Flap design for palatal bone augmentation: opinions?

Usually that area does not need to be grafted since implants are not placed that far to the palate. But an envelope flap can be raised and graft material placed under it or graft it at implant placement. Sliding a graft under the flap will be stable since the palate will stabilize it since the tissue is immobile. I would have to see what the defect looks like to advise.

Simple keep all flaps a small as possible to reduce trauma and encourage healing , I always retain the adjacent papillae and use tunnel grafting techniques as well . Have stopped using blocks about 13 years ago , my last 3,000 grafts have followed the same protocol and with great success . Less cutting more success , the body wants to heal lets work with it . Here is my recently published protocol , http://www.hindawi.com/journals/ijd/2015/589135/ Peter

thank you both for this information. I have used envelope approach and it has seemed to work well CRS. There was not much give in the palatal tissues so the membrane was a bit tricky. I don't have permission for posting the scan. P.F. thank you for the link. I think I have met you, or rather heard you speak at an event hosted by an imaging company. In the biomaterial in your cases I understand no membrane is required but would still require primary closure? I understand papilla sparing incisions although I do worry about what width of papilla is required to be left attached to the bone so it does not loose its blood supply. I guess its fine when the mesio-distal space is enough. I definitely agree avoid large flaps though. Not related to the posted case: I really like your idea of extract, wait for the gum to grow over then graft/implant/socket preservation. Is the new gum really weak or easy to manipulate at 4 weeks? I find the regular socket preservation techniques covering the grafted but open socket with a membrane or collagen plug are compromised and I don't want to advance the flap to get primary closure, its a waste of gum that might be needed later.

Hi Haraldo , great yes the Materials and Protocol appear to a significant host up-regulation to healing and dramatic reduction in host morbidity and swelling . I have not used a traditional membrane in 13 years and do a couple of grafts every day . I feel ( which is back up current research including a rabbit study we are finishing ) that they are a hinderance to healing . The Stromal cell derived factors are induced by the periosteum and the placement of membranes may interfere with this inhibiting the host healing . As long as the graft is stable no membrane is needed which improves the host regeneration . Again as you know I never use autogenous ( Dead , body has to remove ) as well and rely on the improved vascularisation of the site to get bone regeneration at the correct time scale . Yes the surgery with the soft tissue can be delicate at 3- weeks healing but with care and practice it is achievable routinely . In the rare cases where I socket graft at extraction agin new materials have shifted the paradigm and all I use is a collagen fleece which is gone in 2 days to help the clot formation . We had a Poster on healing by secondary intention over stable graft materials at the EAO in Stockholm and are writing up a full paper now. Yes it contradicts a few of the old "rules " but it does not contradict basic biology . This is true minimally invasive surgery a term often abused Regards Peter

Peter I ordered some easy graft which hopefully is a similar product available in the U.S. I have a question what method do you use for a very narrow mandibular ridge for an only graft when there is just not enough bone to simultaneously place an implant. This seems to be my most challenging scenario,I too no longer use block grafts and am backing off on the membranes I think it heals better without a membrane. Please advise, I think there could be a different paradigm in the states since cadaver bone seems to be plentiful here.

Hi CRS , visit the website for Ethoss and you can see a few cases and videos , on narrow ridges I use tunnel grafting techniques which is not on the site as better to get the easier jobs done initially when dentists start out on a new protocol . I agree allografts were good especially many years ago but the new generation BTcP products are more Osteo-inductive leading to a very high percentage of true host bone earlier , consistently . I have used Easygraft as well for about 7-8 years and have had great results with it using the same protocol ( it was not included in the paper as the material was significantly different being poly-lactide coated ) .. Regards Peter

We posted an excellent video from Dr. Peter Fairbairn showing a case with Ethoss at: http://www.ddsgadget.com/ddsgadgetwp/educational-video/bone-regeneration-anterior/

Yes Thank you moderator , this is an easy case but shows the basics of how the protocols Help host healing to a true host bone situation in 10 weeks ..... DDS Gadget has some fine CS products and these materials are a good way forward ..... Peter