Bone Lamina Technique: Suggestions for exposed lamina?
About a month ago I used the Bone Lamina Technique to augment the lateral width in the posterior mandible of a healthy 50 year old male patient. In the space obtained between the lamina and the bone, we inserted a mixture of xenograft and human bone mixed with PRF. Over this, a resorbable membrane was applied and also PRF. The short term, 10 days, post-op, clinical appearance was favorable, after an initial large hematoma had resolved in 4-5 days. Sutures were removed after 10 days. The macroscopic aspect was also favorable at the time. After suture removal the patient left the country so follow up appointments were not possible. At one month, the patient self-examined his mouth and observed the exposed lamina and sent me a photo. The quality of the photo is not optimal but the exposed lamina is observable. The patient is not experiencing any symptoms. He plans to come to my office as soon as possible for an assessment and additional intervention to remediate the problem. Looking forward to suggestions, opinions.
21 Comments on Bone Lamina Technique: Suggestions for exposed lamina?
New comments are currently closed for this post.
Jawdoc
5/2/2016
Looks like osteonecrosis. Is(are) there any systemic condition(s) of the patient that you're unaware of?
sb oms
5/2/2016
I'm not familiar with the term "bone lamina technique". I think what you are referring to is a ridge split where you greenstick fracture the buccal cortical plate outwards and then graft in the gap. From the pic you submitted the buccal cortical plate is now de-vascularized and non-vital. The buccal plate is essentially free-floating and not attached to the mandible anymore. That's why the soft tissues have pulled away or dehisced from the area.
You will need to remove this bone and anything else that is not attached to the mandible. You will find granulation tissue under this dead bone.
Unfortunately, when this heals, you will now have a significantly narrower ridge then you started with.
This is a risk with any ridge split technique. Causes are -
1. over aggressive splitting
2. soft tissue dehiscence from improper handling of soft tissues
3. Inadequate periosteal release
4. Sometimes host issues- pressure from a partial denture, poor wound healing.
The sooner you get this dead bone out, the better.
If beyond your capabilities, refer.
Olimpiu
5/3/2016
Thank you for your answer. This is NOT a ridge split. It is a different technique i.e. bone lamina technique which is a novel approach to bone augmentation. The "Lamina" is a commercially available product (Megagene) consisting of a porcine layer of cortical bone used as a barrier membrane associated with a collagen membrane for lateral ridge augmentation. There is no splitting of the mandibular bone of the patient but this Lamina (OsteoBiol Lamina) is used as a space maintainer for a period of time to secure the augmentation material. It also acts as a barrier to prevent the ingrowth of epithelial or connective tissue cells into the defect which is filled with bone graft material. This lamina thus provides also a support for this graft material and it is resorbable within 5-6 months. The defect is filled with graft material (in the case of this patient I used PRF mixed with allograft and xenograft bone in the gap between the lamina and the buccal plate of the mandibular bone). The lamina is fixed with screws in the pristine bone i.e. patient mandibular bone. To sum up, the picture I uploaded shows this lamina which is now exposed; the screws are also observable. The patient is able to come to my office this week and I shall probably have to remove the "Lamina" and re-suture the flap.
Phil
5/3/2016
"The new bone lamina technique employs a partially demineralized cortical xenogenic lamella to reconstruct the cortical plate. It combines the stability usually only found in non-resobable membranes with the biodegragation only found in collagen membranes. In combination with a resorbable bone substitute the bone lamina technique is a unique approach to a biological regeneration of bony ridge defects in implant dentistry."1
Resource:
1. The bone lamina technique: a novel approach for lateral ridge augmentation--a case series.. Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):491-7.
2. There is a nice video showing the technique here: http://www.ddsgadget.com/ddsgadgetwp/educational-video/horizontal-gbr-cortical-lamina-technique/
Jawdoc
5/3/2016
Dude, the body may be rejecting the xenograft. Autogenous grafts being the gold standard. In any case, it's still osteonecrosis. Pls do wat sboms says.
Phil
5/3/2016
i agree. Not commenting on sboms advice. just providing information for those who had never heard of this technique. thanks
Jawdoc
5/3/2016
Apologies, dude. This was meant to be on Olimpiu's thread. Cheers.
Kastytis Zymantas
5/11/2016
I would not term this as osteonecrosis. This is simply a dehiscence of tissue over an augmented site.
Dr Gee
5/3/2016
Even the autologous cortical fail often, not to mention a xenograft processed cortical plate. I think this is only a marketing hype under "new technique".
Nontheless, in the posterior buccal area, there is a lot of muscle pull. A flap, which is not properly released would fail quickly . Watch out for mental nerve, lingual nerve and facial artery working in that area.
Peter Fairbairn
5/3/2016
Two animal species and human donor ......plus . plus , what about the biology of healing ? and true host BONE we are surgeons not carpenters lets think why and how the host heals .
Regards
Peter
VNT
5/3/2016
Do you use betadine irrigation at final stage? 😅
Jawdoc
5/4/2016
As seemingly inappropriate as this comment might be, it's actually funny :)
Marcusdoc
5/3/2016
It's not true osteonecrosis if it's not exposed, dying host bone. This looks like exposed lamella (I.e. the graft). This probably can't be reconciled. It has has has to be covered by soft tissue (preferably not granulation tissue) to consolidate. Partly bad protoplasm, bad luck, bad technique. It happens but will cost you time and money. I don't know what you promised the patient for an outcome but you shouldn't be expecting the patient to pay to redo this. No matter what videos and texts and pamphlets show nothing trumps (no pun as I'm watching his uncontested win on CNN) experience.
Jawdoc
5/4/2016
What's 'true osteonecrosis'? If the natural/native bone hasn't died, how does the xenograft plate float (being fixated rigidly to the former) & gets exposed? & as the previous & later comments indicate, where's the blood flow which indicates vitality?
CRS
5/3/2016
Not sure how this is supposed to create bone, where's the blood supply for the actual new bone? "Bone grafts" unless autologous are really just spacers to allow blood cell bone precursors to develop new bone. Everything that was described was dead and probably blocked any new bone formation, the body is getting rid of it since soft tissue will not cover dead bone. I have used a product called osteowrap which is human allograft combined with some autologous bone to get some width but it is very thin. This is not carpentry, remove this it is failing. Don't resuture this, it's not tailoring either. The epithelial in growth is not an issue in an edentulous area but in dentate areas where there is communication with the oral cavity around the necks of teeth.
ELIE WARDE
5/4/2016
It is urgent to remove the exposed Lamina.
I think that he exposure was caused by the tension of the flap. You didn't release it enough by splinting the periostium , bleeding holes enhance angiogenesis or maybe you used a bad technique of sutures . Interrupted with Prolene 5/0 and continuous with double interlock with absorbable Glycolon 4/0 ( 3 weeks )
Zdravko Dimitrov
5/4/2016
The problem is most likely the flap has not been released enough or has not been secured for long enough with periosteal suture or apical matress suture.Such a big exposure will inevitably lead to necrosis of lamina and graft.I have had smaller exposures that has healed uneventfully by just applying chlorhexidine gel 3 times a day.
Marc
5/4/2016
Come again? You've had exposures of that magnitude of non-vascularized bone heal with CHX?? I could see vascularized, vital bone (e.g. tori) that was dehisced heal spontaneously but I can't from any biological standpoint envision mucosa creeping over and sealing in dead, foreign bone. That just seems to go against everything we know. I have successfully been able to resuture over a small opening over a block graft or the like. I still think anything less than starting over in this case is a waste of time. Having said that, I would love to be proved wrong.
Zdravko Dimitrov
5/4/2016
If your comment was an answer to mine:I agree,in that situation both cortical lamina and graft are already infected and necrotic and require removal.What I said about spontaneous healing is for a lot smaller expisures-Ive had couple of exposures-the bigger was probably 5-7 mm,which healed uneventfully due to characteristics of cortical lamina.Even very small exposures with rigid membranes so early in healing will lead to necrosis and need to be adressed.
AAslamOMS
5/7/2016
No more denial. The sooner you have this removed, the better. I would just do a couple of tacking sutures if I must after removal and leave this and come back later. We need to understand it is potentially an unforgiving technique, if we do not adhere to sound surgical/biological principles.
The resultant defect now will have soft tissue deficiency both in quality and quantity. I contend PRFs and the related kinds are not magic wands, and cannot be a substitute for an honestly done periosteal release on the facial side, with adequate undermining, and for such kind of a case, lingual flap release too remaining subperiosteally. A 4-0 or 5-0 preferably monofilamentous suture like Prolene (though I prefer PDS) with mattress types done well will be the first step, in addition to cortical punctures to promote bleeding. Ask yourself the question again: Did you do flap release enough?
Good luck with future management. My query would be is if we would want to redo such a case afterwards, would it be soft tissue first or bone augmentation first? This of course will depend on soft tissue health after about 3 months in this kind of case.
Marc
5/7/2016
Here here!
