Efficiencies Of Block Graft Syllabus
2014-09-04
: Pdf Efficiencies Of Block Graft Syllabus Efficiencies_of_Block_Graft_Syllabus 9 2014 pdf
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9/4/2014 Efficiencies in Block Harvest & Fixation H. Ryan Kazemi, DMD Oral & Maxillofacial Surgery Bethesda, MD implant cloud 1 9/4/2014 block graft available bone? stability? implant survival? 2 9/4/2014 block graft available bone? stability? implant survival? ramus good volume low morbidity donor site bone volume tuberocity 2-5 cc chin / ramus 5-10 cc autogenous collection iliac crest - anterior - posterior - trephine < 1cc 30-40 cc 70-140 cc 10-20 cc block graft available bone? stability? implant survival? long-term block graft stability in thin periodontal biotype patients 97% of augmented width maintained after 3.3 years verdugo etal, Int j oral maxillofac implants 2011; 26:325332 osseointegration critical to preservation of grafted bone block graft available bone? stability? implant survival? the potential of the horizontal ramus of the mandible as a donor site for block and particular grafts in pre-implant surgery 99% implant survival rate soehardi a, et al. ijomi 2009 nov; 38 (11) greatest stress of implant at neck / crest + increased bone density of block graft (D1) = distinct biomechanical advantage 3 9/4/2014 clinical recipient cbct << deficiency type defect size soft tissue biotype inter-septal bone vestibular depth defect form defect size anatomy >> classification siebert horizontal: I vertical: II mixed: III allen vertical: A horizontal: B mixed: C Cologne Orientation, graft needs, relation of graft to defect recipient site width height IAN 4 9/4/2014 recipient site shape of ideal block graft recipient site width donor site height IAN 5 9/4/2014 planning block form 0º 10º 20º donor recipient donor recipient 6 9/4/2014 7 9/4/2014 surgical order 1️⃣ draw blood for prgf 4️⃣ 2️⃣ 3️⃣ fixate open open recipient donor site block to site & harvest recipient block incision & flap 8 9/4/2014 block harvest 1️⃣ measure sagittal medio-lateral vertical caudal over extension sagittal, vertical, & caudal >> 10% medio-lateral >> 20% block harvest 2️⃣outline sagittal cut medio-lateral cut vertical cut caudal cut block harvest 2️⃣outline 9 9/4/2014 block harvest 2️⃣outline- caudal block harvest 3️⃣complete osteotomy block harvest 3️⃣complete osteotomy 10 9/4/2014 block harvest 4️⃣split block harvest 4️⃣split block harvest 4️⃣split 11 9/4/2014 block harvest 4️⃣split block harvest 5️⃣block fracture 12 9/4/2014 storage moist guaze prgf ⚠︎ NO saline immersion particulate harvest trephine burs 13 9/4/2014 particulate harvest bone scraper particulate harvest bone scraper autogenous bone + mineralized bone + prgf bone complex prepare recipient maximal interface & stability butt joints at the recipient bed medio-lateral line angle caudal line angle 14 9/4/2014 prepare recipient maximal interface & stability decorticate perforation prepare recipient maximal interface & stability modify block 15 9/4/2014 adapt block adapt block fixation AO- Arbeitsgemeinschaft fur Osteosynthesefragen compression >> lag technique lag screw primary bone healing reduction (contact) rigid fixation compression decreases gap increases stability overdrill near cortex to size of the external diameter of the screw 16 9/4/2014 screw stability and compression of block / recipient overdrill the block hole screw perpendicular to ‘fracture site’ countersink to create a platform select the right screw length two-point fixation screw stability and compression of block / recipient overdrill the block hole screw perpendicular to ‘fracture site’ countersink to create a platform select the right screw length two-point fixation screw stability and compression of block / recipient overdrill the block hole screw perpendicular to ‘fracture site’ countersink to create a platform select the right screw length two-point fixation 17 9/4/2014 screw stability and compression of block / recipient overdrill the block hole screw perpendicular to ‘fracture site’ countersink to create a platform select the right screw length two-point fixation screw stability and compression of block / recipient overdrill the block hole screw perpendicular to ‘fracture site’ countersink to create a platform select the right screw length two-point fixation fixation- 1️⃣ hold block 18 9/4/2014 fixation- 2 vs 3 point min 3 mm 2 3 3 2 prevent stress fracture of block fixation- 2️⃣ first drill min 3 mm fixation- 2️⃣ first drill 19 9/4/2014 fixation- 3️⃣ over-drill 702 bur tip 1.1 mm head 1.6 mm length 4.5 mm lag technique easy rotation of screw without block 0.8 mm displacement 701 bur tip head 1.2 mm length 3.8 mm fixation- 3️⃣ over-drill fixation- 4️⃣ countersink 8 round diamond diameter 3 mm 20 9/4/2014 fixation- 5️⃣ screw fixation- 6️⃣ osteoplasty fixation- 6️⃣ osteoplasty 21 9/4/2014 fixation- 7️⃣ perforations flap release- tensionless flap release- tensionless complete flap elevation periosteal scoring supra-periosteal dissection 22 9/4/2014 bone gap fill prgf autogenous particulate bone mineralized allogenic bone to expand bone gap fill bone gap fill 23 9/4/2014 membrane membrane prgf membrane 24 9/4/2014 prgf membrane tension-less closure prgf clot in donor site implant planning 25 9/4/2014 implant planning before after Implant Placement Implant Placement 26 9/4/2014 Implant Placement Implant Placement cad / cam customized bone blocks 27 9/4/2014 predesign & prefabricate an ideal block simplify improve adaptation decrease operative time cad allografts CBCT Ridge Augmentation Using Customized Allogenic Bone Blocks: Proof of Concept and Histological Findings Customized Allogenic Bone Blocks Schlee, M, Rothamel, D: Implant Dent 2013; 0: 1-7 3-D planning software defect drawn on 3-D surface 3-D information converted CNC programming graft milled out of a single block cad allografts Ridge Augmentation Using Customized Allogenic Bone Blocks: Proof of Concept and Histological Findings Schlee, M, Rothamel, D:Implant Dent 2013; 0: 1-7 28 9/4/2014 cad allografts Ridge Augmentation Using Customized Allogenic Bone Blocks: Proof of Concept and Histological Findings Schlee, M, Rothamel, D:Implant Dent 2013; 0: 1-7 cad allografts Ridge Augmentation Using Customized Allogenic Bone Blocks: Proof of Concept and Histological Findings Schlee, M, Rothamel, D:Implant Dent 2013; 0: 1-7 cad /cam customized autogenous bone blocks 29 9/4/2014 CBCT 3-D design of block harvest block chair-side milling machine immediate placement ❓bone handling ❓sterility ❓cellular response ❓cost stay tuned www.facialart.com 30 9/4/2014 V. Broumand, DMD, MD Assistant Professor of Surgery Director of Resident Medical Education University of Miami Miller School of Medicine Complications during surgery, immediate post operative and long term for the harvest site Autogenous Bone Harvesting For Ridge Augmentation 1. 2. 3. 4. Tibia Symphysis Ramus Maxillary Tuberosity 1 9/4/2014 Tibia Bone Harvest An Office Procedure 2 9/4/2014 Gerdy’s Tubercle 3 9/4/2014 4 9/4/2014 5 9/4/2014 6 9/4/2014 Post Op Instructions 1. 2. 3. 4. Normal activity No sports, running, or stairs for 6 weeks Ice x 48 hours Elevate leg at night 7 9/4/2014 8 9/4/2014 Tibial Bone Harvest In Office Setting 571 consecutive tibial bone graft donor sites were assessed for intraoperative and postoperative morbidity. Results Harvested bone quantities ranged from 11 ml to 40 ml with a mean of 22.4 ml. 9 9/4/2014 Morbidity Blood loss range from 25 ml to 122 ml with a mean of 45 ml. There were no intraoperative misadventures such as knee joint entrance, cartilage damage, or affect to patellar tendon. Potential Complications Tibia Harvest 1. 2. 3. 4. 5. Ecchymosis Dehiscence Hematoma Entering the knee joint Scar Morbidity Parameters Fractures Gait Disturbance Knee Joint Entrance Knee Joint Complaints Hematoma Dehiscence Objectionable Scar Ecchymosis 0 0 0 0 4 12 9 44 (0%) (0%) (0%) (0%) (0.7%) (2.1%) (1.6%) (7.7%) 10 9/4/2014 Tibial Harvest Complications O’Keefe in 1991 – 230 grafts for orthopedic reconstruction in operating room setting. Complication rate 1.4%. Tibial Harvest Complications Marx, Schalit, Bartholomew 1997 – 2004 571 grafts in office setting for oral and maxillofacial surgery Complication rate 1.1% Tibia Bone Harvest Advantages 1. 2. 3. 4. 5. 6. Minimal morbidity Good quality bone (note, slightly less than ilium) Office or operating room procedure Straightforward anatomy and technique Requires minimal instrumentation Can be accomplished under IV sedation 11 9/4/2014 Tibia Bone Harvest Disadvantages 1. 2. 3. Limited to 30 cc of bone Edema about ankles No block graft capability Symphysis Graft Harvest 12 9/4/2014 13 9/4/2014 Potential Complications Symphysis Harvest 1. 2. 3. 4. Parasthesia * Fracture Tooth root damage Change in lip position Ramus Graft Harvest 14 9/4/2014 15 9/4/2014 16 9/4/2014 17 9/4/2014 18 9/4/2014 Potential Complications Ramus Harvest 1. 2. 3. 4. 5. Parasthesia * Fracture Nerve transection Tooth root damage Hematoma 19 9/4/2014 Complication Parasthesia – Nerve Injury 1. 2. 3. 4. If no observation of nerve injury: observation If nerve transected: Immediate nerve reanastamosis or < 3 months If nerve observed as injured but not transected: repair immediately or < 3 months If parasthesia persists with unknown but suspected nerve injury: explore and repair nerve < 3 months 20 9/4/2014 Tuberosity Graft Harvest 21 9/4/2014 22 9/4/2014 Complications Oral Antral Fistula 1. 2. Ensure healthy sinus Two layered closure: A. local tissue inversion and palatal flap B. buccal fat pad transfer nd local mucosal advancement 23 9/4/2014 24 9/4/2014 25 9/4/2014 26 9/4/2014 Potential Complications Tuberosity Harvest 1. 2. 3. Oral-antral fistula Sinusitis Tooth root damage Sinus Lift 27 9/4/2014 28 9/4/2014 Contraindications of Maxillary Sinus Grafting Acute sinusitis Cysts Tumors Foreign Bodies 29 9/4/2014 30 9/4/2014 31 9/4/2014 32 9/4/2014 33 9/4/2014 Etiology of the Sinus Perforation Window osteotomy Infracturing of the bony window Reflection of the sinus membrane 34 9/4/2014 Management of the Perforation If a large perforation cannot be sutured or covered by a collagen barrier, the graft material should not be placed 35 9/4/2014 36 9/4/2014 COMPLICATIONS OF THE SINUS LIFT 37 9/4/2014 INTRAOPERATIVE COMPLICATION BLEEDING MEMBRANE PERFORATION DAMAGE TO ADJACENT DENTITION MAXILLARY SINUS VASCULAR SUPPLY BRANCHES OF THE MAXILLARY ARTERY INFRA ORBITAL ARTERY SPHENOPALATINE ARTERY POSTERIOR SUPERIOR ALVEOLAR ARTERY Solar et al COIR 1998. BLEEDING VISUALIZED IN CT SCAN 53% AVERAGE HEIGHT 16.4 mm 20% OF OSTEOTOMIES AGE RELATED Elian et al JOMI 2005. 38 9/4/2014 BLEEDING MEMBRANE ELEVATION BECOMES MORE DIFFICULT INTERFERES WITH PLACEMENT OF GRAFT MATERIAL HEMATOMA FORMATION ELIAN et al JOMI 2005. NICOLAAS et al J OMS Surg 2001. BLEEDING PREVENTION: PREOP IDENTIFICATION SMALL WINDOW TWO WINDOWS MANAGEMENT PRESSURE BONE WAX CAUTERIZATION MEMBRANE PERFORATION MAIN COMPLICATION INCIDENCE OF 7% - 44% INFILTRATION OF GRAFT MATERIAL INTO THE SINUS BACTERIAL PENETRATION INTO THE GRAFT MUCOUS INVASION INTO THE GRAFT Schwartz – Arad et al J Periodontol 2004. Periklis et al JOMI 2004. 39 9/4/2014 MEMBRANE PERFORATION WHEN DOES IT HAPPEN? WINDOW OPENING MEMBRANE ELEVATION 40 9/4/2014 MEMBRANE PERFORATION MANAGEMENT OF SMALL PERFORATION SUTURE CLOSURE FIBRIN ADHESIVE COVER WITH A MEMBRANE Schwartz – Arad et al J Periodontol 2004. 41 9/4/2014 MEMBRANE PERFORATION TREATMENT OF WIDE PERFORATION MEMBRANE ABANDON PROCEDURE Pikos M Implant Dentistry 1999. Fugazzotto et al Inn in Perio 2003. 42 9/4/2014 MEMBRANE PERFORATION BLEEDING CONTROL 43 9/4/2014 44 9/4/2014 MEMBRANE PERFORATION DENTAL RELATED IMPLANT RELATED 45 9/4/2014 46 9/4/2014 47 9/4/2014 FRACTURED IMPLANTS INVOLVES MANUFACTURI NG USE OF EXCESSIVE FORCE FRACTURES ARE NOT VERY COMMON 48 9/4/2014 PRESENCE OF SEPTA 30% INCIDENCE 75% 2nd PREMOLAR – 1st MOLAR REGION USUALLY BUCCOPALATAL DIRECTION HIGHER RISK OF MEMBRANE PERFORATION MODIFICATION OF THE WINDOW DESIGN Ulm et al JOMI 1995. Betts et al J OMS Surg 1994. 49 9/4/2014 DAMAGE TO ADJACENT DENTITION EXCESSIVELY LARGE WINDOW DEVITALIZE ADJACENT TEETH REDUCE BONY SUPPORT SINGLE TOOTH SINUS LIFT POSTOPERATIVE COMPLICATION USUALLY OCCURS WITHIN THE FIRST 3 WEEKS WOUND DEHISCENCE INFECTION ACUTE LOCALIZED INFECTION SINUSITIS OSTEOMYELITIS GRAFT / IMPLANT LOSS Schwartz – Arad et al J Periodontol 2004. 50 9/4/2014 POSTOPERATIVE COMPLICATION PREVENTION ANTIBIOTICS NASAL DECONGESTANTS MOUTH RINSES SINUS PRECAUTIONS WOUND DEHISCENCE PREVENTION WOUND CLOSURE OVER INTACT BONE NO TENSION PASSIVE CLOSURE WOUND DEHISCENCE PREVENTION WATER TIGHT CLOSURE NO REMOVABLE PROSTHESIS 51 9/4/2014 MANAGEMENT OF WOUND DEHISCENCE SMALL MOUTH RINSE SECONDARY INTENTION LARGE REAPPROXIMATION OF THE WOUND MARGIN ETIOLOGY OF SINUS INFECTION FROM SINUS LIFT SURGERY CROSS CONTAMINATION TRAUMATIC SURGICAL TECHNIQUE UNDIAGNOSED SINUS PERFORATION FOREIGN BODY REACTION IMMUNOLOGIC DISORDER GRAFT CONTAMINATION UNDIAGNOSED SINUS PATHOLOGY INFECTION LEADING CAUSE OF IMPLANT FAILURE BLOCKAGE OF THE OSTIUM SPREAD OF INFECTION 52 9/4/2014 Orbital Cellulitis Management of Infection Incision and drainage Irrigation Debridement of hard and soft tissues Removal of graft/implant ORO-ANTRAL FISTULA 53 9/4/2014 COMPLICATIONS INTRAOPERATIVE – – – – – BLEEDING SINUS PERFORATION PRESENCE OF SEPTA DAMAGE TO ADJACENT TEETH FRACTURED IMPLANTS POSTOPERATIVE – WOUND DEHISCENCE – INFECTION – FAILURE 54 9/4/2014 Thank you References Fonseca, R.J. Walker, R.V. Betts, N.J. Barber, H.D. Oral and Maxillofacial Trauma. Saunders. 1997 Miloro, M. Ghali, G.E. Larsen, P.E. Waite, P.E. Peterson’s Principles of Oral and Maxillofacial Surgery. BC Decker INC. 2004 Marx, R.E. Philosophy and particulars of autogenous bone grafting. Oral and Maxillofacial Surgery Clinics of North America. 5:599-612, 1993 Marx, R.E. Biology of Bone Grafts. Oral and Maxillofacial Surgery Knowledge Update. 1:3-17. 1994 Piecuch,J.F. Silverstein, K. Quinn, P.D. Bone grafts in Preprosthetic Surgery. Oral and Maxillofacial Surgery Knowledge Update 2:11-35. 1998 Stevens, M.E. Bone Harvesting Techniques. Oral and Maxillofacial Knowledge Update. 1:19-34. 1994 Roberts, W.E. Roberts, J.A. Epker, B.N. Burr, D.B. Remodeling of Mineralized Tissues, Part I: The frost Legacy. Seminars in Orthodontics 12:216-237. 2006 Roberts, W.E. Roberts, J.A. Epker, B.N. Burr, D.B. Remodeling of Mineralized Tissues, Part:II Control and Pathophysiology. Seminars in Orthodontics 12:238-253. 2006 The End 55
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