Advice on flap exposure with Titanium mesh?

It depends on how long it has been since the exposure. It is has been more than 3 weeks before the exposure, just leave it alone and let them keep it clean with a q-tip. Advancing a flap won't likely work. So if it's let than 3 weeks remove hardware graft . let it heal and reattempt. This is basically straight from Michael Pikos recommendations

Hard to advise without a photo but best to keep it clean until mesh can be removed. I would use peridex.

Titanium mesh happens to be one of my favorite techniques for bone grafting. It works well, and is not expensive. When you attend lectures, you see the emphasis is always on releasing incisions, and attempting tension free primary closure......God bless the lecturers.......but they never show you what happens from the time they install them until they are ready to be removed. I use this technique a lot, because we are installing a form which will be a growing chamber, much the same way a plywood form is used to contain liquid concrete when building sidewalks..... It is extremely rare to have the titanium mesh totally covered by soft tissue during the entire 4-6 months it is needed to be in the mouth...... a part of it will usually peek out, and it can be sharp and irritating to the tongue or cheek. I prefer to use a more rigid form of titanium mesh available from Ace Surgical, because it can be folded, keeps its shape, is dead soft, and can be used without fixation screws or tacks..... especially helpful when there is not sufficient bone to screw or tack on to.......you are installing a saddle..... and I cover the porous titanium mesh with a PTFE membrane to block the holes, keep the particulate granules from creeping out....... and by the time exposure occurs, there is a developing osteoid with non keritanized gingiva under it to protect the developing graft. Patients are instructed to keep the area clean,rinse with Peridex, use a drop of Peridex on a Q-Tip to wipe the exposed membrane after the PTFE been removed or has fallen off, and to rinse and clean several times a day. A rough surface can be slightly folded in or cut away in the dental office, or if the dentist is not around, a piece of orthodontic wax or chewing gum can cover it until they can get in to the office for service...and it does happen., ( as do orthodontic wires slip off)........the irritation it causes is an advantage........ R.A.P. is created....... R.A.P. stands for Regional Acceleratory Phenomenon which invites phagocytes, non differentiated mesenchymal cells, etc to rapidly develop into fibroblasts and osteoblasts which can speed up the healing process 2-10 times..... so the irritating factor is good. When the mesh is installed as an over the ridge saddle, it is usually the lingual portion that tends to get exposed... and as the soft tissue pulls away from it....parts of the mesh on the lingual or occlusal can be cut off early, and an osteoid with hard and soft tissue will develop...and will become keritanized rapidly, while the buccal portion will stay covered for the entire 5-6 month period. At the end of the time allotted, a flap is opened, and you will need a strong haemostat to pull it off (even if there are no screws or tacks ), and you will see the pattern of the mesh on the underlying newly created surface....give it a little time to mature, and you will have a nicely developed ridge to place implants into. For further information check out some of my publications on this subject at Implant News & Views. Gerry Rudick Montreal, Canada

Thanks so much, Dr Rudick, for compact outline of the overall situation re: titanium meshes! This helps us put things in better perspective.

GARY.....I hope I caught you on time!!!!!!! Leave the exposed titanium mesh as it is!! Just try to keep the patient comfortable by folding the exposed sharp edge, or cutting a piece of it off..... the irritation is causing R.A.P..... the site is healing more rapidly.... just give the patient a bottle of Peridex to rinse or wipe the mesh with a Q-tip..... it should work out just fine. Please let us know what happened with your case. Gerry Rudick Montreal

As always, excellent comments by Dr. Rudick. In case you are interested, for future reference, if you like using Ti-Mesh, we have an ultra-thin, and smooth, titanium mesh that reduces irritation, you can learn more about it here

Dear Gary....I am glad I caught you on time.... Just leave the mesh and the implants as they are....... if there is some irritation from the mesh, make it more comfortable by cutting a small piece of the irritant off, or gently folding down a rough edge...... the patient must be diligent in the home care, and Peridex is a good additive. We are all anxious to know how it turned out......please post photos and xrays of your very successful graft and implant when they are ready to be uncovered. Gerry Rudick Montreal

Before I started the post, pt was already booked in for 2 hours so I didn't see any point of cancelling him. Anyway to cut things short when the patient returned, the abutment holding onto the mesh was really loose and my gut feeling was that the implant was failing. Dammit!!! I lifted a flap and removed the mesh only to find early vascular bone forming all around the implant and no threads exposed. Implant was solid and the bone graft was absolutely solid as well. Just resutured the site with collagen membrane and that's it. Gerry was absolutely right so it's good to know what to expect in future.

Dr. Ruddick, I am so glad I read this post. I am going to print it out and keep it for future reference. The advice you gave is price less!!!!

Peridex will delay healing as noted in the literature, it kills fibroblast. The best day of my life is when it stopped using it. I understand a lot of speakers say use it--why?? Yes, it does kill bacteria, but fibroblast as well.