Graft protection when primary closure impossible?
My patient needed the extraction of two adjacent teeth in the maxillary arch. He needs Guided Bone Regeneration for site development to place implants. The vestibule is very, very shallow and prevents primary closure by releasing the flap. My experience with PTFE and college membranes, when exposed, tells me not to rely on membranes as a solution, for this case. I am considering using PRF as a membrane, but I have no experience in trying it under the above described circumstances. What do you recommend in this case?
11 Comments on Graft protection when primary closure impossible?
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Joseph Choukroun
3/28/2017
When you do socket preservation, you may (must) leave the PRF exposed without any primary closure..
When you do bone augmentation, I do not recommend you to use PRF as a membrane exposed.. it's a lotery game..! the primary closure is obligatory. Then you must do th flap release and do the closure with an apical mattress which is the guarantee of non reopening site.
Geoff
3/28/2017
You can do "delayed, early" re-entry. Up to about 8 weeks post extraction, the remaining bony architecture will remain fairly intact without significant resorption. At 6-8 weeks, the soft tissue will be closed so you can re-enter and have similar bony architecture to immediately post-extraction but soft tissue available to close. I would shoot for 6-8 week reentry. If the patient delays or cancels and overshoots, then you are likely to find more pot-extraction resorption. That allows you to do primary closure.
Good Luck,
Geoff
Peter Fairbairn
3/28/2017
Always follow same protocol ( published , see pubmed ) for last 15 years , leave for 3-4 weeks post extraction .... clean, place and graft simple ... after 4,000 plus grafts seems to be OK
George
3/28/2017
Thank you for the replies. The delayed grafting is something I've done in the past and it works just fine. It looks like there is only so much magic to go around.
Thank you all for taking the time.
Oleske
3/28/2017
If I can't get primary closure, I will place a Cytoplast non-resorbable membrane (usually Txt-200). I have experienced little to no complications. Suture with Vicryl or PTFE, remove sutures in 10 days, remove membrane in 3-4 weeks. I have had few complications. Anything I can do to have a predictable result without a second surgery tends to make patients happy.
Oleske
3/28/2017
Sorry, Didn't notice you said bone augmentation. Primary closure or nothing. In that case I agree, delayed re-entry
Tony
4/4/2017
Interesting and informative comments - thank you all.
Peter's 2015 publication that he mentions is worth a read .
Peter what beta TCP product are you currently using?
Must it contain C S to set hard?
Peter Fairbairn
4/5/2017
Hi Tony , yes both Products used in that paper were BTcP and CS to stabilise it . You can leave open and it will heal over by secondary intention ( see another paper of mine in Pubmed ) but in some cases ( especially upper molar area ) some graft may lost ........ so we are publishing a new protocol to eliminate this loss .
Have a case using these materials and no closure where it was photographed every day for 3 months to show healing by secondary intention over a stable graft material...
Now using EthOss .........which I have helped develop , but as always surgical skills always needed
Regards
Peter
CRS
4/4/2017
Seems like if the vestibule is shallow there must be little alveolar height so you will probably need to gain height with a sinus lift. You are just building a base after the extractions and graft. In the Maxilla you can always extend into the buccal mucosa to get primary closure may need to do a vestibuloplasty later. Actually harder when there are adjacent teeth with closure. Need to post a photo or xray. Fairbairn's technique works well so does cytoplast.
Manny
4/4/2017
Develop the site properly with a soft tissue graft first (usually a FGG for me) and then you have plenty of quality soft tissue for primary closure for your GBR.
Girish Bharadwaj
4/5/2017
Alloderm is a great substitute if there are concerns about primary closure .
You can get s tension free closure and quality soft tissue in 6-8 weeks . Perfectly fine for re entry . No second surgery or additional graft site .
