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Dr Bavitz Handout Part 1 Oral Surgery Course 2008

Dr Bavitz Handout Part 1 Oral Surgery Course 2008

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BetaBeta-Tricalcium Phosphate

Brands: 1.Synthograft 2.Cerasorb 3.Graftek

Completely unique and synthetic, GEM 21S® is an innovative combination of a bioactive protein (highly purified recombinant human platelet derived growth factor, rhPDGF-BB) and a biocompatible osteoconductive matrix (beta-tricalcium phosphate, -TCP) GEM 21S® contains 1000x more active growth factor (PDGF) than found in platelet rich plasma. Compared to bone graft substitute without PDGF Provides 3x more bone fill at 6 months Provides a more predictable treatment option even in the most severe cases

.Sockets with intact buccal and lingual plates heal well without grafting consider grafting with resorbable osteoinductive material if plates compromised and implants planned grafting with connective tissue if pontic esthetics an issue.

except elective endodontics not performed . but an option for preserving alveolar bone when performing full mouth extractions on young patients Teeth must be vital with good periodontal health Similar tooth selection as conventional overdentures.Vital Root Retention Never our first choice.

asymptomatic root Depending on rate of alveolar resorption. then remove 2 mm more tooth sub osseous Consider grafting autogenous bone over tooth. bone grows coronally over a vital. then close primarily Ideally. will help preserve ridge 35 years before exposure/extraction .Vital Root Retention Amputate teeth at crest.

Remove 2 mm tooth structure below bone Suture 2 mm .

New Bone Prosthesis .

Hankins M. which for the assessment of delayed eruption of the root fragments is not sufficient as this process may continue for up to 10 years. Sproate C The length of follow up was about two years.J Oral Maxillofac Surg.43(1):7-12. 2005 Feb. However.43(1):7randomized controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. it seems that coronectomy reduces the incidence of injury to the inferior alveolar nerve without increasing the risk of dry socket or infection. . Renton T. A Feb.

CONCLUSION: Coronectomy appears to be a viable technique in those cases where removal of the whole tooth might put the inferior alveolar nerve at considerable risk of damage. Coronectomy: a technique to protect the inferior alveolar nerve. . may minimize this problem.J Oral Maxillofac Surg.62(12):1447-52. There was 1 case of transient lingual nerve involvement. Root migration was noted in approximately 30% of patients over a 6 month period. or intentional root retention. RESULTS: There were no cases of inferior alveolar nerve-involved damage in this study of 41 patients who underwent 50 coronectomies. Muff DF. Lee JS. Pogrel MA. 2004 Dec. One patient required subsequent removal of the roots of both lower third molars because of failure to heal. probably from the use of the lingual retractor. The technique of coronectomy. and 1 patient required subsequent removal of a root because of subsequent migration to the surface. PURPOSE: Damage to the inferior alveolar nerve when extracting lower third molars is often caused by the intimate relationship between the nerve and the roots of the teeth.

PrePre-op (Oral bisphosphonates X 5 years) Immed Post 10 month post .

and no active infection Success rates ~ to normal Most typical sites: anterior teeth and 1st premolars Advantages? May reduce loss of labial plate and improve esthetics. as well as save time .Immediate Implant Placement Following Extractions Need 3-4 mm of solid bone at base of socket.

Platelet Rich Plasma What s Hot Release various growth factors that aid in hemostasis and increase rate of healing (mitogenesis. angiogenesis) What s Not Cost Is there any difference at 6 weeks? Invasive. borrow 4545-90ml of blood .

Casap et al. . J Oral Maxillofac Surg 2007. Immediate Implantation Into Debrided Infected Sockets.

Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog.Does placing implants into fresh extraction sockets preserve bone? J Clin Periodontol. 2005 Jun. The resulting height of the buccal and lingual walls at 3 months was similar at implants and edentulous sites. Araújo MG. Lindhe J.32(6):645-52. . Sukekava F. CONCLUSIONS: Marked dimensional alterations had occurred in the edentulous ridge after 3 months of healing following the extraction of the distal root of mandibular pre-molars. The placement of an implant in the fresh extraction site obviously failed to prevent the re-modeling that reoccurred in the walls of the socket. Wennström JL.

J Periodontol. The radiographic bone loss pattern adjacent to immediately placed. 2007 Mar-Apr.22(2):187-94. Piattelli A.18(4):965-71. 2007 May. Barone A . Vertical crestal bone changes around implants placed into fresh extraction sockets. immediately loaded implants.Most human trials however. Cornelini R.78(5):810-5. J Craniofac Surg. 2007 Jul. Immediate loaded dental implants: comparison between fixtures inserted in postextractive and healed bone sites. Ishikawa S. Carinci F. Kolesar M. reveal results similar to implants place via the old school approach. Kumar A. >55 Y/O) Int J Oral Maxillofac Implants. Fiorellini J. even when immediately loaded (caution in soft bone. Covani U. Jaffin R. Degidi M.

but esthetic result suboptimal Prevent pathologic fracture Poor function/esthetics/retention of conventional removable prosthesis .Why Reconstruct? Not enough bone for implants Enough bone.

How? Autogenous Bone Grafts with Implants .

Autogenous Block Grafts Gold Standard Osteoinductive and Osteoconductive No need for membranes Holds form Remodels into 100% high quality bone No concerns about transmissible diseases .

Autogenous Block Grafts Donor site morbidity Quantity is limited Lose 20-30% during healing .

Intra-oral Autogenous Bone Sites .

Allogenic Block Graft .

What about membranes? Useful in containing particulate grafts Useful around teeth/exposed implant threads Add expense Infection risk Unnecessary with block grafts ADA 4266 Resorbable ADA 4267 Non-Resorbable .

BMP 2 for spinal fusions.Bone Morphogenic Protein (BMP) Grow bone at will? Presently two are FDA approved. and BMP 7 for long bone defects Studies show excellent results for socket preservation.00 for a sinus) . sinus lifts Expensive ($5000.

It has been previously approved by the FDA for use in certain lumbar spine fusion and tibial fracture repair procedures. The purpose of the protein. which occurs naturally in the body. is to stimulate bone formation. 2006. .FDA Panel Unanimously Recommends Approval of Third Indication For Medtronic s INFUSE Bone Graft Nov. 9. INFUSE Bone Graft is recombinant human bone morphogenetic protein-2 (rhBMP-2) applied to an absorbable collagen sponge carrier.

Distraction Osteogenesis Generation of bone (and soft tissue) through distraction of an osseous callus .

O Keefe RJ. In this article we will also present data to show that selective COX-2 inhibitor delays allograft healing and incorporation. Furthermore. which inhibit cyclooxygenase (COX) activity. These results demonstrated that COX-2 is essential for bone allograft incorporation. 2006 Apr. . our data support the notion that COX-2dependent PGE2 produced at the early stage of bone healing is prerequisite for efficient skeletal repair. COX-2 has a critical role during incorporation of structural bone allografts. Xie C Nonsteroidal anti-inflammatory drugs (NSAIDs). Tiyapatanaputi P.1068:532-42. reduce pain and are commonly used in patients with skeletal injury.Ann N Y Acad Sci.

Wise Old Oral Surgeon Says Beware of: 3rd molars in function Lone standing molars Teeth in bruxers/ Cl. III skeletal patterns 3rd molars + post-menopausal women postPrior TMD history Prior bad oral surgery experience Distoangular lower 3rds/ nerve proximity .

5. 6. possible fx Prevent orthodontic relapse? Treat pain of unknown origin . Why? Prevent/treat pericoronitis (infection) Prevent periodontal problems 2nd molar Prevent/treat caries to 2nd / 3rd molar Prevent odontogenic cysts/tumors Strengthen mandible. 4. 2.3rd Molar Surgery 1. 7. 3.

. A newly discovered and as yet unnamed species of the bacterium genus Bergeyella was found in the mouth and amniotic fluid of a woman with a uterine infection who gave birth prematurely (24 weeks). as might be expected. The finding confirmed what some scientists have suspected. the bacterium was not detected in a vaginal swab.D. However. of Case Western Reserve here. 2006 . causing uterine infections that can lead to preterm birth in pregnant women. Han. Microbiology. Ph.Extract 3rds: Oral/Systemic Link? CLEVELAND..The first hard evidence has been uncovered that bacteria in the mouth may find their way to the uterus. that intrauterine infections don't always "ascend" from the genital tract but can "descend" from the oral cavity. Han and colleagues said in the April issue of the Journal of Clinical Microbiology. reported microbiologist Yiping W. April 6. Dr.

PhD Journal of Oral and Maxillofacial Surgery Volume 65. Pages 377-383 3. White. March 2007. Jr DDS. 3771.What is the recovery like for those who have them removed.What happens to asymptomatic patients who keep their third molars? 2. and what can we do as surgeons to improve post operative outcomes? .Progress Report on Third Molar Clinical Trials Raymond P. Issue 3.

nerves more pliable.3rd Molar Surgery When? Before roots 100% developed After roots: 1/3 formed Morbidity/complications minimized as bone more flexible. and PMH less complicated Don t forget tooth transplant if apex not closed .

121(2):110-9. Czochrowska EM. 2002 . Stenvik A. the 30 teeth in the 25 patients we examined yielded a survival rate of 90%. Outcome of tooth transplantation: survival and success rates 17-41 years post treatment. and the mean observation period was 26. Bjercke B. The mean age at surgery was 11. Of the 33 teeth transplanted in the 28 patients. 3 teeth were lost after 9. and 2 others failed to fulfill the proposed criteria. Am J Orthod Dentofacial Orthop. The patients generally responded very favorably regarding their perception of the treatment. It was concluded that survival and success rates for teeth auto transplanted when the root is partly developed compare favorably in a long-term longperspective with other treatment modalities for substituting missing teeth.5 years. The success rate was 79% because 2 transplants had ankylosed. Therefore. respectively. and 29 years.Feb. 10. 17-41 years). Their only hesitation was related to some discomfort during surgery. Zachrisson.4 years (range.

3rd Molar Surgery Extremes of age No oral communication (full bony) Intimate root-nerve Relationship Risks > Benefits When Not .

3rd Molar Surgery Alternatives? No Surgery: dentist feels risk: benefit ratio not favorable or patient refuses document and recommend radiograph q 3-5 years .

No High Speed Air embolus Air emphysema Blow debris into flap Blow bacteria into flap Non-sterile water .

.

3 B.4 C. 1.Which are true? 1.2. None of the above . a transplant must have endo 4. Most transplants will ankylose A. 3 only E. 2. Tooth transplants are usually done on patients 20-30 2. 1. In order to work. Average success rate for a tooth transplant is 20-30% 3.3 D.

How can I assess the relationship between the 3rd molar root and the inferior alveolar nerve? .

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