Bio-Gide Membrane Exposed: Comments on Long Term Management?

One of the most frequent reasons of wound opening, subsequent to bone augmentation procedures, is the inadequate surgical management of the flaps. The tension free closure of the flaps was probably not fully achieved. This mistake is typical of beginners (as you define yourself). Moreover In these cases a matress suture combined with single stitches works better than a simple interrupted suture. As for re-suturing, usually it does not work. Assuming that no infection is present in the area, the management of the open wound (with resorbable membranes) highly depends on the extent of the boney defect, present at the time of surgery, and on the size of the opening of the wound: If a small augmentation was done and a small dehiscence is present, let it heal, extend the antibiotic therapy and wait for reepithelization. In this case you will loose some graft, which should not be an issue. Possible minor aesthetic drawbacks (loss of soft tissue volume) should be of little concern in this kind of patients (I guess). A large wound dehiscence in a large augmentation procedure may represent a severe occurrence, since the healing (that eventually occurs) could lead to a significant exposure of the implants. In this cases the removal of the implants and of the graft is indicated before the osseointegration occurs. For some reasons I guess (and hope) that your case belongs to the first hypothesis I mentioned. Good luck.

Paolo Rossetti - Milano ,very good comment.

Paolo Rossetti – Milano has summed it up so well. dont need a comment after that i believe

I agree with the above comments. I might be wrong butyour implants are placed at an angle typical of a right handed dentist. When I started placing implants 20 years ago I found that taking an x-ray with guide pins at the first drill allowed me to correct angulations. This is not a criticism but rather an observation. It may make your life a bit easier in the esthetic prosthetic challenges that you will no doubt be exposed to in the future.

Very precise and accurate, nothing else to say thanks Dr. Rossetti

Additionally, consider some of these 1 reduce denture wear ,remove buccal flange and ease fitting surface of crest,or soft reline ,avoid denture wear 2 continue with corsodyl M/W & gel 3 Ozone application 4 Soft diet,avoid chewing on implant quadrant 5 Add healing collars to crest level to reduce amount of concentric re-epethelialisation needed 6 Cover area with periodontal dressing[coe-pak] 7 Consider in other cases immediate bridge work 8 Submucosal grafting 9 Tissue glue[tissucol] 10 Change flap design to incision more palatally Good luck, Dan

All of the above with just one addition. With all respect, this is probably not a good case for a "relative novice".

Re-suturing is only possible if the dehiscence is small and the patient is seen within 24 hours. It won't work after 7 days. The soft tissue and Bio-Gide are contaminated. There is a saying about Bio-Gide, 'Once exposed, you're toast'. Implant at site 13 had perforated the sinus floor. I would get help from an experienced colleague; for the fact that the patient is a diabetic and would not let you re-suture the wound (doctor-patient relationship).

A few questions. Were there multiple threads exposed on the implants? Is this a quick or slow turning over alloplast? What was the graft? As studies on GBR have shown, once a membrane is exposed (probably happened before you noticed it), there is a range of healing probabilities ranging from minimal loss of graft to loss of native bone and possibly implants as well. BioGide maintains zero integrity when exposed, it probably was all gone before you looked into the site. Why 3g amox preop? Why switch to metronidazole? Early studies on CHX documented slower initial wound healing from decreased fibroblast migration. This may have been a case where Dr. Tarnow would state that there are only so many miracles that a body can heal at one time. If there is a removable prosthesis over the site, there's probably no way to relieve it to keep pressure off the grafted site. I don't mean to be the voice of doom and gloom. We all get bitten on occasion. The keys are to diagnose ideally first, have sufficient training and expertise to handle cases like this, and, in patients with questionable healing, move more slowly. Good luck.

Did you all not read Ben's comment? We were not supposed to comment after the one prior to his. Mum! Bv

dan again, ozone helps and initiates healing ,it is a powerful oxidising agent ,can be applied to the graft and soft tissue pre,during &post op see ref:- Bocci,Lynch E,Mckenna d, the comment about corsodyl & delayed healing is a good point ,so i tell patients to avoid it until a day after surgery ,can take it pre op also tell patient not to blow out their cheeks when using M/W,can tear the sutures,a sponge stick dipped in M/W can be dabbed on the surgical site Beware of smokers ,this is a cause for suture lines to open and grafts to fail Avoid the use of straws with drinks Diabetics can be a problem if not in balance,the gum health is a good pre -op indicator as well as sugar levels dan

Suggestions for the future. Perform periosteal releasing incisions and suture with mattress sutures and interrupted sutures. You may want to use Alloderm as a membrane!

March 23 and 24th, San Diego Ca, Perio Institute, "Ridge Preservation and Suture Techniques" (Day 1) "The Next STep in Bone Grafting and REpairing the Aiing Implant" (Day 2). 800-327-3746. Sounds like it is a course you would benefit from.

Give the guy asking the question a break, some of the advice has been very supportive, however all you other mothers have been really condescending and somewhat patronising to certain extend. I am sure you all were not born highly skilled and experts.

Thank you all for all your comments, some very encouraging, but some indeed very patronizing. Anyway, asked the patient to continue with Chlx oral bathing of the surgical site, and at 3 weeks review, the site had healed really well. I have taken photos, however there is no way of posting them. Anyway thank you to everyone.

You can post the additional case photos by using the "Post a Case" at the top left of the website or on the menu. Just be sure to reference this case post and use the same information you used when you posted the case the first time.

Mechanisms of Delayed Wound Healing By Commonly Used Antiseptics, Thomas et al, J Trauma, 2009 BACKGROUND: The cytotoxic effects of antiseptics on pivotal cell types of the healing process have been well documented. The purpose of our investigation was to explore the ability of subcytotoxic levels of antiseptics to interfere with fibroblast function CONCLUSIONS: When debridement of the wound bed is not sufficient to reduce bacterial loads, the application of broad-spectrum antiseptics maybe indicated. Our data would suggest that H2O2 and iodine are poor choices, potentially retarding the contribution of fibroblasts to the healing process. Silver sulfadiazine and chlorhexidine, at levels still proven to be bactericidal, had fewer detrimental effects on fibroblast activity in these assays. The silver-containing antiseptics may even increase the proliferative potential of these cells in culture.

Any update on the case, Dr. R?

Dear Paolo Thank you for your interest and all useful comments. Soft tissue healed really well, implants fully integrated and currently in the process of fitting the bridge. Will upload new radiographs and photographs in due course. Thank you once again