Large defect at extraction site: best way to approach this?

Without any additional information about your procedure, the one area I find most difficult to control is vertical releasing incisions, especially when they are close to the grafted site. I can get almost identical results using a wide range of graft materials or types of membranes/barriers. However, singularly, the number one cause of failure of grafts is failure to achieve primary closure for the required healing time, or dehisence of the flap. Wide flaps that extend several teeth from the grafted area, adequate flap advancement, and atraumatic healing are the best ways to ensure adequate healing. Additionally, you can add a biologic such as L-PRF to get faster soft tissue closure. A resorbale membrane without retention of shape/volume, even with good primary closure, will result in additional collapse of volume during the catabolic (resorptive) phase. Try the same technique, but this time with a different approach to raising your flaps. RJM

No regenerative procedure is successful 100% of the time. But as Dr Miller has correctly noted " ...the number one cause of failure of grafts is failure to achieve primary closure for the required healing time, or dehiscence of the flap." For this reason we have developed flapless socket grafting. Greg Steiner Steiner Laboratories

I am going to assume there was no buccal plate hence the need for a membrane. The "trick" to a vertical releasing incision is undermining and advancing the flap to allow closure. If a small amount of teflon membrane is exposed you watch it and allow the tissue to granulate under it, removing it probably disturbed the graft. Now you have burned a bridge. The defect can be corrected with an onlay graft either solid block or particulate with growth factors. Now you REALLY need to be able to advance a flap with primary closure since this didn't happen the first time, please do the right thing and refer it to someone who can do this, even better go watch the surgery! I don't like flapless techniques since you are only guessing as to the quality or quantity of buccal plate, you need to see it. I agree with RJM however, going in a second time with the same skill set is not in the patient's best interests.

Dear Colleague, Incision line opening is one of the most frequent, if not the most frequent, of post-surgical "complications". In order to minimize the occurence of this complication, proper flap management and the understanding of proper flap design is imperative. In addition, the pre-operative clinical and biologic state of the surgical site, needs to be understood in order to make the proper pre-operative tentative decisions about applications of the proper surgical and biological regenerative materials and techniques. The scientific literature is varied and rich with such information. All that being said, there are several biologically enhancing materials available, and, Choukroun's PRF is an excellent choice; however, these materials assume that proper surgical technique is administered. Take home message: If we are going to do this science in the clinical setting, let's be sure that we know how to troubleshoot the possible complications. To do this stuff, you can get away with only needing a recipe. To troubleshoot, however, you better know your science and the scientific literature. Good Luck. Dr Mario Marcone Montreal, Canada

Well said Dr Marcone.

This is why I discourage the vertical release, however if it must be done, it should be so far away from the surgical site that it doesn't matter if it breaks down. Let us see some images. I bet if you wait three months, you will find that there is enough bone to proceed. Your first procedure " failed", so let nature take its place. You can always augment the buccal aspect of your implant, it the bony topography is not perfect at the time of placement . Bvinci

I think to wait 6-8 weeks and go back is a good plan. I would see the patient a few days prior to the surgery to make sure the gum will be healthy and will allow you to obtain primary closure this time. A gum grafting might be required prior to a new bone graft depending on what you have. A collagen membrane alone is a good option depending on the type and the extent of the defect. I agree with Dr Miller. The result does not depend on the type of membrane you use, but rather on your understanding of guided bone regeneration. Beware, failure with resorbable collagen membrane can lead to severe bone loss and headaches. Sometimes, it is better for our patient, our sleep, our reputation and our wallet to refer out a colleague who can do GBR. Good luck.

Thanks to everyone that replied I appreciate all of your thoughts Brent

Hi, well make your flap wider and releasing inscision longer, (given that you have placed and secured your membrane and biomaterial in the surgical site)' de-epethilialize, both ends of your flap, so that good coaptation will occur, also with proper width and hight of the flap do a Burgers flap, in which once again you deepithilialize the edges of your gingive to be sutured, blood should ooze a little upon closure... Witha good pressure gauze pack, followed by the clot, your good to go:)