β-TCP)
GEM 21S® contains 1000x more active growth factor (PDGF) than found in
platelet rich plasma. Compared to bone graft substitute without PDGF
Provides 3x more bone fill at 6 months
Provides a more predictable treatment option even in the most severe cases
“Sockets with intact buccal and lingual plates
heal well without grafting… consider grafting
with resorbable osteoinductive material if
plates compromised and implants planned”
grafting with connective tissue if pontic
esthetics an issue.”
Vital Root Retention
• Never our first choice, but an option
for preserving alveolar bone when
performing full mouth extractions on
young patients
• Teeth must be vital with good
periodontal health
• Similar tooth selection as
“conventional” overdentures, except
elective endodontics not performed
Vital Root Retention
• Amputate teeth at crest, then remove
2 mm more tooth “sub osseous”
• Consider grafting autogenous bone
over tooth, then close primarily
• Ideally, bone grows coronally over a
vital, asymptomatic root
• Depending on rate of alveolar
resorption, will help preserve ridge 35 years before exposure/extraction
Remove 2 mm tooth
structure below bone
Suture
2 mm
New Bone
Prosthesis
J Oral Maxillofac Surg. 2005 Feb;43(1):7-12. A
randomized controlled clinical trial to compare the
incidence of injury to the inferior alveolar nerve as
a result of coronectomy and removal of mandibular
third molars. Renton T, Hankins M, Sproate C
• The length of follow up was about two
years, which for the assessment of
delayed eruption of the root fragments is
not sufficient as this process may continue
for up to 10 years. However, it seems that
coronectomy reduces the incidence of
injury to the inferior alveolar nerve
without increasing the risk of dry socket or
infection.
J Oral Maxillofac Surg. 2004 Dec;62(12):1447-52.
Coronectomy: a technique to protect the inferior alveolar
nerve. Pogrel MA, Lee JS, Muff DF.
PURPOSE: Damage to the inferior alveolar nerve when extracting lower
third molars is often caused by the intimate relationship between the
nerve and the roots of the teeth. The technique of coronectomy, or
intentional root retention, may minimize this problem.
RESULTS: There were no cases of inferior alveolar nerve-involved
damage in this study of 41 patients who underwent 50 coronectomies.
There was 1 case of transient lingual nerve involvement, probably from
the use of the lingual retractor. One patient required subsequent
removal of the roots of both lower third molars because of failure to
heal, and 1 patient required subsequent removal of a root because of
subsequent migration to the surface. Root migration was noted in
approximately 30% of patients over a 6 month period.
CONCLUSION: Coronectomy appears to be a viable technique in those
cases where removal of the whole tooth might put the inferior alveolar
nerve at considerable risk of damage.
Pre-op (Oral
bisphosphonates X 5
years)
Immed Post
10 month post
Immediate Implant Placement
Following Extractions
• Need 3-4 mm of solid bone at base of
socket, and no active infection
• Success rates ~ to “normal”
• Most typical sites: anterior teeth and
1st premolars
• Advantages? May reduce loss of labial
plate and improve esthetics, as well as
save time
Platelet Rich Plasma
• What’s Hot
– Release various
growth factors that
aid in hemostasis
and increase rate
of healing
(mitogenesis,
angiogenesis)
• What’s Not
– Cost
– Is there any
difference at 6
weeks?
– Invasive, borrow
45-90ml of blood
Casap et al. Immediate Implantation Into
Debrided Infected Sockets. J Oral Maxillofac Surg
2007.
Does placing implants into fresh extraction
sockets preserve bone?
J Clin Periodontol. 2005 Jun;32(6):645-52.
Ridge alterations following implant placement in fresh extraction
sockets: an experimental study in the dog.
Araújo MG, Sukekava F, Wennström JL, Lindhe J.
CONCLUSIONS: Marked dimensional alterations had occurred
in the edentulous ridge after 3 months of healing following the
extraction of the distal root of mandibular pre-molars. The
placement of an implant in the fresh extraction site
obviously failed to prevent the re-modeling that
occurred in the walls of the socket. The resulting height
of the buccal and lingual walls at 3 months was similar at
implants and edentulous sites.
Most human trials however, reveal results similar
to implants place via the “old school” approach,
even when immediately loaded (caution in “soft”
bone, >55 Y/O)
Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):187-94.
The radiographic bone loss pattern adjacent to immediately placed,
immediately loaded implants.
Jaffin R, Kolesar M, Kumar A, Ishikawa S, Fiorellini J.
J Craniofac Surg. 2007 Jul;18(4):965-71.
Immediate loaded dental implants: comparison between
fixtures inserted in postextractive and healed bone sites.
Degidi M, Piattelli A, Carinci F.
J Periodontol. 2007 May;78(5):810-5.
Vertical crestal bone changes around implants placed
into fresh extraction sockets.
Covani U, Cornelini R, Barone A
Why Reconstruct?
• Not enough bone for implants
• Enough bone, but esthetic result
suboptimal
• Prevent pathologic fracture
• Poor function/esthetics/retention of
conventional removable prosthesis
How? Autogenous Bone Grafts
with Implants
Autogenous Block Grafts
• “Gold Standard”
• Osteoinductive and Osteoconductive
• No need for membranes
• Holds form
• Remodels into 100% high quality bone
• No concerns about transmissible diseases
Autogenous Block Grafts
• Donor site morbidity
• Quantity is limited
• Lose 20-30% during healing
Intra-oral Autogenous Bone Sites
Allogenic Block Graft
What about membranes?
• Useful in containing particulate grafts
• Useful around teeth/exposed implant
threads
• Add expense
• Infection risk
• Unnecessary with block grafts
• ADA 4266 Resorbable
• ADA 4267 Non-Resorbable
Bone Morphogenic Protein
(BMP)
• Grow bone at will?
• Presently two are FDA approved,
BMP 2 for spinal fusions, and BMP
7 for long bone defects
• Studies show excellent results for
socket preservation, sinus lifts
• Expensive ($5000.00 for a sinus)
FDA Panel Unanimously Recommends Approval of Third
Indication For Medtronic’s INFUSE Bone Graft Nov. 9, 2006.
INFUSE Bone Graft is recombinant human bone
morphogenetic protein-2 (rhBMP-2) applied to an
absorbable collagen sponge carrier. The purpose of the
protein, which occurs naturally in the body, is to stimulate
bone formation. It has been previously approved by the FDA
for use in certain lumbar spine fusion and tibial fracture repair
procedures.
Distraction Osteogenesis
• Generation of bone (and soft tissue)
through distraction of an osseous callus
Ann N Y Acad Sci. 2006 Apr;1068:532-42. COX-2 has a
critical role during incorporation of structural bone
allografts. O’Keefe RJ, Tiyapatanaputi P, Xie C
Nonsteroidal anti-inflammatory drugs (NSAIDs), which
inhibit cyclooxygenase (COX) activity, reduce pain and
are commonly used in patients with skeletal injury. In
this article we will also present data to show that
selective COX-2 inhibitor delays allograft healing and
incorporation. These results demonstrated that COX-2
is essential for bone allograft incorporation.
Furthermore, our data support the notion that COX-2dependent PGE2 produced at the early stage of bone
healing is prerequisite for efficient skeletal repair.
Wise Old Oral Surgeon Says
Beware of:
• 3rd molars in function
• Lone standing molars
• Teeth in bruxers/ Cl. III skeletal patterns
• 3rd molars + post-menopausal women
• Prior TMD history
• Prior “bad” oral surgery experience
• Distoangular lower 3rds/ nerve proximity
3rd Molar Surgery – Why?
1.
2.
3.
4.
5.
6.
7.
Prevent/treat pericoronitis (infection)
Prevent periodontal problems 2nd molar
Prevent/treat caries to 2nd / 3rd molar
Prevent odontogenic cysts/tumors
Strengthen mandible, possible fx
Prevent orthodontic relapse?
Treat pain of unknown origin
Extract 3rds: Oral/Systemic Link?
CLEVELAND, April 6, 2006 - The first hard evidence has been
uncovered that bacteria in the mouth may find their way to the
uterus, causing uterine infections that can lead to preterm birth in
pregnant women.
A newly discovered and as yet unnamed species of the
bacterium genus Bergeyella was found in the mouth and
amniotic fluid of a woman with a uterine infection who gave
birth prematurely (24 weeks), reported microbiologist Yiping W.
Han, Ph.D., of Case Western Reserve here.
However, the bacterium was not detected in a vaginal swab, as
might be expected. The finding confirmed what some scientists
have suspected, that intrauterine infections don't always
"ascend" from the genital tract but can "descend" from the oral
cavity, Dr. Han and colleagues said in the April issue of the
Journal of Clinical Microbiology.
Progress Report on Third Molar Clinical Trials
Raymond P. White, Jr DDS, PhD
Journal of Oral and Maxillofacial Surgery
Volume 65, Issue 3, March 2007, Pages 377-383
1.What happens to asymptomatic patients who keep their third
molars?
2.What is the recovery like for those who have them removed,
and what can we do as surgeons to improve post operative
outcomes?
3rd Molar Surgery – When?
• Before roots 100% developed
• After roots: 1/3 formed
• Morbidity/complications minimized
as bone more flexible, nerves more
pliable, and PMH less complicated
• Don’t forget tooth transplant if
apex not closed
Outcome of tooth transplantation: survival and
success rates 17-41 years post treatment.
Czochrowska EM, Stenvik A, Bjercke B,
Zachrisson. Am J Orthod Dentofacial Orthop. 2002
Feb;121(2):110-9.
The mean age at surgery was 11.5 years, and the mean
observation period was 26.4 years (range, 17-41 years). Of
the 33 teeth transplanted in the 28 patients, 3 teeth were
lost after 9, 10, and 29 years, respectively. Therefore, the
30 teeth in the 25 patients we examined yielded a survival
rate of 90%. The success rate was 79% because 2
transplants had ankylosed, and 2 others failed to fulfill the
proposed criteria. The patients generally responded very
favorably regarding their perception of the treatment. Their
only hesitation was related to some discomfort during
surgery. It was concluded that survival and success
rates for teeth auto transplanted when the root is
partly developed compare favorably in a long-term
perspective with other treatment modalities for
substituting missing teeth.
3rd Molar Surgery – When Not
• Extremes of age
• No oral
communication
(full bony)
• Intimate root-nerve
Relationship
• Risks > Benefits
3rd Molar Surgery Alternatives?
• No Surgery: dentist feels risk: benefit
ratio not favorable or patient refuses –
document and recommend radiograph q
3-5 years
No High Speed
• Air embolus
• Air emphysema
• Blow debris into flap
• Blow bacteria into flap
• Non-sterile water
Which are true?
1. Tooth transplants are usually done
on patients 20-30
2. Average success rate for a tooth
transplant is 20-30%
3. In order to work, a transplant must
have endo
4. Most transplants will ankylose
A. 1,3
B. 2,4
C. 1,2,3
D. 3 only
E. None of the above
How can I assess the relationship between the
3rd molar root and the inferior alveolar nerve?