Exposure of Membrane: Why?

This sounds like you aren't releasing the flap adequately. A tension free flap is something you will pick up over time, especially if you observe someone doing it. Releasing incisions are just part of achieving this...it usually requires proper scoring of the periosteum and muscle attachments as well. Again, try to watch someone do this since it can be done wrong with severe complication (hitting a vessel/nerve or causing large tear in flap). Might I suggest finding an implantologist to help mentor you during the early stages of implant placement. If you have exposure of your membrane then you are probably losing your graft and can potentially cause problems in the future. In my experience, placing the implant is not as difficult as proper tissue management and many times reflecting the flap shows a much different bone topography than what is clinically assessed. Just remember, you usually want the flap to extend past your incision line by at least 4mm if not more. Don't just meet the flap ends together and suture. This will open most of the time. Give proper meds to decrease swelling and ice it down right after. Ice is not evidence-based but I do it because it makes the patient put light pressure on it and I feel it helps. Hope this helps

You shouldn't attempt to provide advanced grafting and implant placement simultanously unless you are an experineced surgeon. If you are begining to place implants, you should extract and graft and place your implants a few months later. If your patients truly need ridge augmentation, you should refer to an expericened specialist. There is plenty to go around and no weekend or weekly class will provide you with equivilant of 3-5 year residency. Besides relaseing your flap as mentioned above, your suturing in very important too. I usually use long lasting sutures to approximate the flap edges for 3-4 weeks. Your choice of membrane is important too. Some membranes have a bounce to them that lifts the flap. Bioguide or Ace membranes have almost no memory and adapt well to the site. Please refer your more advenced cases to your perio or OS. You should only attempt slam dunk cases. Extract & graft, then placement in a few months

suture technique and enough release of your flap are very important. if the membrane is eposed then it is going to resorbe quickly and soft tissue will go inside your graft material and you will get soft tissue instead of bone

Which membrane are you using? If you are using polymeric membranes, their placement is technique sensitive (e.g. molding the membrane, sometimes it is too large, release the flap properly, etc.). You should use an easily moldable membrane like calcium sulfate (DentoGen) membrane. When setting solutions are added to calcium sulfate, it forms a nice putty that could be easily molded as a barrier. Since it is completely degradable, you do not even have to go back to remove it. They are cheaper too compared to polymeric membranes.

In addition to the above helpful comments I suggest you not to perform GBR the day of tooth extraction, unless you remove all internal epithelial part of the socket. The former sulcular epithelium prevents integration of the flap borders, and graft or membrane exposure will be inevitable. According to the review articles, the frequency of membrane exposure over extraction sockets is about 50%. In such cases I always wait at least 3 weeks after extraction to assure the epithelial integrity of the soft tissue. Again, tension-free flap is a must!

If you tighten your sutures too tightly, the resultant post-operative soft-tissue swelling can cause a local ischemia of the mucosa right next to the suture, thus resulting in the suture tearing loose and opening of the wound. Remember the old adage: Approximate, don't strangulate!

Hi I agree ...Release the flaps adequately depending upon the volume of graft to be placed .Common rule would be that the flaps should not be bouncing[retracting] back .....should be passive in the graft site. Ashish www.drashish.com

The best membrane to cover the grafted areas of the jawbones, no matter what kind of grafting material has been used, is patient's own Periosteum on premise. The surgeon would be able to achieve a thorough tension free pedicled rotational or lateral sliding flap using some releasing back-cuts in the periosteal fibrous layer to cover the grafted area. In my experience, it has decreased the number of graft exposure cases drammatically.

Soft tissue management around implants is crucial in modern implantology.Those of you who would like to have the ability to practice on patients are invited to join the hands on live patient courses done at the university of Belgrade.

Hi I have recently started placing implants have done a few graft with Bio glide and these have gone well so far. Have been reviewing them every 6 weeks. I would recommend watching Dr Tidu Mankoo lectures on the online dental education web site. There are three lectures I have seen two of them and they have been extremely helpful. Good scientific background and excellent live video demo. Best of luck P.S. can people give more helpful tips.

I kinda of wonder, how many responses on this board are actually from Doctors or from company Reps pushing products or CE courses. I wholeheartedly agree with Dr. J comments. People need to refer. Patients are people not guinea pigs. Once again I have no problem with a General Dentist placing implants, as there is plenty to go around. But why do we feel so proud that we are going to eleminate the referral process entirely. Dr. H start with the simple implants that have plenty of bone and that dont need grafting. Refer the more advanced cases. Attend a implant program like NYU or Loma Linda or take the plunge and become a specialist if you want to do advanced cases. One cant dabble in surgery. When you dabble you will eventually hurt a patient. Example, if you doing a periosteal release in the mandible to free up a flap you could hit a vessel or a nerve. Dr. H ask yourself, if you can handle the complication, procede, if you cant maybe you need to rethink your "more seamless flow for care for my patients" approach. Just my opinion. Good Luck to you.

Mainoralsurgeryman....you are SO right! Why are some GP's so proud that they can eliminate collaboration with specialists? If this doctor would have a good working relationship with a periodontist or OMFS guy well versed in implants, then there would be no problem here....She would be able to just call her colleague for advice on this problem. As you said, there are plenty of cases to go around for everyone. It's good advice to know your limitations, and know what COULD happen if a complication occurred. If such a problem as you describe did occur, like a facial artery bleed, (and it certainly could), then this GP could lose her license, her practice, her kid's college fund, and all she has worked for. Patients deserve better than this. As one of my favorite mentors in my perio residency liked to say...."there's no substitute for competence"

I saw an online video for brain surgery. It was very informative. Now I can do it! If patients only knew what some of these guys here are doing...

I think we GPs all started off referring our implant cases to oral surgeons. Things were fine initially, then the problems rolled in. Implants in the wrong places. The prosthesis promised by the oral surgeon differs from the one we deliver. Costs surprise the patients as charges quoted to the patients differ from those given to us. Then, the oral surgeons start taking impressions, fitting crowns and our well-off patients are so impressed with the oral surgeon's posh practice that fail to come back! By referring your implant patients, you are effectively sending your best patients to another person's practice. There was an oral surgeon who referred a perio case to a periodontist. The latter did extractions and placed implants! So what about the oral surgeons? Are they keen on referring their best patients to charismatic periodontists who do implants? Fortunately for me, I have a couple of roaming oral surgeons whom I can engage when I come across a difficult case. Everything is done in my clinic, the patient pays through my clinic only and I pay the oral surgeon a consultant fee. I think other GPs can consider this option if there are roaming oral surgeons in their area. Oral surgeons who are not practising full time can also consider not setting up their own clinics and roam around like anaesthetists instead. This will make the process seemingly seamless. Having said that, the surgery Dr H engaged in is not complex at all. GPs should give all the formal courses a miss. They are mostly a waste of time and money. They only way to learn implant dentistry is to begin by assisting oral surgeons and then having them watch over you while you operate. Pay them to supervise you. This sort of training is better than any of those lecture-rich, hands-on courses. We learn by operating on live patients under supervision and not by attending courses. Nerve lateralistion is complex and risky. Bone grafting is not.

Thank you very much. As an oral and maxillofacial surgeon, I feel that I am being looked at as a bell boy rather than a respected consulting colleague. I guess that those ROAMING oral surgeons are feeling honored a lot.

Chan Joon Yee lets not put all the blame for what is occuring in dentistry on Oral surgeons and lets look at the problem closer. First off in my opinion if you refer a patient to an oral surgeon he should follow the treatment plan that the GP gives him. The problem is many gps dont have to restorative experience to know what you can and can't accomplish with implant dentistry. Plus implants arent just sticking a screw in bone. You have to take into account, local anatomy, width and hieght of bone, occlusion, restorative space and so on. The problem isnt just with the oral surgeons or periodontist. Many a time the GP dont have the basic knowledge needed to restore the implant and problems arise. Putting implants in the wrong place wouldnt happen if the GP gave the surgeon a surgical guide. Today if GP's do refer, they send the patient over with give me an implant in tooth #3 approach with no surgical guide and no throught into what is needed to get an implant in tooth number 3 site. And lets face it by keeping everything in your practice your increasing your bottom line and you justify it by saying what a poor job oral surgeons do, without considering what the GP's could have done to improve the situation. When you say "bone grafting isnt risky" you obviously dont realize the potential complications that can occur froma "simple" bone graft and more interested in the money you can get froma bone graft. Many a times the GP is too busy to call or review the case with the oral surgeon, they dont give a surgical guide( because they dont have a clue how to make on or dont care enough), they dont explain the cost to the patient and they dont have the first clue about what the patient may need in order to get the implant (grafting, sinus lift, block graft, etc.). In my practice I will not place an implant unless the GP and I are on the same page. All my GP's send me a surgical guide and we work to educate each other. I educate my GP's in surgical knowledge and they educate me on the restorative plan. We have a great relationship because we work togethor in the best interest of the patient. Any specialist that would steal a patient from thier referring dentist should lose the referral. I recieve lots of referral and when things are done correctly, I should not have to worry about stealing a crown to get by. I also receive referrals from periodontists. There are plenty of cases where a patient comes to me for grafting ( that may require a hip graft or a tibia graft) that is beyond the scope of the periodontist. When I am done with the graft and the follow-up and the patient is ready to recieve implants I send them back to the periodontist to place the implants. The key to a successful implant practice and referral process is communication. Communication not only with the patient but also all dentists, specialist involved in that patients care. So DR YEE lets not put all the blame on the oral surgeon without looking at the whole problem.

I really enjoyed all the debates. I, as a periodontist, believe that implant dentistry should be classified for GPs and specialists like all other fields in dentistry. For example in periodontics, a GP can do scaling well, but he/she should refer the patient with severe periodontal involvemet to a specialist. Today, with lots of patients who require implant therapy, no one can limit implant dentistry to specialists. General practitioners can and should participate in treatment planning, in prosthetic or even some surgical parts. IMPLANT THERAPY IS AN INTERDISCIPLINARY WORK. SUCCESS COMES FROM GOOD TEAMWORK. GPs should learn how can help a patient requires implant therapy. Fortunately, now implant dentistry is taught in Universities in Iran for undergraduate students. Experience in implant therapy is another most important critera that may be much more crucial in comparison with other fields in dentistry. About graft or membrane exposure, I would like to add that the need of soft tissue management (adequacy of keratinized tissue and vestibular depth) should be considered carefully before any bone augmentation procedure or even implant surgery. It is necessary for a good closure. Good luck

This is rare, but I agree with mainoralsurgeryman. I am a gp, however I place and restore implants and place implants for other gp's. Grafting does have it's risk and yes there can be questionable out comes. Smontimes the patient simply has poor genetics/biology/habbits/or just does not listen. Sometimes the bone topography,density and quality is bad. Sometimes the referring gp needs alot of hand holding. Oral implantology is not a hobby. You have to be serious and be a student again, REGARDLESS IF YOU ARE A GP, OMFS, PERIODONTIST OR PROSTHODONTIST. The patient deserves the best we can offer. Consider using other modalities such as blades, disk, ramus blades, subs, endo implants and mucosal inserts prior to grafting. Sometimes it's just too much for the patient and too complicated. Also, the referring gp should know what they want and convey this to the surgeon. You can also refer to an Oral Implantologist and let them do the whole thing, just like you would do with an ortho referral. So if you are going to get into the game get serious.

Bone grafts don't work all the time. The same goes with implants that don't require bone grafting, wisdom tooth surgery, single canal endos, crowns, dentures and even amalgam fillings. Something can go wrong and a responsible practitioner minimises the chances of failure and complications by being well equipped with the necessary skills and equipment. Sure, there are numerous biological considerations in implant placement, but it is not rocket science. It takes me considerably less time to place an implant than to do a posterior endo. It takes even less time and effort to place an implant in a favourable site than to remove an impacted wisdom tooth. Orthodontists often voice their envy over implant practitioners who finish high value cases much faster than they do. If a GP already has the anatomical knowledge and surgical skill to remove deep horizontal impactions, what are chances that he also posseses the aptitude to learn to place implants and do bone grafting successfully? If it is assumed that GPs don't know much more about anatomy than carpenters, then the assumption that they will never be fit to do implants will follow. Sure, GPs have not been formally trained to place implants in dental school, but they can learn and the best way to learn is to bring oral surgeons into their clnics and discuss their cases with them. This will minimise the chances of implants placed in the wrong places, altered treatment plans etc. It's convenient for the oral surgeon to blame the referring GP's ignorance when a case doesn't turn out right. The main problem is really with communication. Sometimes, the oral surgeon is the one not able to visualise the final prosthesis. The GP who has been doing crown and bridge work can sometimes have a better idea of where to put the implant than the oral surgeon. I have seen well-trained prosthodontists place implants without any surgical guides. The skill with which you place multiple implants parallel to one another is not very different from the skill required to cut a multiple abutment long-span bridge. From personal observation, some periodontists are as good if not better at bone grafting and soft tissue management than oral surgeons. Anaesthetists don't need offices. More and more oral surgeons in Asia are following that path. Roaming does not make the profession less glamorous. It is the best way to avoid conflicts, miscommunication and everyone gains - including the patients.

I am very confused now. I should refer if I think the patient can have better care elsewere. So if I take this into account and then I see me as a GP in the next setting: I am becoming an inbetween person just to refer my patient to the specialist for every case. I know there is a specialist better in endodontics, fillings, implants, diagnostics, etc, etc. So I will refer, refer and refer. Maybe you as a specialist can pay me a fee for every patient I refer to you, also the very simple cases. So for oral surgeons not only the difficult extraction but also the "simple" ones at which your fees are very low. I notice that this is most times not accepted because these simple cases don't bring you the money. But today I had a simple tooth extraction case with a child and this became a severe case because of an allergic reaction ( second time she had ever had anesthetics). I put in my epipen, put in some dexamethasone and tavegil for the secondary 48 hour reaction. So I think I should refer every case I do, because even the simples cases can become sometimes complex. In my country I only know to patients who died because of bleeding after placing implants in the under yaw. They were performed by oral surgeons with quite some experience??? So where do the experts refer to, because maybe there is a clinician who is beter then you are. So enough mud throwing arround. My problem seems to be in the choice of the membrane. I choose the inion membrane to cover up the augmantation. It has the porperties that it will resorb completely over time, but in contact with body fluids it becomes rigid and has a function as a space-maintainer. The problem with this membrane is that it fractures very easy after a few days in position when there is some external pressure on it and the fractured membrane pieces are sharp and cut through the gingiva. My lesson I that I can't believe the manufactures at all, but I know it is difficult to see what is right or wrong because you can find papers that support the product, which sometimes are publiced in very good papers. The same has happened with the research on cancer in which the well payed researcher doubled all his findings to get the right outcomes for his team and manufacturers. As a oral surgeon you know what I mean because this was a big issue for oral cancer treatment and outcomes. ( the man from scandinavia). i have switched to another brand of membrane and I don't have these problems nowadays. The oral surgeons in my regio will not help me because they want to do all the implants by themself. Even if I don't ask for it and sent in my patient for something else I find sometimes an implant as a second therapy. Where is the respect for the GP's. I prefer working togehter instead of against each other. You back each other up and try to give the best help to your patient as possible. Sometimes I do something wrong and need the back up from the oral surgeon because he/ she has more experience in this area and more means, but I do and did the same for the oral surgeon in other area's and in a lot of cases with children. To the mainoralsurgeryman: I build up my surgical experience by courses given by oral surgeons, but I think these were the wrong ones. Where and when can I follow a course and mentorship from you, because you are the best surgeon in the world! It seems to be that you never make a wrong choice or mistake and you never experience troubles after surgery. I like to know where I can refer all my patient to, because I can promis them a full 100% garantee lefel by treaatments performed by you. That would be wonderfull for me, because it helps to built m name as well as a good dentist. Why are you so against GP's who should be you bell boy. I follow more discussions on these pages and you are always against Gp's.......What did happen to you?

Due to advances in bio-materials I have not used a membrane in the last 4 years ( 2 grafts a week generally),to take advantage of the periosteal blood supply.With hundreds of sucessful cases ( recorded)the key is to assist the body to heal. With the next generation of these materials soon to be clinically available we can look to the future