Membrane exposure post GBR: what can be done?
I did a direct sinus with Novabone putty [synthetic bone substitute] and planned to place implants after 9 months later because there were some fractures in the cortical bone. I have done some intramarrow penetration with placement of Novabone putty and covered with BioMesh membrane. I closed the surgical flap with simple loop and horizontal mattess sutures. During the healing period there was no membrane exposure but then on tenth day I noticed that the sutures were open so removed them. If I pull on the cheek the buccal gingiva moves. I have kept patient on daily cholrhexidine rinses. There were no soft tissue changes and no inflammation. Now what do you recommend I do? Can I put at Collaplug [resorbable collagen] on top of the membrane or should I leave it as it and allow it to heal? There is also a partially impacted #1 [maxillary right third molar; 18] which can be seen in the photograph.
membrane exposure- the distal one is impacted third molar
membre exposure- the distal one is impacted third molar
18 Comments on Membrane exposure post GBR: what can be done?
New comments are currently closed for this post.
CRS
9/25/2013
I don't know what a direct sinus procedure is but the membrane can be allowed to granulate over. Placing a collaplug at this late date will not help. Do you have any idea why the flap broke down? Do you think the graft is infected or failing? Can you post an X-ray difficult to diagnose without a film. Could the partial impacted molar be a source of infection?
Timothy Hacker DDS D-ABOI
10/1/2013
You did not release tension enough on your buccal flap before you closed. Collaplug is a waste of time and materials. Studies show that Chlorahexadine inhibits fibroblastic growth, so be conservative with that.
Don't panic. Your flap will granulate in over time. I am not sure how long it will take for your "Novabone" to be replaced by your patient's bone, nor how dense it will be. Most low density bovine derived products turn over in 6-9 months (I do not personally use any of that). So, you will see granular closing of your flap in a month or so. If you place 3-0 PGA horizontal mattress sutures now, it will stabilize the moveable buccal flap. That's about all you can do right now. You will be fine in 9 months to re enter and place your implants.
You have learned now to aggressively release tension on these buccal flaps.
CRS
10/2/2013
Actually bovine bone does not turnover it stays there forever by turnover I mean resorption and replacement with host bone.i agree that it is inadequate flap release but infection or graft failure can't be ruled out at this point, what concerns me is the movement and lack of understanding of wound management. The CHX is probably not a big deal this far out, the wound has to be kept clean . And Peter I agree about the membranes I close primarily unless I want to block epithelial in growth then I will use a membrane for mor complex cases. Time will tell.
Peter Fairbairn
10/2/2013
Having not used a membranbe once in the last 10 years and thousands of grafts , I feel that they are a hinderance to healing which is even the title of one of my talks.
Periosteal blood supply and the ability for vessel ingrowth is compromised as is Stromal cell derived factor induction , these factors seriously inhibit to bodies healing ability .
As I always say the body wants to heal lets work with it.
Understanding you graft materials and bone physiology is the key to this .
Peter
CRTooth
10/2/2013
Hi Dr. Fairbairn and CRS,
I'd just like to thank both of you for your contributions to these forums. As a circuit lecturer and responsible for thousands of fixtures both placed and restored, your insights on "implant" dentistry and basic surgical protocols and treatment planning completely fall in line with my practice and way of thinking. It is refreshing to see honest opinions based on clinical truth and backed by sound logical biological principles. Completely agree with the effects of routinely using membranes and the fact that they completely contribute and dare I say, cause, the number one cause of flapped surgical site post-op complication : dehiscence
Kudos to you both
CRS
10/2/2013
Well thank you very much I appreciate the complement. I also learn from my fellow posters!
kent tan
10/5/2013
Peter, my understanding of barrier membranes was to prevent ingrowth of soft tissue into the grafted site during the bone healing period as soft tissue regenerates faster than bone. Do you have issues with failed grafts/a greater volume of your graft site being resorbed if membranes are not used?
Also what are good post op guidelines to follow after implant surgery? Currently I recommend 1min CHX rinse twice daily for 2 weeks to help prevent infection of the site. On occasions AB 1 week post op also.
CRS, did you proceed with attempting flap closure as recommended by Timothy?
CRS
10/6/2013
I did not post the case, but I can usually get primary closure. I think the soft tissue in growth is critical when there is not a bone graft to retain the space, my grafts do best with primary closure when there is good buccal plate. I think it boils down to the morphology of the defect and the complexity of the case. There is nothing magic about a membrane it is a barrier provides additional stability but it does slow down in growth. As for the periosteum being a big vascular source, I think there is more surface area within the endosteum probably providing most of the blood supply. I honestly think it is about morphology of the defect and understanding how things heal. Actually with the laser generated blood clot with particulate graft I will be using less membranes in exposed site. If the area is closed primarily it should be fine also. Your protocol seems fine, if you can close primarily without losing the vestibule you can save money on these ridiculously expensive membranes!
Peter Fairbairn
10/6/2013
Thank You Dr . , I guess we all try to understand healing and physiology . Maybe it is MId-West thinking...
Regards
Peter
peter Fairbairn
10/6/2013
Hi Kent , yes that is the idea but as with mobile phones ( yes I remember when you needed a Brick and got no reception ) things with graft materials have moved on over the years where the graft now is its own "membrane " and stable throughout leading to better bone regeneration in line with the Schenck et al research . Hence you can work with the healing timeline for improved regeneration .
After a few thousand grafts and numerous research projects with a success rate of over 99% even when dealing with extreme cases we feel this is the way forward .
Patients like it as well as we never use autogenous so no donor sites .
Next talk in Rome this week.
Regards
Peter
OMS Resident
10/8/2013
Dr. Fairbairn, I can't find any of your publications on Pubmed. Where should I look to get to know some of your research on synthetic graft materials?
Peter Fairbairn
10/9/2013
Hi OMS Resident , Being a busy clinician finding time ( AND more importantly FUNDING ) to do my own research has not been a priority until about three years ago ( although I have spoken on their use globally for about 7 years ) but I can send you , a few posters from the EAO , some journal articles and an animal study which has been accepted for publication . But if you look there is extensive other published work from Podoropolus ( Dog study ) , Smeets etc. and the Genome study by Zhao ,Watanabe et al , which is a great read .Synthetic materials have changed a lot and our understanding of them is improving , but as I said funding is the main issue in this area of bone regeneration.
I do however record most cases extesively and often take cores for micro CT and and histology .
This information is for personal speaking reasons only .
e-mail me and I can forward articles to you .
Regards
Peter
ljm1n
10/9/2013
Peter, do you use PRF in your procedures?
Thank you, Larry J. Meyer DDS
OMS Resident
10/9/2013
Thank you, dr. Fairbairn. I'll e-mail you.
peter Fairbairn
10/13/2013
Hi Dr Meyer , sorry about the delay was speaking at University of Rome , where I was asked that exact question by a delegate . PRF has limited soft tissue benefits although PRF may have more benefits in the sinus especially .
The biocompatible nature of the graft materials and the smaller flap size ( no membrane to be forced in ) result in good soft tissue healing so no need .
I sometimes de-grnulate the socket but do not remove the tissue leaving it attached at one side then place and graft . After the graft has set then re-place the granulation tissue back over the top of the graft for improved soft tissue healing ..
Peter
Richard Hughes, DDS, FAAI
10/13/2013
Peter,
Replacing the granulation tissue atop to improve soft tissue healing is a novel approach. Possibly beneficial! Do you have any compariiative photographs?
Very creative!
Peter Fairbairn
10/13/2013
Yes I have many case Photographs but one I use most often is on a 86 year old patient Where we have a large infected defect , and I have used my routine protocol and replaced the tissue over the graft . The healing in 4 days is amazing , I have recently placed another 2 Implants in her ( She is now 91 ) adjacent to that site and all very nice ....... give it a try .
I showed it at my US school and the students were intrigued.
Regards
Peter
mengb
10/15/2013
My opinion is, the exposure site shoule be as it is now. There are three resasons,1)it has been ten days after the surgery, and some fiberal cells have went into the bone graft materials, and it will generate new epithelial tissues after about 2 weeks. 2) It is not nessary to put a new resorable collegan,becasue the exposure site has been explosed and contaminated, and it will not take effect if you put a new collegen.3)The epithelium cells have a stong generation ability,and will cover the expousre site soon. Therefore, what you should do is asking the patient to keep the expusure site clean by daily cholrhexidine rinses.
