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Khurrum posted an update
I know this is an implant study club but I wanted to share a disappointment I had in my most recent bone graft. Patient came in for second opinion and after going over options and non restorable #31 I extracted and grafted the site. Post op PA showed that the M canal and defect was still present. This did have a buccal wall defect and I placed a resorpable membrane. I decided to go back in and pack more bone but it was not beneficial.
What could I have done differently?
Did the membrane move? Should I have reflected a flap vs placing it gingivally?
I appreciate feedback and your comments.
Jedediah, Alvin and Ivan16 Comments-
So, when you say you decided to go back and pack more bone, do you mean you did that in the same appointment?
And how big was the defect on the buccal wall? I’m guessing it must’ve been pretty substantial.
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@chester it was larger than anticipated. I saw the post-op PA and I removed a suture placed, and found a small access and packed more bone against the membrane. Placed a new oraplug and suture. When he returns in 2 weeks I will take a new PA.
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Here there Khurrum I’d love to hear the play by play for this case. Can you walk us through the exact steps you performed for this graft?
Also, do you routinely do rebuilds when there are buccal wall defects? I’d love a little more info to try to give you the best feedback I can 🙂
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Tagging some folks to chime in on their thoughts 😉 @javohiros @suredds @ghouse122 @Dreamchaser @nguyenanhduytrung @chasec_dds
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@ivan-chicchon sure. atraumatic extraction. removed with elevation and #23 forcep. i curette with a lucas curette which i love because it has “teeth”. in this case I knew I was not going to have primary closure and had a buccal wall defect on the M root with a sinus tract, so with periosteal elevator created a little envelope and seated membrane on buccal and enough to cover occlusal. here i decided to use copios extend membrane by zimmer. pack bone and suture. took a pA and was disappointed on the M root packing. so I remove a suture, pushed lightly on the membrane buccal and packed more bone using a condesor, and than replaced the suture and got hemostasis. maybe the membrane moved during the suture? maybe i should have reflected and placed the membrane flat that way vs inserting it.
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@kssheikh what type of bone did you use, doc?
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@nguyenanhduytrung allograft corticocancellous freeze dried by Maxxeus
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@kssheikh Hi, I think in case of socket grafting, xenograft can be effective, can I ask that after the extraction phase, how many bone walls left?
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@nguyenanhduytrung there was a buccal wall defect. so the m, d, and l wall were present.
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oh I see, in case of buccal wall defect, I am thinking about how to get the membrane stablized?
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In my experience this is nothing to be worried about especially given that you’ve gone in the second time and packed more bone! The dark spot is filled with bloodclot right now because on top of it there is packed bone, membrane and sutures. It’s all good, don’t even worry about it. You will have a new bone there in about 2months.
A Cbct would be much more helpful though to see the buccal defect and decide whether a titanium mesh is needed to give this zone a larger thickness or perhaps an autogenous bone transplant to give in more thickness.
Personally I wouldn’t worry one bit. Just get a control cbct to see more details and let’s circle back then
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@javohiros thanks, i did not even think of blood clot
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@Khurrum I would mirror what @Javohir said here. Excellent attention to detail and care by going back in after the post op PA.
In my hands, resorbable membranes are the go-to for any GBR or socket preservation to avoid secondary surgical intervention. In a case like this I would definitely be reaching for whatever cross linked long lasting membrane you keep in stock. But with good suturing and membrane stabilization after you reopened it, this site should heal just fine I would expect. It may just need a little more time than expected to allow lamellar bone maturation through the site, but this is also where bone graft material choice comes into play.
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@chasec_dds freeze dried allograft. I use Maxxeus.
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I agree with all the previously mentioned statements. I think you just packed yourself out of the area. Make sure laterally condense. It’ll be fine. I was told by “The Claw,”the oraplug, or collagen plug, resorb quick that you can have more epithelial ingress b/c the bone matures apical to coronal.
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One of the most important aspects of that treatment (socket preservation) is to be very thorough cleaning the site out of all infected soft tissue. Often this doesn’t happen and it is more likely to get those results. Even when done properly there can be poor outcomes depending on the pt., age, medical history, etc. Often times the curette cleaning the site out will take longer than the extraction.
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