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Knowledge for Clinical Practice

Guided Bone Regeneration Procedures

Stuart J. Froum DDS, Sang-Choon Cho DDS, Lon Pariente DDS

A Surgical Protocol for

PART 1 in A seRies

Using Absorbable Membranes to Minimize and Treat Complications

Inside earn

2 CE Credits
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aBsTRaCT Guided bone regeneration is a widely-used technique to augment alveolar ridge defects to allow implant placement and improve the final esthetic outcomes of implant-supported restorations. Since the introduction of guided bone regeneration, which is based on the theory of guided tissue regeneration, scientific evidence has demonstrated its effectiveness in regenerating lost bone. A biologically based technique must be used for clinical success and to avoid the occurrence of treatment complications that could be patient-, material- or technique-related. Should complications associated with guided bone regeneration occur, these must be treated as soon as possible.

aBoUT THE aUTHoRs stuart J. Froum DDs

Dr. stuart J. Froum is an international lecturer, and Clinical Professor and the Director of Clinical Research in the Depart ment of Periodontology and Implant Dentistry, at New York University Dental Center and has been in private practice for over 35 years. He is on the Research Committee for the Academy of Osseointegration, and is the Vice President of the American Academy of Periodontology where he has previously served as Board Liaison to the Continuing Education Oversight Committee, a member of the Con tinuing Education Committee and as a District Trustee. Dr. Froum has published over 100 articles in peerreviewed journals, was the editor for the recentlypub lished book titled Dental Implant Complications Etiology, Prevention and Treat ment, coauthor of Comprehensive Periodontics for the Dental Hygienist (2001), and a contributing author for the 11th edition of Carranzas Clinical Periodontology as well as a coauthor of 3 chapters in Sinus Bone Graft (2006) and Implant Site Development (2010). He is also a reviewer for the Journal of Periodontology, Inter national Journal of Periodontics and Restorative Dentistry and for Compendium. Dr. Froum was awarded the William J. Gies Award for Service to the American Academy of Periodontology in 2006, the American Academy of Periodontology The Special Citation Award in 2005, the Hirschfeld Award NESP in 1999, the Clinical Research Award in both 2004 and 2005, and the J. Coslet Distinguished Lecturer Award from the University of Pennsylvania Dental School in 2003.

EDUCaTIonal oBJECTIVEs

The overall objective of this article is to provide the reader with information on a step-by-step surgical protocol for the use of guided bone regeneration with absorbable membrane barriers for ridge augmentation, designed to achieve successful augmentation and minimize potential complications. On completing this article, the reader will be able to do the following: 1. Present and describe the step-by-step technique for using guided bone regeneration with absorbable membrane barriers to augment deficient bony ridges for implant placement 2. Review the materials used with this procedure 3. List and describe the factors essential for success 4. Discuss the most frequent complications that may occur with this technique and describe their treatment.

sang-Choon Cho DDs, Ms

Dr. sang-Choon Chois a fulltime Clinical Assistant Professor and Director of Advanced Program for International Dentists in Implant Dentistry in the Department of Periodontology and Implant Den tistry, at New York University College of Dentistry (NYUCD). He is a graduate of both the DDS program and the Advanced Program in Implant Dentistry for International Dentists at NYUCD and also holds a dental degree and an MS degree from Kyungpook National University in South Korea. In addition to teaching and conducting research at NYUCD, Dr. Cho serves as a liaison to the NYUCD South Korean Alumni Study Club.

lon Pariente DDs

Dr. lon Pariente is a graduate of the Advanced Program for International Dentists in Implant Dentistry as well as the Advanced Program for International Dentists in Comprehensive Dentistry at NYUCD. Dr. Pariente also holds a dental degree from the University of Paris V.

SPONSOR/PROVIDER: This is a Dental Learning, LLC, continuing education activity. No manufacturer or third party has had any input into the development of course content. DESIGNATION STATEMENTS: Dental Learning LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning LLC designates this activity for 2 CE credits. Dental Learning is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. Dental Learning, LLC is also a California Provider. The California Provider number is RP5062. This course meets the Dental Board of Californias requirements for 2 units of continuing education. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29 for 2 CE credits. PUBLICATION DATE: August, 2012. EXPIRATION DATE: July, 2015. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidenced-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest with any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Monique Tonnessen, does not have a leadership or commercial interest with any products or services discussed in this educational activity. She can be reached at mtonnessen@dentallearning.net. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC, in writing. Go Green, Go Online to www.dentallearning.net take your course. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to mtonnessen@dentallearning.net.

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A Surgical Protocol for

Guided Bone Regeneration Procedures

Using Absorbable Membranes to Minimize and Treat Complications
Introduction

ental implants have been documented to have a high degree of success for single tooth replacement and the restoration of partially and completely edentulous arches.1-6 However, horizontal and/or vertical alveolar bone deficiencies constitute a major challenge for implant placement. Many techniques are available today for the experienced surgeon to rebuild lost bone, including autogenous onlay block grafts,7 allograft block grafts,8 distraction osteogenesis9 and guided bone regeneration (GBR).10 The latter is one of the most well-documented and versatile procedures for regenerating bone in both horizontal and vertical defects, thereby allowing successful implant placement.10,11 The principles of GBR have been developed based on the theory of guided tissue regeneration introduced in the late 1980s10 and 1990s12. The surgical procedure consists of placing an occlusive physical barrier between the connective tissue and the bone defect to prevent the migration of

the epithelial and connective tissue cells into the defect and to stabilize the blood clot and graft. This allows the slowermigrating osteogenic cells to proliferate and form new bone, thereby selectively repopulating the wound with osteoblasts prior to the migration of connective tissue and epithelial cells.12 Scientific evidence in animals and humans has demonstrated that GBR is an effective technique to regenerate lost bone.13 Despite the fact that GBR is a predictable procedure, complications can arise that may compromise outcomes membrane exposure, fenestration/dehiscence, infection, graft particle leakage, collapse of the grafted site and excessive bleeding are the most frequently reported complications. Recently, a classification of complications with GBR procedures using non-resorbable membranes was published.14 Clinical guidelines for the procedures described in this paper, although not evidence-based, were obtained from the experience of the authors over the last 20 years in the treatment of patients at New York University College of Dentistry, Department of Periodontology and Implant Den-

Figure 1. Preoperative view of site #10: Treatment plan requires implant placement with simultaneous horizontal bone augmentation

Figure 2. Preoperative occlusal view of site #10

Figure 3. Preoperative occlusal view of 2-3 mm horizontal defect in site #10

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tistry, with GBR for site development prior to, or simultaneously with, implant placement.

Technique
The following describes the step-by-step GBR technique utilizing resorbable membranes (RMB) for successful bone augmentation, together with recommendations for avoiding complications (Figs. 1-3, see page 3). Flap design The incisions are designed in accordance with the following five goals: A. Access to the bone defect B. Maintenance of the blood supply of the elevated flap and the neighboring tissues C. Preserving the interdental/implant papillae D. Providing sufficient advancement of the flap E. Allowing for tension-free primary closure. A full-thickness midcrestal (or slightly facial to the midcrest) incision is made between the teeth bordering the defect. If the defect extends to 2 or more teeth, the incision is made extending one tooth mesial and distal to the defect (or in fully edentulous arches a 1-to-2-tooth distance beyond the borders of the defect). Two full-thickness vertical incisions (preserving the bordering papillae) are then made down to the bone, starting in the area of the base of the vestibule and continuing coronally in one continuous cut to meet the crestal incision. The vertical incisions are made parallel or trapezoidal with the base, widening apically to ensure an adequate blood supply and easy coronal reposi-

tioning of the flap after augmentation with the graft material. In an edentulous area the incision design is a rectangular shape, whereas in a dentulous area the vertical incisions extend apical to the root apices. These incisions extend past the mucogingival junction into the mucosa and are designed to preserve the mesial and distal papillae while maintaining the blood supply of the neighboring tissue (Fig. 4). The papillae and keratinized tissue on the adjacent teeth can be preserved utilizing a Z-shaped incision slightly coronal to the mucogingival junction on the adjacent teeth and continuing apically in a vertical direction to the mucosa (Fig. 5). The required osteotomy is then prepared, the implant is placed and good primary stability must be achieved. Following implant placement, GBR procedures are performed when the facial bone shows a concave morphology requiring horizontal augmentation (Figs. 6-7). Recipient site preparation The bony defect is debrided of granulation tissue and tissue tags, using curettes and back-action chisels. Cortical perforations (decortications) are then made with a #1 or #2 round bur using high speed with copious irrigation to create bleeding at the surgical site (Fig. 8). The decortications are designed to increase the blood supply and osteogenic progenitor cell migration from the bone marrow to the site of augmentation.15 Following wound hemostasis, these decortications will help promote graft contact and stability. Releasing incisions Periosteal releasing incisions are made with a sharp 15C

Figure 4. Incision design: Mesial and distal vertical incision connected to midcrestal incision, preserving the mesial and distal papillae

Figure 5. Flap is elevated, allowing for access to the buccal bone

Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

blade on the inner apical portion of the flap, between the vertical incisions, creating a 2-3mm split-thickness dissection (Fig. 9). These releasing incisions allow for better flap release and subsequent advancement for flap closure. Moreover, thicker tissue in the apical area of the vertical incision reduces the risk of flap perforation, provides an abundant blood supply and limits the trauma to the augmented site (Fig. 10). Making these periosteal incisions early in the surgery is recommended, while good visibility is present, to allow easy access to the apical periosteum for the stabilizing sutures. This exposed apical periosteum will be used as anchorage for the membrane-stabilizing sutures (Fig. 11). Graft materials and membrane placement The sterile container wrapping of the collagen mem-

brane or autoclaved tinfoil is used as a template, fitted and trimmed to the ideal shape. A resorbable collagen membrane is then cut to the same shape as the template and placed over the surgical site (Fig. 12). Once the membrane is in the correct position, a single tack is positioned apically through the membrane into native bone for stabilization. The membrane is rotated 180 around the tack and with a tissue forceps is pulled over the ridge to maximize the containment space for the graft. It is then adjusted to extend 2-3 mm beyond the augmented area (Fig. 13). The graft material (e.g., mineralized allograft bone and/or anorganic bovine bone matrix) is placed and condensed to fill the bone defect, ensure proper space maintenance and bone contact, and support the membrane (Fig. 14).

Figure 6. Implant placement (Straumman Bone Level 3.3 mm x 12 mm SLA active)

Figure 7. Occlusal view after implant placement; note that there is no fenestration or dehiscence, despite the bone concavity

Figure 8. Decortications of the surgical site to create bleeding

Figure 9. Periosteal releasing incisions creating a 2-3 mm split-thickness dissection

Figure 10. Diagram of a sagittal view with arrow showing the location and direction of the releasing incision

Figure 11. The exposed periosteum is used as anchorage for the membranestabilizing sutures

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Stabilization of graft material and barrier membrane Stabilization of the membrane and the underlying graft material is achieved by using horizontal mattress sutures extending from the apical portion of the facial periosteum to the palatal aspect of the flap (Fig. 15). To minimize the risk of irritation and infection on the palatal aspect, the suture knot is positioned and stabilized inside the flap and only 2 to 3 mm of suture is exposed palatally (Fig. 16). Chromic gut suture (4-0) is the material of choice since it is strong enough to stabilize the flap16, absorbs in 10-14 days following the surgery and because its monofilament structure limits plaque accumulation. Proper containment and stabilization of the graft material and membrane with these sutures, combined with

pressure on the surgical site with nonwoven moist gauze, is critical to preventing secondary (rebound) bleeding that may occur when the vasoconstrictors in the anesthetic have dissipated. Suturing to advance the flap coronally To coronally advance the flap, a horizontal mattress suture is used to connect the inner middle portion of the buccal flap to the inner aspect of the palatal flap (Fig. 17). On the facial aspect the suture is placed to the depth of the tissue, while not perforating completely through the flap. The periosteum is then coronally advanced together with the flap, allowing passive tension-free closure of the flaps (Fig. 18).

Figure 12. A sterilized tinfoil template (left) is trimmed to the correct dimension and tried on the defect. A resorbable collagen membrane (right) is then adjusted accordingly

Figure 13. The graft material is brought to the site with the use of a bone syringe, placed under the membrane and condensed

Figure 14. The membrane-stabilizing sutures shown in Figure 11 are now connected to the palatal aspect of the flap

Figure 15. The sutures are tightened and the knot is positioned inside the flap

Figure 16. The membrane-stabilizing sutures in place

Figure 17. A horizontal mattress suture is placed to connect the inner middle portion of the buccal flap to the inner aspect of the palatal flap

Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

Suturing to ensure primary closure Final tissue adaptation is achieved by means of multiple interrupted 4-0 chromic gut sutures, regularly spaced to close the incisions (Figs. 19, 20). Provisionalization A provisional prosthesis is used when necessary to provide esthetics and function for the patient and to protect the augmented site during healing. The healing phase of hard-tissue augmentation procedures requires that no transmucosal pressure be placed on the grafted and/or regenerated ridge tissues or the implants themselves. A fixed provisional restoration is recommended. However, in some cases a clasp partial removable denture can be used if it is properly adjusted to ensure no contact with the augmented area. A vacuum-formed shell can also be used and the missing teeth filled with acrylic or resin composite (Fig. 21, see page 8). The patient should be shown how to insert, remove and clean any removable provisional prosthesis. Healing Two to 4 months of healing is necessary to establish osseointegration of the implant and 4-6 months is needed for healing of the graft (Figs. 22-29, see page 8).

Maintenance The patient should return biweekly for 2 months following the surgical procedures. These visits should include examination of the surgical site and provisional restoration and debridement of the surgical site. Identifying potential complications Guided bone regeneration is a technique-sensitive procedure, and complications may arise.17,18 The etiology of complications is usually multifactorial and may be patient, material, or technique related.19 Patient-related complications Patient-related complications are divided into two major categories. The first includes the presence of systemic diseases including diabetes, autoimmune diseases or osteoporosis. Patients taking immunosuppressive medications or who have undergone radiation therapy present a higher risk of complications. This is also true of patients who presently are receiving, or have a history of, treatment with intravenous bisphosphonates, smokers and patients who are heavy drinkers.19 The second category is related to patient compliance. It has been found that nicotine and alcohol impede proper healing of the tissue, and smoking has also been

Figure 18. The elevated periosteum is advanced coronally by the sutures, thus providing strong anchorage and allowing passive tension-free closure of the flaps

Figure 19. Tissue adaptation is achieved by means of multiple 4-0 chromic gut sutures: occlusal view

Figure 20. Tissue adaptation and full coverage of the membrane and graft are achieved by means of multiple 4-0 chromic gut sutures: buccal view

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Figure 21. Provisional restoration relieved to avoid transmucosal loading

Figure 22. Buccal view of the site healing, 4 weeks after surgery

Figure 23. Radiograph before and after implant placement and bone augmentation

Figure 24. Occlusal view 2 months after surgery

Figure 25. Comparative occlusal view preoperatively (left) and 2 months postoperatively (right)

Figure 26. Buccal view 2 months postoperatively

Figure 27. Buccal view of final restoration 3 months postoperatively

Figure 28. Radiograph of customized abutment try-in (left) and porcelain fused to metal crown (right)

Figure 29. Computerized tomographic axial view of site #10 at 6 months prior to surgery (left) and 3 months after surgery with implant placed and buccal bone augmented (right)

Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

reported to reduce revascularization of the bone in regenerative procedures, mainly due to vasoconstriction of the arteries.19-23 Alcohol intake has been reported to affect the outcome of GBR treatment, affecting bone metabolism by inhibiting osteoblast proliferation and by increasing osteoclastic activity, which results in an accelerated bone resorption rate.19,24,25 Any patient who smokes should be offered a smoking cessation program, and social drinkers should be advised to refrain from alcohol during the healing phase. Alcoholics should be urged to seek professional help. Material-related complications Material-related complications can be minimized if the graft and membrane are biocompatible, immunologically inert and physiologically stable. There should be no risk of transmission of disease, and the grafting materials should ideally provide osteogenicity, osteoinductivity and osteoconductivity and should be absorbed as new bone formation occurs.19 In studies comparing resorbable and non-resorbable membranes for GBR procedures, more infections were found with the use of slowly resorbing or non-resorbable membranes in association with bovine bone graft material. In a systematic review, Rochietta et al27 reported that the complication rate when using non-resorbable membranes for vertical augmentation varied from 0% to 45.5%. Fontana et al 14 suggested a classification of healing complications when using a non-resorbable membrane barrier, based on the size of membrane exposure and the associated clinical signs. The classification includes 4 types of membrane exposure: Class I, small membrane exposure (3 mm) without purulent exudate; Class II, large membrane exposure (>3 mm) without purulent exudate; Class III, membrane exposure with purulent exudate; and Class IV, abscess formation without membrane exposure. This classification may be used with RMB with the treatment modifications listed later in this paper. However, the treatments of complications associated with RMB differ from those recommended with non-resorbable barriers. The

outcome and treatment of complications with RMB appear to be more favorable when compared with those with non-resorbable membranes, which often require early removal to ensure the resolution of the complication in Class I, II, III and IV membrane exposure. Consequences for the augmented site will then depend on the degree of complication (Class I to Class IV) and the timing of membrane removal. Technique-related complications The most common complications in this category are: 1) Membrane exposure (Fig. 30, see page 10) 2) Dehiscence of the wound (Fig. 31, see page 10) 3) Infection of the surgical site (Fig. 32, see page 10) 4) Graft particle leakage (Fig. 33, see page 10) Other complications that have been discussed with resorbable barriers (i.e., flap damage, neurologic complications and vascular complications) can occur regardless of the membrane used and should be treated as previously described.14 However, these complications often occur because of improper surgical technique, absence of tension-free flap closure, absence of primary closure, incorrect incision design or technique, improper tissue apposition, improper graft containment with improper space maintenance, or premature reentry for implant placement.17,19,25

Prevention of complications
In order to prevent complications, the biology of wound healing and the principles of guided bone regeneration should be familiar to and respected by the clinician.25 These include obtaining adequate tension-free primary flap closure, ensuring adequate blood supply, providing a proper scaffold for regeneration, space maintenance during healing and stability of the implants. In cases of simultaneous GBR and implant placement, submerging the implant and selection of an appropriate fixture surface are necessary. In addition, proper provisionalization is essential and must include avoiding pressure on the surgical area to allow undisturbed healing. The skill and experience of the surgeon as well as a thorough understanding of the healing process play a central role in the

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Figure 30. Membrane exposure (note arrow) 2 weeks after GBR using a resorbable membrane in site #3

Figure 31. Membrane dehiscence (note arrow) 1 week after GBR using a resorbable membrane in sites #29, 30, 31

Figure 32. Infection (note arrow) 5 weeks after GBR using a resorbable membrane in site #18, 19, 20

Figure 33. Graft particle leakage (note arrow) 3 weeks after GBR using a resorbable membrane in site #8

success of treatment and incidence of complications.

Prevalence and treatment of the most frequent complications

There is limited information in the literature regarding the prevalence of resorbable membrane exposure in GBR procedures. However, a human study28 showed membrane exposure in 7.1% of cases, shortly after ridge augmentation, which resolved within 2 to 4 weeks with spontaneous re-epithelialization. These complications did not compromise outcomes. To date, there is no scientific data available on the prevalence of dehiscence, infection or particle leakage after GBR procedures with the use of resorbable membrane barriers in humans. The treatment of the most frequent complications is described below. Treatment of membrane exposure without flap necrosis a. The surgical area should be irrigated several times with saline solution followed by irrigation with a diluted (1:1 with water) hydrogen peroxide solution to remove food debris and plaque.

b. Patients should be instructed to use cotton tips impregnated with chlorhexidine solution to lightly swab the exposed membrane several times a day. c. In addition to the above, if there are signs of infection (i.e., acute pain, swelling or fever), antibiotics should be prescribed. The antibiotics of choice are Augmentin (875 mg, 2 times a day for 7 days), or amoxicillin (500 mg, 3 times a day for 7 days). Patients allergic to these antibiotics should be placed on clindamycin (150 mg, 4 times a day for 7 days). d. If the infection is not resolved or the membrane becomes fully exposed, removal of the membrane should be performed, the area irrigated and loose graft particles removed. The flap should then be advanced and closed. For the cases where closure is not possible, a connective tissue graft may be used, placed over the exposed bone and sutured under the edges of the flap. Dehiscence a. The area should be irrigated several times with a saline solution followed by irrigation with a diluted (1:1 with

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Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

water) hydrogen peroxide solution to remove food debris and plaque. b. If the flap readapts passively, it should be sutured (4-0 Vicryl or chromic gut) to obtain primary closure. The wound borders should be de-epithelialized, removing internal epithelium from the flap to optimize the closure and to prevent trapping of epithelium under the flap. If tensionfree primary closure cannot be achieved, releasing incisions should be made before suturing. Suturing should be performed with 5-0 chromic gut sutures using a P-3 needle. Infection 1. Early infection (0-4 weeks postoperatively) a. The area should be irrigated several times with a saline solution followed by irrigation with a diluted (1:1 with water) hydrogen peroxide solution to remove food debris and plaque. b. Antibiotics should be prescribed for 7-10 days using a combination of Augmentin (500 mg, 3 times a day) or amoxicillin (500 mg, 3 times a day), together with metronidazole (500 mg, 3 times a day). c. The etiology (i.e., lack of patient compliance, flap mobility due to the pressure of the provisional prosthesis, or disturbance of the surgical site by food or trauma) should be determined and the problem corrected. d. If the infection does not resolve with the above treatment, removal of the graft and membrane should be performed, the area debrided and irrigated, and the flap resutured. 2. Late infection (more than 4 weeks postoperatively) a. The etiology (i.e., lack of patient compliance, mobility due to the pressure of the provisional prosthesis, or disturbance of the surgical site by food or trauma) should be determined and the problem corrected. b. If the infection is localized, incision and drainage should be performed. c. Antibiotics should be prescribed for 7-10 days using a combination of Augmentin (500 mg , 3 times a day) or amoxicillin (500 mg, 3 times a day), together with metronidazole (500 mg, 3 times a day).

d. If the infection does not resolve with the above treatment, surgery should be performed following the same instructions described above for Early infection. Graft particle leakage a. The area should be irrigated several times with a saline solution followed by irrigation with a diluted (1:1 with water) hydrogen peroxide solution to remove food debris and plaque. b. Remove excess material if the dehiscence is large, de-epithelialize the internal aspect of the soft tissue and resuture the flap. c. Prescribe chlorhexidine rinses 2 times a day for 2-3 weeks. d. Schedule weekly visits for the patient and repeat step 4 at each visit until flap closure is achieved.

Take-home hints
To achieve success and minimize complications using GBR procedures with RMB, the following surgical recommendations should be followed: A. Avoid compromising the blood supply 1. The number of vertical incisions should be limited, and the base of the flaps should be wider than the coronal portion. 2. Three-dimensional arrangement of the sutures should be interspersed with horizontal mattress sutures along the incision site to avoid compromising the blood supply. 3. The defect area should be debrided of granulation tissue. Cortical perforations should be made to create a bleeding bed at the augmentation site, and to promote blood supply and egress of progenitor cells from the bone marrow. 4. Graft material (e.g., mineralized allograft bone and/ or anorganic bovine bone matrix) should be placed and condensed in the defect. Avoid overfill because this will prevent tension-free flap closure. 5. A collagen membrane should be fitted, trimmed and

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positioned 2-3 mm beyond the augmentation area. B. Stabilization 1. If the membrane is stable, then no attempt to affix a tack is necessary. However, if the membrane is not stable, immobility must be achieved by use of resorbable sutures and/or tacks.25 2. Secondary bleeding is minimized upon stabilization of the graft site by achieving good hemostasis with the use of wet gauze and pressure combined with tension-free primary closure. C. Tension-free primary closure 1. Along with standard GBR procedures, a new flap design and suturing technique for tension-free primary closure has been described. To aid primary flap closure, a fullthickness incision is made followed by horizontal partialthickness releasing incisions with periosteal incisions apically to the base of the flap. The partial-thickness incision is made apical to the site requiring augmentation. 2. A buccal horizontal mattress suture is placed apical to the releasing incision into the periosteum and then passed over the graft site and ligated to palatal tissue. This creates stabilizing sutures that hold the graft and membrane in place. A second horizontal mattress suture is placed coronal to the partial-thickness flap and also sutured over the ridge, allowing for advancement and approximation of the facial and lingual flaps. Tension-free primary closure is thus achieved, pressure on the grafted site avoided and secondary bleeding minimized. D. Undisturbed healing A provisional prosthesis is used when necessary to provide esthetics and function for the patient but also to protect the augmented site during healing. At all times, transmucosal pressure on the surgical site must be avoided. Fixed provisionalization is preferred using a resin-bonded or conventional resin bridge. A removable alternative is a vacuum-formed appliance.

Summary
The etiology of GBR complications using RMB may be multifactorial. Therefore, meticulous surgical and restorative procedures are necessary to reduce the prevalence of complications. Understanding and utilization of proper incision design and flap advancement, releasing incisions, bone decortication, stabilization of the graft and membrane, tension-free primary closure of the flap, and postoperative patient compliance are crucial factors in obtaining predictable outcomes with the GBR technique as described. If complications occur, the clinician should identify and treat them as soon as possible and evaluate the results weekly for 2-3 months following treatment.

References
1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387416. 2. Esposito M, Grusovin MG, Coulthard P, Thomsen P, Worthing ton HV. A 5year followup comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Impl 2005;20:557568. 3. Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C, et al. Survival of the Branemark implant in partially edentu lous jaws: a 10year prospective multicenter study. Int J Oral Maxillofac Impl 1999;14:639645. 4. Romeo E, Lops D, Margutti E, Ghisolfi M, Chiapasco M, Vogel G. Longterm survival and success of oral implants in the treatment of full and partial arches: a 7year prospective study with the ITI dental implant system. Int J Oral Maxillofac Impl 2004;19:247259. 5. Weng D, Jacobson Z, Tarnow D, Hurzeler MB, Faehn O, Sanavi F, et al. A prospective multicenter clinical trial of 3i machinedsurface implants: results after 6 years of followup. Int J Oral Maxillofac Impl 2003;18:417423. 6. Wohrle PS. Singletooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. PPAD 1998;10:11071114; quiz 1116. 7. Levin L, Nitzan D, SchwartzArad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007;78:1821.

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Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

8. Nissan J, Marilena V, Gross O, Mardinger O, Chaushu G. His tomorphometric analysis following augmentation of the anterior atrophic maxilla with cancellous bone block allograft. Int J Oral Maxillofac Impl 2012;27:8489. 9. Chiapasco M, Consolo U, Bianchi A, Ronchi P. Alveolar dis traction osteogenesis for the correction of vertically deficient edentulous ridges: a multicenter prospective study on humans. Int J Oral Maxillofac Impl 2004;19:399407. 10. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1988;81:672676. 11. Simion M, Fontana F, Rasperini G, Maiorana C. Longterm evaluation of osseointegrated implants placed in sites augment ed with sinus floor elevation associated with vertical ridge aug mentation: a retrospective study of 38 consecutive implants with 1 to 7year followup. Int J Perio Restor Dent 2004;24:208221. 12. Nyman S. Bone regeneration using the principle of guided tissue regeneration. J Periodontol 1991;18:494498. 13. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of randomized con trolled clinical trials. Int J Oral Maxillofac Impl 2006;21:696710. 14. Fontana F, Maschera E, Rocchietta I, Simion M. Clinical classification of complications in guided bone regeneration procedures by means of a nonresorbable membrane. Int J Perio Restor Dent 2011;31:265273. 15. Greenstein G, Greenstein B, Cavallaro J, Tarnow D. The role of bone decortication in enhancing the results of guided bone regeneration: a literature review. J Periodontol 2009;80:175189. 16. Vasanthan A, Satheesh K, Hoopes W, Lucaci P, Williams K, Rapley J. Comparing suture strengths for clinical applications: a novel in vitro study. J Periodontol 2009;80:618624. 17. Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int J Perio Restor Dent 1993;13:2945. 18. Buser D, Dula K, Belser UC, Hirt HP, Berthold H. Local ized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int J Perio Restor Dent 1995;15:1029. 19. Li J, Wang HL. Common implantrelated advanced bone grafting complications: classification, etiology, and manage ment. Implant Dent 2008;17:389401. 20. Cartsos VM, Zhu S, Zavras AI. Bisphosphonate use and the

risk of adverse jaw outcomes: a medical claims study of 714,217 people. J Am Dent Assoc 2008;139:2330. 21. Haber J, Kent RL. Cigarette smoking in a periodontal prac tice. J Periodontol 1992;63:100106. 22. Lambert PM, Morris HF, Ochi S. The influence of smoking on 3year clinical success of osseointegrated dental implants. Ann Periodontol 2000;5:7989. 23. Saldanha JB, Pimentel SP, Casati MZ, Sallum EA, Barbieri D, Moreno HJ, et al. Guided bone regeneration may be negatively influenced by nicotine administration: a histologic study in dogs. J Periodontol 2004;75:565571. 24. Koo S, Konig B Jr., Mizusaki CI, Allegrini S Jr., Yoshimoto M, Carbonari MJ. Effects of alcohol consumption on osseointegra tion of titanium implants in rabbits. Implant Dent 2004;13: 232237. 25. Wang HL, Boyapati L. PASS principles for predictable bone regeneration. Implant Dent 2006;15:817. 26. Zitzmann NU, Naef R, Scharer P. Resorbable versus nonre sorbable membranes in combination with BioOss for guided bone regeneration. Int J Oral Maxillofac Impl 1997;12: 844852. 27. Rocchietta I, Fontana F, Simion M. Clinical outcomes of ver tical bone augmentation to enable dental implant placement: a systematic review. J Clin Periodontol 2008;35:203215. 28. von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implant Res 2006;17:359366.

Webliography
AAPCommissioned Review. Bone Augmentation Techniques (2007). Available at: http://www.perio.org/resourcesproducts/ pdf/lrboneaugmentation.pdf Chiapasco M, Zaniboni M. Clinical outcomes of GBR proce dures to correct periimplant dehiscences and fenestrations: a systematic review. Clin Oral Implants Res. 2009 Sep;20 Suppl 4:11323. Abstract available at: http://www.ncbi.nlm.nih.gov/ pubmed/19663958 Clementini M, Morlupi A, Canullo L, Agrestini C, Barlattani A. Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: a systematic review. Int J Oral Maxillofac Surg. 2012 Jul;41(7):84752. Epub 2012 Apr 26. Abstract available at: http://www.ncbi.nlm.nih.gov/ pubmed/22542079

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DENTAL LEARNING

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CEQuiz
1. __________ deficiencies constitute a major challenge for implant placement. a. Horizontal alveolar bone b. Vertical alveolar bone c. Transapical alveolar bone d. a and b 2. __________ is one of the options for the experienced surgeon to rebuild lost bone. a. An autogenous onlay block graft b. Distraction osteogenesis c. Guided bone regeneration d. all of the above 3. During guided bone regeneration, __________ is placed between the connective tissue and the bone defect to prevent the migration of the epithelial and connective tissue cells into the defect. a. an inclusive physical barrier b. an occlusive physical barrier c. a reclusive physical layer d. an occlusive mental layer 4. allowing the slower-migrating osteogenic cells to proliferate and form new bone enables selective repopulation of the wound with __________ prior to the migration of connective tissue and epithelial cells. a. fibroblasts b. remodelling osteoclasts c. osteoblasts d. none of the above 5. _________ is one of the goals of incisions during flap design. a. Access to the bone defect b. Preserving the interdental/implant papillae c. Providing sufficient advancement of the flap d. all of the above 6. If the bone defect extends to 2 or more teeth, the incision is made extending _________ to the defect. a. one tooth mesial and distal b. two teeth mesial and distal c. one tooth mesial and two teeth distal d. two teeth mesial and one tooth distal 7. In an edentulous area, the incision design is a _________ shape. a. parallel b. trapezoidal c. rectangular d. b or c 13. Graft material is placed and condensed to _________. a. fill the bone defect b. ensure proper space maintenance and bone contact c. support the membrane d. all of the above 8. Following placement, GBR procedures are performed when the facial bone shows a _________ morphology requiring _________ augmentation. a. concave; vertical b. convex; vertical c. concave; horizontal d. concave; horizontal 9. During recipient site preparation, the bony defect is debrided of granulation tissue and tissue tags using _________. a. hoes b. curettes c. back action chisels d. b and c 10. Periosteal releasing incisions _________. a. are made on the inner apical portion of the flap b. allow for better flap release c. allow for advancement for flap closure d. all of the above 11. Periosteal incisions allow easy access to the apical periosteum, which will be used as anchorage for the _________. a. periosteal sutures b. membrane-stabilizing sutures c. periosteal staples d. all of the above 12. after the resorbable collagen membrane is placed and manipulated, it is adjusted to extend _________ beyond the augmented area. a. 1-2 mm b. 2-3 mm c. 3-4 mm d. any of the above 14. Proper containment and stabilization of the graft material is critical to prevent _________. a. secondary bleeding b. rebound pain c. swelling d. all of the above 15. Final tissue adaptation during GBR procedures is achieved by means of multiple _________ 4-0 chromic gut sutures. a. mattress b. interrupted c. cross-horizontal d. none of the above 16. The healing phase of hard tissue augmentation procedures requires that no transmucosal pressure be placed on _________. a. grafted tissues b. regenerated ridge tissues c. the implants themselves d. all of the above

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Using Absorbable Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures

CE QUIZ
17. Two to four months of healing is necessary _________. a. for healing of the graft b. to establish osseointegration of the implant c. to ensure no shrinkage of the graft d. a and b 18. Following surgical GBR procedures, the patient should return biweekly for 2 months for visits that should include _________. a. examination of the surgical site b. debridement of the surgical site c. examination of the provisional restoration d. all of the above 19. Potential complications associated with GBR procedures may be _________. a. patient-related b. material-related c. technique-related d. all of the above 20. a higher rate of complications is seen with patients who _________. a. are taking immunosuppressive medications b. have undergone radiation therapy c. are receiving, or have a history of, treatment with intravenous bisphosphonates d. all of the above 21. alcohol intake has been reported to affect the outcome of GBR treatment _________. a. by inhibiting osteoblast proliferation b. by increasing osteoclastic activity c. resulting in an accelerated bone resorption rate d. all of the above 29. The surgical area should be irrigated several times with saline solution followed by a diluted (1:1 with water) hydrogen peroxide solution to remove food debris and plaque as part of the treatment for _________. a. membrane exposure without flap necrosis b. dehiscence or infection c. graft particle leakage d. all of the above 22. Tobacco smokers should be offered _________. a. a cigar instead of cigarettes b. a smoking cessation program c. accelerated treatment d. a or b 23. Material-related complications can be minimized if the graft and membrane are _________. a. biocompatible b. immunologically inert c. physiologically stable d. all of the above 24. In a systematic review, Rochietta et al reported that the complication rate when using non-resorbable membranes for vertical augmentation varied from 0% to _________. a. 25.5% b. 35.5% c. 45.5% d. none of the above 25. a Class II membrane exposure is defined as one that _________. a. is accompanied by purulent exudate b. is 3 mm but is accompanied by purulent exudate c. is >3 mm without purulent exudate d. is >3 mm and associated with an abscess 26. _________ is one of the more frequent technique-related complications. a. Graft particle leakage b. Paresthesia c. Asymmetrical esthetics d. all of the above 27. Complications often occur in the absence of _________. a. a tension-free flap closure b. primary closure at the time of surgery c. a proper surgical technique d. all of the above 28. In cases with simultaneous GBR and implant placement, submerging the implant and selection of an appropriate fixture surface are _________. a. preferable b. necessary c. undesirable d. none of the above 30. To achieve success and minimize complications using guided bone regeneration procedures with resorbable membranes, it is important to _________. a. avoid compromising the blood supply b. achieve tension-free primary closure c. ensure stabilization and undisturbed healing d. all of the above

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Membranes to Minimize and Treat Complications

A Surgical Protocol for Guided Bone Regeneration Procedures Using Absorbable

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resent and describe the step-by-step technique for using guided bone regeneration with absorbable P membrane barriers to augment deficient bone for implant placement Review the materials used with this procedure and describe the factors essential for success List Discuss the most frequent complications that may occur with this technique and describe their treatment.

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