The lost buccal plate

“Perio-Implant Synergy”- Two lectures on “Lost Buccal Plate- Complications and Management” and “Failing to Plan is Planning to Fail”. Organized by the Society of Periodontists and Implantologists of Kerala” at PMS Dental College, Trivandrum, India on 17/9/2018.

1. Dr R Viswa Chandra MDS;DNB;PhD Professor and Head Dept of Periodontics SVSIDS Mahabubnagar TS THE LOST BUCCAL PLATE COMPLICATIONS AND MANAGEMENT

2. Ganz SD. The triangle of bone—a formula for successful implant placement and restoration. Article in The Implant Society: [periodical]· January 1995. Garcia JJ et al. A new protocol for immediate implants. The rule of the 5 triangles: A case report – EAO 2014. Biotype Primary stability Implant design Jumping Gap Buccal Plate Rule of five triangles

3. “I found a way to see in the dark. Close your eyes.” ― J.R. Rim

4. Schropp L, et al. Int J Periodontics Restorative Dent. 2003 Aug;23(4):313-23. Hämmerle CH, et al. Clin Oral Implants Res. 2012 Feb;23 Suppl 5:80-2. Weng D, et al. Eur J Oral Implantol. 2011;4 Suppl:59-66. Two-thirds of resorption occurs within the first three months

5. The buccal plate is the weakest amongst the socket walls Buccal plate thinning, dehiscences or fenestrations are common reduction in almost 50% of cases post extraction *H. D. Barber and N. J. Betts. Implant Dentistry, Vol. 2, No. 3, 1993, pp. 191-193. Schropp L, Wenzel A, Kostopoulos L, Karring T. Int J Periodontics Restorative Dent. 2003;23:313–323. Thinning Dehiscence Fenestration

6. What is a “lost buccal plate”? Esposito M et al. Eur J Oral Implantol 2009;2(3):167–184. Extraction Socket Dehiscence Defects Horizontal Defect Vertical Defect

7. What is a “lost buccal plate”? I II III Intact Socket Dehiscence- Fenestration Large Dehiscence

8. Fragility of the buccal plate Novaes Jr et al. J Periodontol 2011;82:872-877. Higher Density More marrow spaces Less thinner ̴ 1mm

9. Causes of buccal plate loss LOSS OF BUCCAL PLATE BIOLOGICAL BONE ›Bone Quality ›Bone Quantity MECHANICAL SOFT TISSUE ›Biotype ›Flap Design IMPLANT SIZE ›Diameter ›Length IMPLANT DESIGN ›Macrosurface ›Microsurface Hämmerle CH. et al., Int J Oral Maxillofac Implants. 2004;19 Suppl:26-8.

10. Immediate Implant Metal Show (IIM) Delayed Implant Shadow Show (DISS) Delayed Implant Actual Show (DIAS) Mazen Almasri. Surgical Science. 2013:4;110-113. Signs of a “losing or lost buccal plate”

11. The need for intervention * Vignoletti F, et al. Clin Oral Implants Res. 2012 Feb;23 Suppl 5:22-38. **Weng D, et al. Eur J Oral Implantol. 2011;4 Suppl:59-66. › Poorer maintenance of healthy periimplant soft tissues › Poorer aesthetic outcomes › 10 times greater need for hard tissue augmentation at implant placement without previous Ridge Preservation

12. Intervention Prevent volume loss Improve the aesthetic outcomes Cardaropoli D, et al. Int J Periodontics Restorative Dent. 2014 Mar–Apr;34(2):211-7. Morjaria KR, et al. Clin Implant Dent Relat Res. 2014 Feb;16(1):1-20.

13. P ROBLEM O UTCOME IMMEDIATE IMPLANT DELAYED IMPLANT T ECHNIQUE SP ESR ISD SP - Socket preservation ESR - Extraction Site Reconstruction ISD -Implant Site Development

14. Clinical decision tree for alveolar ridge-preservation procedures *RONALD E. JUNG,ALEXIS IOANNIDIS,CHRISTOPH H. F. H€AMMERLE & DANIEL S. THOMA. Periodontology 2000, Vol. 0, 2018, 1–11.

15. Selection criteria for regeneration in lost buccal plate It is important that the regenerative material used to fill defects correspond the number of walls of host bone remaining in contact with the graft. Misch & Misch (2010) and Ogunsalu (2011) gave a standard criteria in this regard. *Christopher Ogunsalu (2011). Bone Substitutes and Validation, Implant Dentistry - The Most Promising Discipline of Dentistry, Prof. Ilser Turkyilmaz (Ed.), ISBN: 978-953-307-481-8.

16. Additional active elements are beneficial in this graft since bone does not surround the defect. GTR/GBR+OSTEOINDUCTION/GENESIS . 1 2 3 4 Four wall defect ~ Labial bone loss

17. GBR/GTR+ Cortical AUTO/ALLOGENOUS GRAFT . Alloplasts are NOT advantageous 1 2 3 Two/Three wall defect ~ Labial bone loss

18. IMPLANT SITE DEVELOPMENT Bartee (2011) 1-2 Missing walls Autogenous bone Osteoinductive Materials Rigid membranes >2 Missing walls Block Grafts Rigid fixation No membranes Bartee BK. Implant Site Development and Extraction Site Grafting. 2011 by Osteogenics Biomedical, Inc

19. Managing the Plate of Bone Greenstein and Cavallaro (2013) NO ADDITIVE TREATMENT BONE GRAFT +/- GROWTH FACTORS BARRIER ONLY BARRIER + BONE GRAFT ›Flap positioned over defect › Flap Placed at crest ›Flap positioned over defect › Flap Placed at crest ›With Flap Advancement ›Without Flap Advancement ›With Flap Advancement ›Without Flap Advancement Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement. Continuing Education . Course Number: 159 2013

20. No additive treatment Flap placed over the defect Small defects with respect to height and width could be eliminated without the use of a membrane and/or a bone graft. Chen ST, Darby IB, Adams GG, et al. A prospective clinical study of bone augmentation techniques at immediate implants. Clin Oral Implants Res. 2005;16:176-184.

21. Objectives › One-stage treatment of hard and soft tissues › Preservation of the alveolar bone volume › Long-term good aesthetic outcome in front teeth with short treatment time.

22. No additive treatment Flap positioned at bone crest Gaps < 2 mm usually heal without allografts, xenografts, and barriers when implants are submerged Juodzbalys G, Wang HL. Soft and hard tissue assessment of immediate implant placement: a case series. Clin Oral Implants Res. 2007;18:237-243.

23. Compensating for osteogenic jumping distance LARGER DIAMETER IMPLANT BUCCAL POSITIONING GRAFTING ON BUCCAL BONE X Bone response? X Loss of prosthetic centre X More Bone loss M. G. Araujo, F. Sukekava, J. L. Wennstrom, and J. Lindhe, Clinical Oral Implants Research, vol. 17, no. 6, pp. 615–624, 2006.

24. Objectives › The technique minimizes the treatment time › The treatment maintains the archetype of the soft and hard tissues

25. NO ADDITIVE TREATMENT BONE GRAFT +/- GROWTH FACTORS BARRIER ONLY BARRIER + BONE GRAFT ›Flap positioned over defect ›Flap Placed at crest ›Flap positioned over defect › Flap Placed at crest ›With Flap Advancement ›Without Flap Advancement ›With Flap Advancement ›Without Flap Advancement Managing the Plate of Bone Greenstein and Cavallaro (2013)

26. Graft with or without Growth Factors With Flap over the defect

27. *RONALD E. JUNG,ALEXIS IOANNIDIS,CHRISTOPH H. F. H€AMMERLE & DANIEL S. THOMA. Periodontology 2000, Vol. 0, 2018, 1–11. Turchi JL. Dent Today. 2008 Jun;27(6):112, 114. If the endpoint is high quality bone, use Autografts and Bioactive glasses

28. Graft with or without Growth Factors With Flap at the crest Markus Glocker, , Thomas Attin and Patrick R. Schmidlin. Ridge Preservation with Modified “Socket-Shield” Technique: A Methodological Case Series. Dent. J. 2014, 2(1), 11-21; https://doi.org/10.3390/dj2010011 GLOCK’s Technique

29. Growth factors combined with Socket-shield preserves up to 88 % of the ridge width and promote more new bone formation vs no membrane Perelman-Karmon et al. Int J Periodontics Restorative Dent. 2012 Aug;32(4):459-65. Jung RE, et al. J Clin Periodontol. 2013 Jan;40(1):90-8.

30. NO ADDITIVE TREATMENT BONE GRAFT +/- GROWTH FACTORS BARRIER ONLY BARRIER + BONE GRAFT ›Flap positioned over defect ›Flap Placed at crest ›Flap positioned over defect ›Flap Placed at crest ›With Flap Advancement ›Without Flap Advancement ›With Flap Advancement ›Without Flap Advancement Managing the Plate of Bone Greenstein and Cavallaro (2013)

31. De Stavola L, Tunkel J. Int J Oral Maxillofac Implants. 2014 Jul-Aug;29(4):921-6. doi: 10.11607/jomi.3370 "Obtained Primary Closure” 87.6% “Compromised closure” 44.6% of complications attributable to improper closure Barrier only placed over defect With Flap advancement

32. It may be beneficial to use a barrier, and this would necessitate elevating a flap in order to achieve wound closure. Pearce AI, Richards RG, Milz S, et al. Animal models for implant biomaterial research in bone: a review. Eur Cell Mater. 2007;13:1-10.

33. Barrier only placed over defect No flap advancement * Rosen PS, Rosen AD. Compend Contin Educ Dent. 2013 Jan;34(1):34-8, 40. OPEN GBR CONCEPT Altering the amount of keratinized tissue Altering soft-tissue landmarks Increased pain, swelling or paraesthesia ProTiss®

34. ProTiss® With a flapless approach, it is suggested that overfill of the gap with bone helps support the soft tissue and reduces recession and bone loss. Tarnow D. Immediate vs. delayed socket placement: what we know, what we think we know and what we don’t know. American Academy of Periodontology Annual Meeting; November 14, 2011; Miami Beach, FL

35. TISSUE GRAFTS- PEDICULATED/ NON-PEDICULATED El Chaar E, Oshman S, Cicero G, Castano A, Dinoi C, Soltani L, Lee YN.Soft Tissue Closure of Grafted Extraction Sockets in the Anterior Maxilla: A Modified Palatal Pedicle Connective Tissue Flap Technique. Int J Periodontics Restorative Dent. 2017;37(1):99-107.

36. Objectives › Almost complete maintenance of the ridge volume is achieved › After 8–10 weeks, the soft tissue has a quality and maturity that is adequate for early implant restoration.

37. NO ADDITIVE TREATMENT BONE GRAFT +/- GROWTH FACTORS BARRIER ONLY BARRIER + BONE GRAFT ›Flap positioned over defect ›Flap Placed at crest ›Flap positioned over defect ›Flap Placed at crest ›With Flap Advancement ›Without Flap Advancement ›With Flap Advancement ›Without Flap Advancement Managing the Plate of Bone Greenstein and Cavallaro (2013)

38. Stevens MR, Emam HA, El Alaily M, Shar-awy M. Implant bone rings. One-stage three-dimensional bone transplant technique: a case report. J Oral Implantol 2010;1:69–74. 21. Barrier placed over graft With Flap advancement

39. Bone-ring techniques offer multiple advantages of a 1-stage procedure for immediate implant placement and 3-D bone augmentation. Proper treatment planning and careful surgical execution are essential to ensure predictability. Kaufman E, Wang PD. Localized vertical maxillary ridge augmentation using symphyseal bone cores: a technique and case report. Int J Oral Maxillofac Implants 2003;18:293–8.

40. Barrier placed over graft Without Flap advancement

41. Several recent articles have indicated that if a flap is not raised, there is better increase in bone dimensions when a graft is used. Vera C, De Kok IJ, Chen W, et al. Int J Oral Maxillofac Implants. 2012;27:1249-1257. Degidi M, Daprile G, Nardi D, Piattelli A. Clin Oral Implants Res. August 13, 2012. doi: 10.1111/j.16000501.2012.02561.x. Brownfield LA, Weltman RL.. J Periodontol. 2012;83:581-58

42. Objectives › Fast and scar-free soft-tissue regeneration › Optimal clinical and aesthetic result for the patient

43. A partially missing buccal plate is not a critical factor for primary stability Even complete loss of buccal plate is no issue if primary stability can be obtained Delayed implant placement approach is recommended in extreme buccal plate loss Biomaterials can be placed without a barrier Degidi M, Daprile G, Nardi D, Piattelli A. Clin Oral Implants Res. doi: 10.1111/j.16000501.2012.02561.x.

44. “Learn to do common things uncommonly well.” ― George Washington Carver

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