Grafting a 1 or 2 walled defect/socket: Discussion

Hi, we actually use very little membranes, since we use mostly Easygraft that does not need it. In relation to extraction sites without immediate implant placing we do alveolar preservation with easygraft crystal (partially resorbable) and at a later date we do flapless implants.If we are doing a simultaneous implant placing, we do a Dr. Palti style graft (Drill and then intralveolar graft that is formed with osteotomes preventing the flow into the osteotmy and the implant is placed intermediately after the graft) if we have full buccal wall we use easygraft classic (fully resorbable) that has fast turnover and if there is need to restore the bucal plate we use Crystal, without laying a flap. With a very small petrungaro periosteal elevator we separate the gingiva and make a pocket that allows us to fix the deffect and make a small veneergraft that extends beyond such deffect in the mesio-distal and cervico - apical aspects at least 2mm, that almost warranties us a success in aesthetic terms , generally we leave our implants connected that ensures a good emergence profile and mostly no second stage surgery. hope this helped cheers

HI Alejandro , see you in Lucerne .......... I have not used a collagen type membrane or any membrane except the Graft s own properties as its own membrane in 11 years and 2,500 grafts ..... But it would take a day to discuss , and the question is very broad .. Peter

Call me overly cautious, but I do use a flap to expose the socket and/or defect. I am liking a new material from Mis called Bondbone, which is a biphasic calcium sulfate. You can forget the membrane when you use this material. I too overlap the bone surrounding a buccal wall defect by at least 3-5 mm. In a very large defect, I may mix allograft with it 50/50. I would not use a membrane on this either. Just one periodontist's opinion.

We are now living in an era when we can take advantage of natural growth factors to help regenerate boney defects. Natural autogenous membranes can be formed from the PRF harvested from the patient's blood, particulate biologics can be mixed with the Vitreonectin and Fribronectin that is obtained from the pressing of the harvested fibrin clots to form these membranes. Further information can be found in the articles or webinars by Dr. Joseph Choukroun M.D. Nice France ; Dr. Avi Chitrit Miami Florida , Dr. Eduardo Anitua Spain If it is absolutely necessary to open a full thickness flap because of the defect, then do so, otherwise why interfere with the blood supply to the bone which is mostly supplied from the periosteum . Gerald Rudick dds Montreal AF AAID; F,D, M. ICOI

The bone ring technique is a viable option in these conditions. A membrane or membranes are in order. Peter is on to something. Please share with us. You have captured my attention.

Man, I like the idea of not using a membrane for a number of reasons! Can you please expound on that method, Peter? Thanks. -Kevin

Hi Kevin and Richard , "The body wants to Heal lets work with it " is my mantra , and have spoken at Zurich Uni stating that the Collagen type membrane is posibly a hinderance to the healing process which was interesting . We work in a job where sometimes industry and not Biology shape our decisions made by what we hear and read. We need to think why more and apply basic biology and Physiology to that thinking. Hence my Protocols ( same for last 12 years ) no membranes ( use materials which set and are hence soft tissue cell occlusive , yet vascular nano- porous) , no autogenous ( introduces Osteoclastic phase early again slowing healing ) , only use fully bio-absorbed materials ( to return site to host bone for efficient turnover , Osteocytes vital ) , always place the Implant early ( up-regulates host bone metabolism ) . Finally load early to get further host bone metabolism up-regulation which at 6-7 weeks has plateaued . Most cases fully recorded with pre and post Osstell readings , extensive photos , long term scans all point to one thing , the host body wants to heal and these protocols work with it as well as having dramatically reduce patient morbidity ( no autogenous or foreign material , and smaller flaps ). Yes , Richard you get it , it is interesting ( Doing another 2 animal studies presently ) and patients seem to be happier . Regards Peter

Peter, Thank you for your explanation. I understand using a material that sets and early loading when possible. Do you also use the barrier by bulk concept? Again thank you.

Dr T , I generally use Beta Tri-Calcium Phosphates , CaSo4 ( first used by Dreesman in 1892 in bone regeneration ) and occasionally poly-lactides .. These materials are very different now and extensive new research ( pubmed our Animal study from Feb) , we are getting to understand their benefits . I have used mainly a product called Vital since 2003 which is FDA approved but mainly used in the more lucrative Orthopedic market , as Dental market not seen as important by many bio material companies. Can mix your own using Bond Bone or its makers own brand 3D but need to know about materials and why things absorb and how quick . Timing is the key to work in the healing envelope and hence BTcp is a good mix partner , but again particle size, shape and porosity are key to Optimise it effect on host healing. Developed own material which is a game changer which is exciting . It seems to be about doing simple things well rather than getting too complicated and hence delaying host healing. Yes , Richard compressive resistance in materials as well as stability appear to be of value along with increasing nano porosity for vascular ingrowth due to the variation of the bi-phasic resorption rates . Results have been very encouraging especially longer term . For research look further than Dentistry Journals , try Bone Journals and Orthopedic research show some interesting newer material. Just some thoughts. Regards Peter

It really depends on the size of discrepancy.if the defect is large and implantation is not immediate then I'm likely to raise a flap if small then i use bond bone by mis , which is inert and acts as a good spacer as well(no flap).