Category Archives: Dental Bone Grafts

Ramsey Amin DDS Case Review – Replace Loose Long Bridge With Dental Implants And Bone Expansion

This Burbank patient had a loose lower bridge.  She had had the bridge for about only 8 years before it failed and became loose.  You know a bridge is failing when it feels painful to bite down or there is movement.  This unfortunately is a daily thing I see every day.  Teeth were never intended to be hooked to other teeth.  She came to me because she wants dental implants to replace the bridge.

The existing lower bridge was made with a metal biting surface because the patient has a VERY  strong bite.  She wanted to make sure that her new dental implants could withstand her bite force.  She has broken other bridges in the past. You can see in her photos that she has worn through some of the porcelain showing through to the old metal layer on the opposite side next to the yellow gold crown.

First day exam visit

First day exam visit – broken root under the bridge

First day exam visit –side view

First day exam visit -panoramic x-ray

First day exam visit — full lower jaw. Failing bridge is the one with the metal biting surface.

thin bone prior to grafting but after extraction of the broken root

Bone grafting showing webbing of Vicryl stitches

10 days of healing after bone grafting showing webbing of Vicryl stitches

Clay model of the patient after bone widening expansion bone graft. Please note how wide and square the bone is compared to how thin it was before.

3-D printed models showing abutment contours

3-D printed models of abutments from top view

top view final bridge on 3-D printed model

side view of final bridge on 3-D printed model. This patient happens to have very short teeth which makes it even more important to have the teeth connected to avoid food impaction between the teeth.

sandblasted abutments in the mouth showing very wide bone and excellent healthy thick gum tissue

postoperative panoramic x-ray showing three dental implants in the lower right jaw.

postoperative panoramic x-ray showing excellent fit of abutments and monolithic zirconia bridge.

final bridge seated over the abutments. The final bridge is on the right of your screen.

When I removed the bridge I found one of the teeth anchors broken.   That broken root canal tooth is not savable and will need to be extracted. The back wisdom anchor tooth is healthy in and of itself but is tilted towards the front.  This patient is unique in that she has very long roots as shown on her panoramic x-rays.

The biggest issue is that the bone in the area where the teeth used to be is super thin.  When you lose a tooth or a segment of teeth, the bone thins out because it is not being used.  This process is called atrophy (BONE LOSS) .  So even though her bone was tall enough, it was not wide enough to have implants properly placed in the center of where the teeth used to be.  If you try to have your implants done without a bone graft, the implants would have to be pushed towards your tongue side and the implants would be a very small diameter with minimal bone on the outer wall… a recipe for disaster.

In her case, I did a bone widening/expansion ridge split.  In this process, I actually purposely “break” the outer layer of bone towards the outside and push the outer layer of bone away from the inner layer of bone.  This creates a big trough which can then be filled with donor cadaver/cow bone and L PRF/PRP made from your own blood.   This is a very advanced bone grafting technique that is not just a typical mild expansion of bone.  It is a full repositioning of the outer wall of the lower jaw bone.

This bone graft was allowed to heal for 4-6 months prior to placing the implants.  In her case I would not advise placing implants at the same time of the bone graft although in many cases I do place the implant simultaneously.  Her case was special and that she was on a bisphosphonate medication in the past for cancer treatment.  The bisphosphonate medications can slow down bone healing and can have really detrimental complications so going slow was better than going fast.  I did some blood tests for her and also consulted with her physician prior to initiating treatment.  It is always best to be safe especially when dealing with dental implants and medications similar to Boniva and Fosamax.

After a few months of healing I decided to place 3 dental implants for a connected-splinted dental implant bridge.  Remember she wants the “strongest possible” solution so I advised her to have 3 implants and a 3 tooth bridge rather than 2 implants and a 3 tooth bridge.  Connecting the teeth is definitely the strongest way and helps prevent food impaction.

In the photographs, you can see how wide the bone is and how the implants are well centered and spaced now that she has the proper amount of bone.  The implants are long and of a really good diameter for a proper emergence from the gums for large molar teeth.

After 3 months of healing, I began to take my initial 3-D video scans of her mouth to fabricate her teeth.  I made 3 titanium abutments on the 3-D printed model in a virtual program.  This way the teeth are fabricated using a computer and not typical gypsum clay molds and messy impression material that gets stuck in your mouth!

The abutments were steam cleaned and sandblasted for proper cement hold and sterility.  This is a another important step which is commonly skipped.  The implant abutment junction must be super clean and the smooth metal must be roughened slightly for micro retention.

The implant bridge was then fabricated using monolithic zirconia.  This material is wonderful because it is white, strong and aesthetic for back teeth.  It is stronger than original bridge with the metal support.  I use this material quite commonly for my full mouth Prettau zirconia dental implant bridges.

Needless to say, she was very happy with the final result of her teeth. I am sure they will last a very long time. The best part was the big hug she gave me at the end. 

😉

Upper Molars with Sinus Bone Graft and Lower Single Implants -Ramsey Amin DDS Reviews

VM (5)
molars
VM (4)
VM (3)
molars2
VM (1)

This is a nice example of basic treatment with dental implants that was well engineered. What you are looking at here are four dental implant molars that I placed in virtual 3-D. The implants are actually surgically placed in the bone but what I did was ‘overlay’ the implants that are actually there with the computerized virtual dental implants. This is done so that the exact position can be seen more easily and you can learn more from this article.

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Before treatment…. patient already has one implant

Notice that all of the implant sizes maximize the available bone volume… The implants are not too small and they are not too large… Both of these can create problems. Also notice that each implant has plenty of bone on the outer wall which will support these implants for a long time and will greatly reduce the chance of ever having bone loss/peri-implantitis.

On the upper right notice there are two dental implants. A sinus bone graft was done in order to create enough height of bone to place these implants. The implants are placed against the medial wall for best trajectory but also avoiding the contents of the nose. Previously she was missing the second molar and the first molar had to be extracted due to periodontal bone loss.

Genetically, her sinuses hang down fairly low which would not allow implants of larger diameter and length to be placed. This is very important for the upper jaw in the back of the mouth. I also suggest that these implants be connected especially if the last two teeth are dental implants. You can clearly see the sinus bone graft over the top of the implants.

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Teeth not on 3 of the implants yet. One of the implants in the upper was placed in eastern europe 20 years ago.

The lower molar dental implants are single tooth dental implants. The one on the left side of the screen is smaller and longer while the one on the right side of the screen is wider and shorter. Even though they are the same lower first molar the anatomy, each area is slightly different. Every tooth is planned in a unique manner.

This patient happens to be the wife of a dentist that I treated. I actually treat many doctors and dentists…. Even we need tooth replacements too!!

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Bone Graft Correcting Dental Implant Peri-Implantitis Bone Loss ~ Case Example

Bone loss can and does occur around dental implants.  Often this is called peri-implantitis and there are a few treatment options.

Review signs and symptoms of peri-implantitis dental implant bone loss in this previous article.

Bone loss on implants happens on about 1-15% of dental implants. That percentage is variable depending on the experience of the dentist. How to deal with it is the big question.  In certain situations your dental implant or implants can be recovered with bone grafting procedures but in some instances the bone loss associated is so significant that the only option is to remove the implant and start all over again.  Bone grafting for peri-implantitis bone loss defects is not standardized and varies widely from dental surgeon to surgeon.  Over many years of doing this I have developed a specific technique for recovering some of the worst bone loss.

Correction of bone loss on dental implant--Ramsey Amin DDSBone loss can occur as a “moat” defect going 360° around the entire implant or it can be just localized to one side of the implant.   If it is 360°bone loss it is much worse than if it is localized to just one side.  The best area to have bone loss is in between the teeth rather than on the outer aspect.  This is easier to graft and has a higher success rate.

If the implant is in the front of the mouth versus the back of your mouth this can make treatment options very different also.  The back teeth are more forgiving and then the front.  The gum and bone is typically thicker in these areas. There are times when the final outcome leaves you with some metal of the abutment or implant showing but disease process was stopped.  Of course in the front of the mouth this is typically unacceptable especially if any metal shows in the smile.

In this example case I will show you the more difficult of the two….  A case where bone was lost on the outer aspect.

In this case this is a 29-year-old female that had a dental implant placed in another country.  The implant overall looks good but it has become tender on the outer aspect of the gum.  One reason in her particular situation why bone loss happened was because the bone was a  too thin to begin with and then the crown on the dental implant became loose at the abutment.  This particular dental implant crown/abutment had a design flaw which caused loosening.

If you look at the implant on a 3-D CBCT scan view from the side you can see that in the mid body of the implant there is very little bone.  Because I never treated this patient to begin with,  we don’t know if the bone was like this from day one or it dissolved to this situation because of the loose dental implant abutment.  Either way it needed to be treated.  We discussed the possibility of removing the implant versus grafting bone and saving the implant.

If you look closely at the gum tissue, of both center upper front teeth you will notice that there is more of a hump on the natural tooth than there is on the dental implant.  This was the first sign that the implant was lacking bone when she smiles.  What makes this case very difficult is that the teeth are generally very long and when she smiles she shows her gumline….  Everything is going to show so this is going to be a critical surgical correction.

You have to be really careful with these cases because sometimes the correction can make the tooth look worse if it is not successful.

The most critical factor in all of this is prevention.  I go to GREAT lengths to prevent dental implant bone loss from occurring in the first place by having a tremendous amount of bone on the outside of the implant if the patient’s anatomy allows.  By having the original implant surgery done well, this is the best way to preserve the bone on the outer wall.  Also when the crown and abutment are made by the dentist, there are so many techniques and choices to make things last and be problem free for many years.  Many patients think that the crown and abutment portion are “easy” and can be made by any regular dentist.  For some patients anatomy, dental implants would not be wise choice…that is the exception rather than the rule.

In her case, I am certain that the result will be long lasting.  The good thing was there was no exposed threads at the very crest of the bone.  The surgery was done under IV sedation through a tunnel flap which is the equivalent of a laparoscopic medical procedure.  I was able to remove the crown and place a temporary crown during the procedure which helped with surgical access. The sutures seen here are designed to be dissolvable because the incision is far away from the actual tooth being treated.

I know these specific and detailed articles but a lot of this information does not exist on the Internet.  I hope this helps those of you that have this problem and those of you to prevent if possible.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Replacing Four Lower Back Teeth With Dental Implants and Bone Grafting – Start to Finish Detailed Video Review -Ramsey Amin DDS

This video has a lot of information on dental implants and bone grafting. There is also a lot of information on how the teeth and dental implant abutments are made in the rationale of why I did everything. You also see the sequence where three of the implants were placed in a delayed fashion and one was placed as an immediate dental implant.

***If you are considering having dental implants and perhaps socket bone grafting, this is a must-see video.**

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Please be sure to watch the entire video as there is so much to learn about the entire process of having teeth replaced with dental implants. In this video I review the diagnosis, treatment planning, 3-D scan analysis, surgical placement of four implants and the restoration of the four implants with for non-connected monolithic zirconia crowns with prefabricated abutments.

This patient has several failing root canals and very heavily worked on teeth. The teeth have been crowned in re-crowned multiple times and now several molars need to be extracted. In fact a few of the crown/root canal teeth came apart during the healing!!! They were added to the list of teeth to extract and replace with dental implants.

I also show after photographs so that you can have a complete start to finish outlook on this procedure. I consider this patient a very basic case in my office. In the 3-D scan analysis, I discuss how the surgery and planning can prevent long-term complications such as peri-implantitis which is bone loss around implants.

I appreciate your comments and questions. I hope this video helps you.

Ramsey Amin DDS
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

 

 

Bone Reduction Leveling For Dental Implants to Avoid a Bone Graft

Bone leveling is a procedure called “alveoloplasty.” Bone leveling is extremely beneficial in cases where a bone graft can be avoided altogether. Especially in the lower jaw when the bone atrophies, (melts away) what’s left of the bone is just a skinny spine knife edge type of ridge where the teeth used to be. That skinny knife edge ridge will not allow a normal size implant to fit inside of it.

stimulation of bone reduction leveling to take off the skinny part of the jawbone.  This is the jawbone in cross section.

stimulation of bone reduction leveling to take off the skinny part of the jawbone. This is the jawbone in cross section.

What’s interesting about our jawbone especially in the lower jaw and even in the upper jaw is it is shaped like a triangle if you look at it in cross section. The top of the bone is the apex of the triangle which is skinniest and the bottom of the bone is the base of the triangle which is the widest. So if your bone is really skinny at the tip and is wider at the base, a bone leveling alveoloplasty reduction procedure can take top of the triangle off leaving a wide base of bone to place the implants.  The procedure has minimal risks.

I do this very commonly when replacing implants in the lower jaw when all teeth are missing. This serves many purposes. One purpose for leveling bone is to avoid bone grafting. A second purpose would be to provide bone around the entire head platform of the implant. Finally, bone leveling for dental implants reduces cost to the patient and decreases the time until you get your final teeth… A win-win situation!

Bone reduction alveoloplasty example (1)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

Bone reduction alveoloplasty example (2)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

sample real case bone reduction for dental implants (1)

Before —note uneven bone that is higher in the front of the mouth where some broken roots remain

sample real case bone reduction for dental implants (2)

After –simultaneous extraction, bone leveling and placement of four dental implants….this is healing at one month

Bone reduction alveoloplasty example (3)

After -Bone reduction alveoloplasty example


Why don’t we just do this for all implants?

Why is this only limited to full arch replacement such as a Prettau dental implant bridge or when replacing large segments of teeth?

The reason is that it makes the teeth longer from the gum line to the top of the tooth. If you are missing all of your teeth bone leveling (as opposed to bone grafting ) can be extremely beneficial because it provides thickness to the overdenture or fixed dental implant bridge such as the Prettau.

Having significant thickness of your bridge will prevent problems that you may not think about such as breaking your bridge or breaking your implant overdenture. This happens so commonly when the depth of the implant is too shallow and a full arch zirconia, hybrid all on 4 bridge or overdenture case is made and the material was so thin that it just breaks in half or the teeth chip or fracture off.

Bone leveling reduction alveoloplasty can be very important for replacing all upper teeth also especially if you are missing gum tissue. Sometimes we have to use pink tissue ceramic colored porcelain to mimic lost gums. You never want this transition between the prosthetic pink gum and your natural gum to show when you smile. Although the pink gum tissue looks very natural, it does not look natural if you see the line between the two in full smile. So sometimes a bone leveling reduction alveoloplasty is done in order to hide the transition. I have been doing this procedure for at least 15 years as of 2015.

Other Benefits

Another other benefit is the bone shavings can be used to graft another area of the mouth that may need bone! This can be combined with L PRF/PRP (made from your own blood)  and other bone grafting materials to as your own bone and make a composite bone graft that is extremely successful.

Bone leveling is also important to make sure that the heads of all the implants are all relatively on the same plane. It is extremely common for the lower jaw to be missing more bone in the back and the bone to be sticking up in the front. This bone that is sticking up in the front is usually reduced for thickness purposes and to make sure the implants are at a good level with the rest of the bone and the other implants. Typically I do this procedure when I am placing anywhere between 3-10 implants in the jaw. It also allows for the gum to be closed very well and stitch in such a way that the gums almost always touch each other. This is called primary closure and leads to fast healing from surgery.

What is the disadvantage of this procedure?

If bone leveling reduction alveoloplasty is used in the wrong location, such as a single missing tooth, you will end up with a huge, open black triangles between your teeth. It is not meant to be used in cosmetic areas of the mouth such as upper front teeth. These areas are better served with bone grafting than bone reduction leveling. It is meant to treat long span missing teeth or when you are missing all teeth. Bone reduction alveoloplasty needs to be carefully planned from a full set of photographs and a 3-D scan. The point is to take away just enough bone but not too much.

Please feel free to comment and ask questions.  Please use the proper area of the blog to do so

Block Bone Graft for Dental Implants 2015 Update-Ramsey Amin DDS Reviews

This article is a follow-up to a video from 2009 that I receive a lot of questions about. Block bone grafting for dental implants is still a very successful procedure…. But a lot has changed in 6 years!

(side note: Many people mistake the term “graft” with “graph.” The correct term is “graft”)

I highly suggest you watch the video and read this post. You’ll gain excellent information from both to help you make an informed decision if this is something you’re considering.

A block bone graft is done when there is a large section of bone that is missing. That area of missing bone is usually the outer wall of bone that faces your cheek. A block bone graft is needed when there is no way to put particulate bone particles into a “hole” like an extraction socket. The block bone graft attaches by screws to your jaw kind of like an orthopedic surgeon who is fixing a broken leg with screws. The screws are only kept in during the 4-6 months that the bone is reconnecting to your own existing bone.

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

after block bone graft, screw in place

after block bone graft, screw in place

So what has changed? My philosophy on where you get the bone from has changed! The reason for this is there is better scientific data to support the use of bone from a tissue donor (cadaver) rather than using your own bone! It used to be thought that using your own bone was the best.

I know this sounds crazy that using bone from somebody else would be better than using your own. But that has been my experience over the last 15 years doing block bone grafts for dental implants. Using block bone graft from your own body requires that I have to cut a piece of bone from your chin under the roots of your lower front teeth) or from the area where your lower wisdom teeth are or used to be. Cutting this piece of bone has its own risk factors especially the risk of permanent numbness because the nerves are close to the area where the bone has to be taken from. Using bone from a tissue donor has an unlimited supply so we don’t have to worry about the bone taken from these areas as not being enough.

What experienced dental implant surgeons around the world have agreed upon is that block bone grafts using your own bone tend to be “avascular.” This means that they do not have a good blood supply. Getting blood into the bone graft to bring it back to life is the key to success of a bone graft. Even though the bone is taken from your own body, sometimes that outer wall we call cortex is too hard and does not get good permeation of blood vessels called capillaries.

The addition of molecular enhancers and growth factors made from your own blood has also changed…. technology is evolving!!  The use of L-PRF, PRP and PDGF made from your own blood tremendously helps a block bone graft. These are made from drawing a little bit of blood at the beginning of your IV sedation and concentrating your own natural growth factors from your own blood . The growth factors and even stem cell will be reimplanted into the bone graft area…. This is truly awesome.

Accredited tissue banks have learned how to properly harvest this bone also. The type of bone I use has origin from the vertebrae (back bone) of another human being. Remember that this bone is 100% dead. Nothing is alive and it. It has undergone severe radiation treatment to kill everything. Your own body will make it alive again. Some small gaps around the bone graft may be filled in using cow bone which is also very safe and well documented over several decades now.

What hasn’t changed is the surgical ability to do this procedure and the ability for you to heal very well. This is definitely a procedure for a very advanced dental implant surgeon with a lot of experience. This would not be the type of bone graft for novice. You as the patient must also be healthy. Smoking , substantial alcohol use and diabetes would be significant risk factors and lowers the success of any dental bone graft and implant procedure.

The examples shown should help for you to understand why a block bone graft is done. On the first images you can see the bone in cross section taken from a 3-D scan. The bone is too narrow to accept the diameter of the virtual dental implant which is outlined over the bone. In order for dental implant to be successful there needs to be an abundance of bone especially on the outer wall of the implant for it to be stable long-term and last a long time. You can see on the images where the bone graft was completed and the screw is holding in the bone.

The gum is lifted, your own bone is prepared in order to receive the cadaver bone and that block bone graft is then screwed to your existing bone. The bone graft is hydrated in your own natural growth factors before it is screwed to your bone. The gum is passively covered back over the top and the block bone graft is allowed to heal for 4-6 months prior to removing the screw that holds the bone graft and placing the dental implant. A special type of temporary must be used for this bone graft if it is for a front tooth.

You can see the massive addition of volume that was added. The 3-D scan that was taken after the bone graft shows that same outline implant now sitting in a proper amount of bone. This will make the dental implant procedure extremely successful from a biological standpoint and from a cosmetic standpoint. When all of the bone is present both vertically and horizontally, there will not be open black triangles between the teeth which can be unsightly especially if it is the upper front area. The teeth on either side must have very healthy bone levels for this to occur. You cannot do a bone graft next to unhealthy teeth.

Block bone grafting using human tissue allograft from a cadaver is no longer a last ditch effort. Of course there are so many different ways to rebuild bone from bone widening expansion, socket bone grafting, sinus lifting, nerve repositioning, guided bone regeneration with membranes

huge dent in jaw --bone loss

huge dent in jaw –bone loss

after block

after block

after block

after block

after block bone graft

after block bone graft

block bone graft Ramsey Amin DDS front tooth (6)

Blood from novocaine injection given after patient was sedated for dental implant

 

After block bone graft --Implant placed --DAY OF SURGERY PHOTO

After block bone graft –Implant placed –DAY OF SURGERY PHOTO

3d Scan before block bone graft ---missing bone!!  Thin!

3d Scan before block bone graft —missing bone!! Thin!

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

Before bone graft --

Before bone graft —

before block bone graft -Missing bone

before block bone graft –bone is very thin

3d scan --before block bone graft

3d scan –before block bone graft

3d scan --after  block bone graft

3d scan –after block bone graft

pre molar block bone graft Ramsey Amin DDS (3)

After –bone very wide…ready for dental implant

 

Implant placed --after  block bone graft

Implant placed –after block bone graft

After block bone graft --Wide bone now

After block bone graft –Wide bone now

…. So there is no one solution for everyone. Your case must be studied carefully to determine what is going to be the safest procedure with the best outcome.

The block bone graft for dental implants is typically done in areas of the upper front and side teeth.  All photos are surgeries performed by me.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Do I Need PRP/PRF/PDGF/BMP For Dental Implants and Bone grafts?

In this video, I described what is PRP and PRF and how to concentrate growth factors, stem cells and molecular enhancers made from your own blood to be used in dental implant and bone grafting procedures. PRP, PRF, PDGF, BMP, and others, are all abbreviations for wonderful enhancers of dental implant bone grafts.

I make it from simply drawing a few test tubes of your own blood from your arm and concentrating your natural growth factors made from your own immune system. I have been using this technique since about 2003 and it always helps to reduce pain and make your bone and gums heal faster and stronger with less complications.

PRP/PRF is also helpful in reducing infections and helping blood to clot in a bone graft and makes the bone graft material handling hold together. It is extremely beneficial and safe because it is made from your own blood. It has been very well studied and documented for many years . Most of my patients that have very large sinus bone grafts usually only need Advil or Tylenol afterwards if they have had PRP/PRF/PDGF/BMP. There are other medical specialties that use this technology including vetrinarians.

it works very well and treating peri-implantitis also.

Watch this video to learn a lot more and feel free to ask questions of course.

Abbreviations
PRP = platelet rich plasma
PRF =platelet rich fibrin
PDGF =platelet derived growth factor
BMP =bone morphogenic protein

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

What Is A Membrane? Do I Need One For My Implant Bone Graft? My Membrane Fell Out/Sticking Out And Exposed

socket membrane Ramsey Amin DDS membrane space membrane ramsey amin dds What is a membrane?  Do I need one for my dental implant bone graft?  My membrane fell out or is sticking out and exposed.

These are questions and comments I receive constantly on my blog and from patients that come to see me in Burbank, California.

Let’s review what a membrane is and its purpose.

A membrane is a barrier.  Its purpose is to prevent gum from growing into the bone cavity.  On many bone grafts for dental implants, a membrane is placed over the bone but under the gum.  There are many different types and styles of membranes but they break down into basically 2 categories.

  1. Dissolvable (resorbable) membranesBurbank Dental Implants membrane
  2. Non-dissolvable (non-resorbable) membranes

Both resorbable and non-resorbable membranes have their use.  A resorbable membrane will dissolve on its own. Non-resorbable membranes typically need to be removed at some stage during your bone graft/dental implant procedure.
collagen membrane

Resorbable membranes:

Most resorbable membranes used, as of 2014, are made of collagen.  Collagen is a protein which you may have heard of in products such as shampoos and conditioners.  It is heavily cross-linked and makes an excellent barrier.  Most commercially available collagen membranes are 15 x 20mm in dimension and look like a flat, white piece of cardboard.

They are trimmed with surgical scissors by a dental implant specialist and typically covered over bone.  Most collagen membranes are made from bovine Achilles tendon or porcine origin, which basically translates into cow and pig.  Some resorbable membranes dissolve very quickly in just days; these are typically called plugs, while other resorbable membranes can last approximately 4 months.  Most resorbable membranes are not tacked in place with titanium fixation tacks.  Some are even pericardium from heart tissue.

The other types of natural resorbable membrane would be one made from your own blood!  Platelet rich fibrin or also known as PRF, can be used to make membranes from your own platelets.  Basically 1-6 test tubes of blood is drawn at the time that I start your IV.  Those test tubes are spun in a machine called a centrifuge, which separates out the layers of your blood.  It also concentrates your blood to be used for other platelet rich preparations called PRP and PDGF.

PRF can be used as a resorbable membrane as it tends to last 7-14 days.  It is stretched out and made thin so that it can be sutured.  It becomes a durable, kind of slimy consistency which can protect a bone graft.  PRF membranes can be used in addition to resorbable or non-dissolvable membranes for dental implant bone grafting.  PRP/PRF can speed up your healing and reduce pain and complications.

There are also synthetic membranes that dissolve, such as Vicryl, which are not as commonly used.

Non-resorbable membranes:

Most non-resorbable membranes can be made of titanium and dPTFE (Dense polytetrafluoroethylene).  They are materials that form a barrier that cannot be dissolved by your saliva.  Some non-resorbable membranes, such as PTFE, are often combined with bone tacks in order to hold the membrane stable and cover the grafted bone.

One benefit of a non-dissolvable membrane– they are very predictable in generating bone.  The main downside– it has to be removed at a second procedure.  Sometimes that second procedure may involve just plucking out the membrane off the top of your socket graft or it may be more involved, such as completely reopening the gum, removing the bone tacks, and then removing the membrane.  Typically when membrane removal involves removing tacks, the dental implants are placed at the same time that the membrane is removed.

PTFE has been used for over 30 years in cardiovascular applications such as suture, vascular grafts, and heart valves. PTFE is bioinert and does not cause inflammation.

Titanium reinforced membranes, or titanium mesh, is best at holding a space.  It works like a tent and prevents collapsing of your gums to build new volume and mass underneath.

Sometimes the membrane on a socket graft will be removed after 1-4 weeks or may even fall out if it is a dPTFE style membrane.  This is okay, generally.  The purpose was to allow your gum to grow underneath it and cover over the bone graft as the membrane protects it.  Once the membrane falls out or is removed from a socket bone graft, the bone still needs to heal for usually another 3-6 months before dental implant placement.

Is it okay that my membrane showing??  It depends!!  If the intention of your membrane was to be exposed from the beginning, then it is okay that it is exposed right now.  If it was the intention for your gum to remain covering over the membrane for 4 -9 months, then you are likely having a minor complication called a dehiscence where the gum becomes exposed and naturally exposes the membrane and bone graft.  The more critical the bone graft is, the more critical it is that the tissue remained closed and the membrane is not exposed at any time.  Critical bone grafts would be onlay block bone graft, lateral window sinus bone grafts, nerve repositioning, and advanced guided bone regeneration (GBR).

A standard socket bone graft (where an outer wall is not missing) would not be considered a critical bone graft; so leaving a membrane exposed is okay.  If an outer wall is missing, this would be considered a critical size defect.

It is important to maintain proper follow-up with your dentist throughout the procedure.  It is likely that you will be on an antibiotic, such as amoxicillin or clindamycin, and a mouth rinse called chlorhexidine gluconate.

Keep in mind there are literally hundreds, even thousands of different membrane manufacturers each claiming to be better than one another.  Yes, there are better manufacturers than others, but ultimately the surgical technique, training, judgment, and expertise of your dental implant specialist is going to be the most critical factor in the success of your bone graft…choose wisely!!!!!!

You can use all of the best materials in the world, including growth factors such as  PRP/PRF/PDGF/BMP, but in the hands of an inexperienced surgeon, results may not be that good.  Of course your ability to heal is of paramount importance.  Smoking never helps.  Alcohol does not help either… Both of these slow down the healing of bone and greatly increase your chance of complications.

Wearing a removable, temporary “flipper” over a bone graft is to be done with extreme caution.  Pressure from a removable temporary will cause the bone graft and membrane to move and almost always results in failure.  Be sure you and your dentist speak about the use of a temporary and how to create space underneath it so there is no chance that it can apply pressure to the bone graft.  Some bone graft membrane reconstructions are so critical and so large that the temporary cannot be worn at all, but that is the exception rather than the rule.

Ramsey A. Amin, D.D.S. (http://www.burbankdentalimplants.com)
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

 

Socket Bone Grafting….Do I Need It for My Dental Implant? Ramsey Amin DDS Reviews

Not all extractions need bone grafts for dental implants. A socket bone graft is done at the time of extraction to preserve the bone from shrinking. If the tooth is extracted and left alone, the bone will literally just melt away starting at just a few days after the tooth is removed. The keyword for a socket bone graft is “preservation.” This is called “bone atrophy.”

Let’s review the pros and cons of socket bone grafting:

So how do you know if you need a socket bone graft or not? The most critical zone of the mouth where socket bone grafts are extremely important are all of the front teeth to the middle “bicuspids.”This is because the bone on the outer wall of these teeth is much thinner than it is in the molar region.

Keep in mind there is massive variation from person to person on how thick the outer wall bone is. Your genetics play a huge role here. Some people have naturally thick outer walls of bone and some people have naturally thin bone which does not do well for dental implants.

Bone Graft NOT done

Bone Graft NOT done so her bone was lost

Bone Graft Done

Bone Graft Done (not same patient) –Wide bone

Patients that have thin bone tend to have thin gums too and are easily prone to recession around their teeth and or future dental implants. Patients that have thin bone and thin gums, have to be slightly overengineered in order to have long-term success with dental implants. Bone grafting for a person with a thin bone/gum “biotype” is always necessary. The outer wall of bone has to be designed in such a way that it is more resistant to shrinkage. This can be done by various surgical techniques and by using the right bone material for your particular situation. Not all bone is the same!

When the existing outer bone plate is thin, it is almost a guarantee that the bone is going to collapse as soon as the tooth is removed. This is because the tooth root is supporting that very thin wall of bone. So once the tooth is pulled, the bone collapses in order to close the socket. This leaves you with a depression of bone in that area. Without correction or prevention of that depression in the first place, an implant would have to be placed in a non-ideal position instead of in the center.

So what about the molars… those are the teeth that are extracted the most!! On many occasions the tooth being extracted has had a root canal. It may have abscessed and is painful. When an abscess occurs bone is often naturally dissolved the way on the outer surface. If the tooth being removed too infected, and has thicker bone, a bone graft may not be necessary or advisable at the time of extraction.

Ultimately the decision to do a socket bone graft for dental implant depends on the training, judgment, and experience of performing socket preservation bone grafting on a regular basis. Not only performing the procedure is important, but evaluating its results both on 3-D scan and how the bone feels at the time of implant insertion. And most importantly, how does this bone holdup long-term? I have personal experience of seeing the results of these procedures for the last 15 years as of 2014. The techniques that I use work well and last a long time.

Look for another post coming soon on membranes as that is a common problem area.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry