Dr. L. asks:
I have seen a new technique for augmentation of vertical height of bone on deficient alveolar ridges. You harvest autogenous bone and mix it with particulate bone graft material and/or particulate hydroxyapatite and deliver this on to the ridge. You cover with a membrane reinforced by a titanium mesh and stabilize with screws. You allow the graft to heal and then go back in to remove the titanium mesh and screws. How difficult is it to back in and remove the titanium mesh? I have not been able to find any photographs of how this is done or the complications that you may have. Has anybody done this and what are your recommendations? How successful is this procedure? Is this something a general practitioner can do?
From what i have red till now and seen, the sandwich technique is the newest using autologue bone. There are also the bio-blocks. Titanium mesh is not very difficult.
The main concern here would be the closure, if you can achieve tension free closure which heals as soon as posible without a tear, you are ok with the technique, BUT BUT BUT aiming to achieve all that with vertcal augmentation is not very easy in inexperienced hands
The main concern here would be the closure, if you think you can acieve a tension free closure with a fast healing without a dehiesence you are ok
BUT
Achieving all this in inexperienced hands is not easy
Success depends not on material but on the experience of the hands
This is not really a new technique. Particulate is not the best material for a vertical augmentation. Also, ti mesh has a pretty high rate of dehiscnce.
For vertical augmentation I like to use a ti re-enforced PTFE membrane and a material like Regenaform. Another option would be to use a tenting screw along with a resorbable collagen membrane.
As stated before- the key is get a tension free closure which does not compress the graft or produce a dehiscence over the membrane.
This isn’t new at all. You can cover it with a titanium reinforced PTFE membrane or titanium mesh. Or use you a suspended cortical strut (you can even do this via a tunnel approach). Series of tent screws covered with a membrane work the same (anything that rigidly holds your volumetric matrix)
This is not a new procedure at all. The screw removal is quite easy. In order to obtain primary closure you have to dissect all the way down to the inferior border both lingually and bucally on the mandible or all the way to the piriform rim on the facial of the maxilla. You also quite often have to filet the periosteum to further release the soft tissue. This technique is extrememly difficult to do on a patient who is not at least moderately sedated. I would not suggest trying this unless you have a great deal of surgical experience and are licensed for IV sedation or GA (an option would be to bring in a dental anesthesiologist). There are cadaver courses that teach this technique.
This is far from new technique. Prof. Massimo Simion (Milan, Italy) and prof. Sasha Jovanovic (UCLA)designed it some years ago. They even cover it within the gIDE course “1 year Master Program in Implant Dentistry”. They do it exactly as you described it, but within a last year they added a new tweak to it – BMP-2. And are able to control it! Nice stuff, definitely not for beginners.
Where can I find this technique illustated – using titanium reinforced PTFE membrane, titanium mesh, and/or tenting screws with collagen membrane?
Its success depends on multiple factors including experience, techniques, materials, patient’s age, blood supply, soft tissue type, primary closure, patient’s compliance and etc..
Its complication varies from post surgery, during healing period to after functional loading such as infection, graft exposure, graft failures with more severe resorption, graft resorption after restoring, esthetics compromise and so on…
Overall, it’s an unpredictable procedure. The more bone loss the more unpredictable.
LOL. Sasha is that you again ? Dr. Jovanovich did not design this technique…it’s been done before he was even practicing dentistry. A number of publications in the literature on this technique, however, it is prone to tissue dehiscence and lost of graft material. Not a predictable procedure in inexperienced hands.
Is anyone familiar with a vertical augmentation technique described by Tatum called a vascularized vertical augmentation?
Guy, Dr. Tatum actually calls it a vital segmented osteotomy.
Definitely not a new technique. No need to do under IV sed, but not a bad thing if the patient is out for any surgery. Tent screws and resorbable don’t work very well. Tent screws and non-resorbable work very well. Ti-reinforced PtFE secured with Tacks is not a bad technique and works well. I have had the best results with Ti mesh and screws. I use particulate bone and always mix in some autogenous cancellous bone. The results are amazing and predictable. The difficulty in the technique is PROPER tensionless primary closure, and proper suturing. This is not a technique I would recommend if you don’t get CONSISTANT results with particulate and resorbable membranes. Very technique sensitive. Be ready to deal with exposed mesh from time to time. If you can get the patient to pay for the BMP-2 this would be the way to go, just add about $5000 to your tx plan.
There are some great vertical augmentation techniques. Tinti published a nice one in the international journal of perio and restorative dentistry.
Last month Dr. Sohn showed a very nice sandwich technique utilizing piezo within the journal of implant and advanced clinical dentistry.
Simion and Jovanovic showed a technique leaving implants high and grafting up to them.
I would like to know ,normally ,after the ridge split mandible technic with implant placement how many weeks should I wait to begin the prothetic reabilitation
Mario, go out 6 to 8 months.
This is a very technique sensitive procedure that should use a reinforced PTFE membrane. I would only suggest attempting this if you have adequate surgical experience.