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DENTAL LEARNING

Guided Bone Regeneration Procedures

A Surgical Protocol for

Using Absorbable Membranes to Minimize and Treat Complications

PART 1 IN A SERIES

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

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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 complica-tions. 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; and4. Discuss the most frequent complications that may occur

with this technique and describe their treatment.

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 2/1/2016 - 1/31/2020. Provider ID: # 346890. Dental Learning, LLC is also a California Provider. The California Provider number is RP5062. This course meets the Dental Board of California’s requirements for 2 units of c ontinuing 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. ORIGINAL RELEASE DATE: August 2012. REVIEW DATE: July 2015. EXPIRATION DATE: June 2018. 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 informa-tion 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, Casey Warner, does not have a leadership or commercial interest with any products or services discussed in this educational activity. She can be reached at [email protected]. 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 [email protected]. Go Green, Go Online to www.dentallearning.net take your course. © 2015

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 biologi-cally 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.

ABSTRACT ABOUT THE AUTHORSStuart J. Froum DDS Dr. Stuart J. Froum is an international lecturer 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 Periodontol-ogy 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 peer-reviewed journals, was the editor for the recently-pub lished book titled ‘Dental Implant Complications Etiology, Preven-tion and Treat ment’, co-author of ‘Comprehensive Periodontics for the Dental Hygienist’ (2001), and a contributing author for the 11th edition of Carranza’s Clinical Periodontology as well as a co-author 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.

Sang-Choon Cho DDS, MSDr. Sang-Choon Chois a full-time Clinical Assistant Professor and Director of Advanced Program for International Dentists in Implant Dentistry in the Department of Periodontology and Implant Dentistry, 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 re-search at NYUCD, Dr. Cho serves as a liaison to the NYUCD South Korean Alumni Study Club.

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

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Art DirectorMICHAEL MOLFETTO

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Introduction

Dental 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, includ-ing 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 horizon-tal 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 connec-tive 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 slower-migrating osteogenic cells to proliferate and form new bone, thereby selectively repopulating the wound with osteoblasts prior to the migration of connective tissue and epithe-lial cells.12 Scientific evidence in animals and humans has demonstrated that GBR is an effective technique to regener-ate 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-

A Surgical Protocol for

Guided Bone Regeneration Procedures Using Absorbable Membranes to Minimize and Treat Complications

Figure 1. Preoperative view of site #10: Treatment plan requires implant place-ment 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 simultane-ously with, implant placement.

TechniqueThe following describes the step-by-step GBR technique

utilizing resorbable membranes (RMB) for successful bone augmentation, together with recommendations for avoid-ing complications (Figs. 1-3, see page 3).

Flap design The incisions are designed in accordance with the fol-

lowing five goals: A. Access to the bone defectB. Maintenance of the blood supply of the elevated

flap and the neighboring tissuesC. Preserving the interdental/implant papillaeD. Providing sufficient advancement of the flapE. 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 inci-sion 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 mate-rial. In an edentulous area the incision design is a rectangu-lar 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 maintain-ing 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 con-tinuing 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. Fol-lowing implant placement, GBR procedures are performed when the facial bone shows a concave morphology requir-ing horizontal augmentation (Figs. 6-7).

Recipient site preparationThe 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 pro-genitor cell migration from the bone marrow to the site of augmentation.15 Following wound hemostasis, these decorti-cations will help promote graft contact and stability.

Releasing incisionsPeriosteal releasing incisions are made with a sharp 15C

Figure 4. Incision design: Mesial and distal vertical incision connect-ed to midcrestal incision, preserv-ing the mesial and distal papillae

Figure 5. Flap is elevat-ed, allowing for access to the buccal bone

A Surgical Protocol for Guided Bone Regeneration Procedures Using Absorbable Membranes to Minimize and Treat Complications

5July 2015

blade on the inner apical portion of the flap, between the vertical incisions, creating a 2-3 mm split-thickness dissec-tion (Fig. 9). These releasing incisions allow for better flap release and subsequent advancement for flap closure. More-over, 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 stabiliz-ing 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 mem-brane 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 mem-brane (Fig. 14).

Figure 6. Implant placement (Straum-man Bone Level 3.3 mm x 12 mm SLA active)

Figure 7. Occlusal view after implant placement; note that there is no fen-estration 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 dis-section

Figure 11. The exposed periosteum is used as anchorage for the membrane-stabilizing sutures

A

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

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Stabilization of graft material and barrier membraneStabilization 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 pala-tally (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 mate-rial 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 coronallyTo 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 dimen-sion and tried on the defect. A resorb-able 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


7July 2015

Suturing to ensure primary closureFinal tissue adaptation is achieved by means of multiple

interrupted 4-0 chromic gut sutures, regularly spaced to close the incisions (Figs. 19, 20).

ProvisionalizationA 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 them-selves. 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.

HealingTwo to 4 months of healing is necessary to establish os-

seointegration of the implant and 4-6 months is needed for healing of the graft (Figs. 22-29, see page 8).

MaintenanceThe patient should return biweekly for 2 months fol-

lowing the surgical procedures. These visits should include examination of the surgical site and provisional restoration and debridement of the surgical site.

Identifying potential complicationsGuided bone regeneration is a technique-sensitive pro-

cedure, and complications may arise.17,18 The etiology of complications is usually multifactorial and may be patient, material, or technique related.19

Patient-related complicationsPatient-related complications are divided into two

major categories. The first includes the presence of systemic diseases including diabetes, autoimmune diseases or osteoporosis. Patients taking immunosup-pressive 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 bisphospho-nates, 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 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 post-operatively

Figure 27. Buccal view of final restora-tion 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)

Figure 21. Provisional restoration re-lieved to avoid transmucosal loading

Figure 22. Buccal view of the site heal-ing, 4 weeks after surgery

Figure 23. Radiograph before and after implant placement and bone augmen-tation


9July 2015

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 complicationsMaterial-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 osteocon-ductivity and should be absorbed as new bone formation occurs.19 In studies comparing resorbable and non-resorb-able 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 al14 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 mem-brane 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 ap-pear to be more favorable when compared with those with non-resorbable membranes, which often require early removal to ensure the resolution of the compli-cation 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 complicationsThe 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 complica-tions 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 ten-sion-free flap closure, absence of primary closure, incorrect incision design or technique, improper tissue apposition, improper graft containment with improper space mainte-nance, or premature reentry for implant placement.17,19,25

Prevention of complicationsIn 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, ensur-ing 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 ap-propriate 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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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 augmenta-tion, which resolved within 2 to 4 weeks with spontaneous re-epithelialization. These complications did not compro-mise outcomes. To date, there is no scientific data avail-able 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 necrosisa. 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 im-pregnated 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 antibi-otics should be placed on clindamycin (150 mg, 4 times a day for 7 days).d. If the infection is not resolved or the membrane be-comes 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.

Dehiscencea. The area should be irrigated several times with a saline solution followed by irrigation with a diluted (1:1 with

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

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

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

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


11July 2015

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 inter-nal epithelium from the flap to optimize the closure and to prevent trapping of epithelium under the flap. If tension-free primary closure cannot be achieved, releasing incisions should be made before suturing. Suturing should be per-formed with 5-0 chromic gut sutures using a P-3 needle.

Infection1. 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 mo-bility 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 treat-ment, 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, mobil-ity 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 metro-nidazole (500 mg, 3 times a day).

d. If the infection does not resolve with the above treat-ment, surgery should be performed following the same instructions described above for “Early infection.”

Graft particle leakagea. 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 hintsTo achieve success and minimize complications using

GBR procedures with RMB, the following surgical recom-mendations should be followed:

A. Avoid compromising the blood supply1. 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 su-tures 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. Stabilization1. 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 closure1. 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 full-thickness incision is made followed by horizontal partial-thickness releasing incisions with periosteal incisions api-cally 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 cre-ates 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 healingA 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.

SummaryThe etiology of GBR complications using RMB may

be multifactorial. Therefore, meticulous surgical and restorative procedures are necessary to reduce the preva-lence 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.

References1. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.

2. Esposito M, Grusovin MG, Coulthard P, Thomsen P, Worthing-ton HV. A 5-year follow-up comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxil-lofac Impl 2005;20:557-568.

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 10-year prospective multicenter study. Int J Oral Maxillofac Impl 1999;14:639-645.

4. Romeo E, Lops D, Margutti E, Ghisolfi M, Chiapasco M, Vogel G. Long-term survival and success of oral implants in the treatment of full and partial arches: a 7-year prospective study with the ITI dental implant system. Int J Oral Maxillofac Impl 2004;19:247-259.

5. Weng D, Jacobson Z, Tarnow D, Hurzeler MB, Faehn O, Sanavi F, et al. A prospective multicenter clinical trial of 3i machined-surface implants: results after 6 years of follow-up. Int J Oral Maxillofac Impl 2003;18:417-423.

6. Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. PPAD 1998;10:1107-1114; quiz 1116.

7. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007;78:18-21.


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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;27:84-89.

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;19:399-407.

10. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1988;81:672-676.

11. Simion M, Fontana F, Rasperini G, Maiorana C. Long-term 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 7-year follow-up. Int J Perio Restor Dent 2004;24:208-221.

12. Nyman S. Bone regeneration using the principle of guided tissue regeneration. J Periodontol 1991;18:494-498.

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;21:696-710.

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;31:265-273.

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;80:175-189.

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;80:618-624.

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;13:29-45.

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;15:10-29.

19. Li J, Wang HL. Common implant-related advanced bone grafting complications: classification, etiology, and manage-ment. Implant Dent 2008;17:389-401.

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;139:23-30.

21. Haber J, Kent RL. Cigarette smoking in a periodontal prac-tice. J Periodontol 1992;63:100-106.

22. Lambert PM, Morris HF, Ochi S. The influence of smoking on 3-year clinical success of osseointegrated dental implants. Ann Periodontol 2000;5:79-89.

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;75:565-571.

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: 232-237.

25. Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8-17.

26. Zitzmann NU, Naef R, Scharer P. Resorbable versus nonre-sorbable membranes in combination with Bio-Oss for guided bone regeneration. Int J Oral Maxillofac Impl 1997;12: 844-852.

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;35:203-215.

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;17:359-366.

Webliography AAP-Commissioned Review. Bone Augmentation Techniques (2007). Available at: http://www.perio.org/resources-products/pdf/lr-bone-augmentation.pdf

Chiapasco M, Zaniboni M. Clinical outcomes of GBR proce-dures to correct peri-implant dehiscences and fenestrations: a systematic review. Clin Oral Implants Res. 2009 Sep;20 Suppl 4:113-23. 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):847-52. Epub 2012 Apr 26. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/22542079

DENTAL LEARNING

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1. __________ deficiencies constitute a major challenge for implant placement.a. Horizontal alveolar bone b. Vertical alveolar bonec. Transapical alveolar boned. 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 regenerationd. 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 barrierb. an occlusive physical barrierc. a reclusive physical layerd. an occlusive mental layer

4. Allowing the slower-migrating osteogenic cells to prolifer-ate and form new bone enables selective repopulation of the wound with __________ prior to the migration of connective tissue and epithelial cells.a. fibroblastsb. remodelling osteoclasts c. osteoblastsd. none of the above

5. _________ is one of the goals of incisions during flap design.a. Access to the bone defectb. Preserving the interdental/implant papillaec. Providing sufficient advancement of the flapd. 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 distalb. 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. parallelb. trapezoidalc. rectangulard. 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; verticalb. convex; verticalc. concave; horizontal d. concave; horizontal

9. During recipient site preparation, the bony defect is debrided of granulation tissue and tissue tags using _________.a. hoesb. curettesc. back action chisels d. b and c

10. Periosteal releasing incisions _________.a. are made on the inner apical portion of the flapb. allow for better flap releasec. allow for advancement for flap closured. all of the above

11. Periosteal incisions allow easy access to the apical periosteum, which will be used as anchorage for the _________.a. periosteal suturesb. membrane-stabilizing suturesc. periosteal staplesd. all of the above

12. After the resorbable collagen membrane is placed and manipu-lated, it is adjusted to extend _________ beyond the augmented area.a. 1-2 mmb. 2-3 mm c. 3-4 mmd. any of the above

14. Proper containment and stabilization of the graft material is critical to prevent _________.a. secondary bleeding b. rebound painc. 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. mattressb. interruptedc. cross-horizontald. none of the above

16. The healing phase of hard tissue augmentation procedures re-quires that no transmucosal pressure be placed on _________.a. grafted tissuesb. regenerated ridge tissuesc. the implants themselvesd. all of the above

CEQuizTo complete this quiz online and immediately download your CE verifica-tion document, visit www.dentallearning.net/GBR-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification docu-ment. We accept Visa, MasterCard, Discover, and American Express.


15July 2015

17. Two to four months of healing is necessary _________.a. for healing of the graftb. to establish osseointegration of the implantc. 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 restorationd. all of the above

19. Potential complications associated with GBR procedures may be _________.a. patient-relatedb. material-relatedc. 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 therapyc. 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 rated. 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 infectionc. graft particle leakaged. all of the above

22. Tobacco smokers should be offered _________.a. a cigar instead of cigarettesb. a smoking cessation programc. accelerated treatmentd. a or b

23. Material-related complications can be minimized if the graft and membrane are _________.a. biocompatibleb. immunologically inertc. physiologically stabled. 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 exudateb. is ≤3 mm but is accompanied by purulent exudatec. is >3 mm without purulent exudated. is >3 mm and associated with an abscess

26. _________ is one of the more frequent technique-related complications.a. Graft particle leakageb. Paresthesiac. Asymmetrical esthetics d. all of the above

27. Complications often occur in the absence of _________.a. a tension-free flap closureb. primary closure at the time of surgeryc. a proper surgical techniqued. 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. preferableb. necessaryc. 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 supplyb. achieve tension-free primary closurec. ensure stabilization and undisturbed healingd. all of the above

CE QUIZ

16

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EDUCATIONAL OBJECTIVES1. Present and describe the step-by-step technique for using guided bone regeneration with absorbable membrane barriers to augment deficient bone for implant placement;2. Review the materials used with this procedure;3. List and describe the factors essential for success; and4. Discuss the most frequent complications that may occur with this technique and describe their treatment.

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