Dentaltown August 2021 - 69

is necessary for de novo bone formation.
Now that we have the allograft (hydrated
with the exudate from the PRF membrane
process) and an overlying collagen membrane,
all that's left is to lay the PRF membrane over
the top of the collagen (Fig. 8a, p. 67). In
this layered technique, from the inside out
we have the existing bone, the hydrated bone
graft, the resorbable collagen membrane, the
PRF membrane, and the overlying fl ap of
gingival and mucosal tissue.
Sutures are used to close the fl ap. I usually
recommend at least one mattress suture for
a deeper cinching of the tissue, which leads
to better immobility (Fig. 8b, p. 67). Several
types of sutures are on the market; most
clinicians will agree that nonbraided materials
such as polytetrafluoroethylene (PFTE)
and poliglecaprone (PGCL) are preferred.
Braided sutures tend to accumulate debris
and bacterial biofi lm, which can increase
the risk of infection and infl ammation. I
usually use a resorbable PGCL suture for
grafts of limited size, such as this case, and
nonresorbable PFTE sutures for securing
larger fl aps.
Pharmacology
The literature has shown that perioperative
antibiotics can decrease failure rates by a
few percentage points. Because most bacterial
species in dental infections are susceptible to
penicillins, using broad-spectrum antibiotics
such as amoxicillin has proven effective in
reducing infection, symptoms and overall
bacterial count.13
Pain-control literature continues to
show that the routine practice of prescribing
opioids for pain may no longer be valid,
especially for minor oral surgery. Again
and again, ibuprofen or combinations of
ibuprofen and acetaminophen have proven
equally effective in postoperative pain
control.14
With opioid addiction being a
very visible problem, the American Dental
Association has adopted a comprehensive
stance that includes urging dentists to
consider nonsteroidal anti-infl ammatory
analgesics as the fi rst-line therapy for acute
pain management.15
Disclosure:
Neither the author nor his family members have fi nancial
arrangements or affi liations with any corporate organization
offering fi nancial support or grant monies for this continuing
education program.
dentaltown.com \\ AUGUST 2021 69
Posthealing follow-up
After four months of healing, the patient
returned for a follow-up CBCT to evaluate
the amount of bone gained. Figs. 9a-9d
show before and after grafting with measurements.
You can also see the before and
after superimposition of virtually planned
implants. There is now enough bone for a
4 mm diameter implant, allowing at least
1.5 mm of bone on either side.
When placing the implant, I usually lay
crestal fl aps to visualize the health of the
grafted bone (Fig. 10a). Sometimes if the bone
particles were not resorbed and new bone was
not formed, it still may appear radiopaque
on a CBCT. As you can see in Fig. 10a, the
bone was fi rm, white and bleeding, all signs
of healthy, viable new bone formation. I then
confi dently placed an implant as planned on
the CBCT imaging software (Figs. 10b-10d).
Placement-in this case, without a surgical
guide-is again restoratively driven to provide
the future restoration with a natural emergence
and physiologic occlusion, which maximizes
the stability and longevity of the prosthetic
connections.16
Conclusion
As your implant practice begins to
grow, there are natural progressions in
case complexity. You can start by placing
implants where there is enough bone, then
graduate to removing teeth and preserving
bone and, as depicted in this case, augment
a defi ciently edentulous site.
Although there may be several different
ways of performing this augmentation, the
general principles of fl ap management, space
and volume maintenance and bioengineering
are the most common. Single-site GBR is
a great starting point for a general dentist
in the process of increasing their menu of
services. ■
References
1. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques
are the most successful in furnishing bony support for
implant placement? Int J Oral Maxillofac Implants. 2007;22
Suppl:49-70. Erratum in: Int J Oral Maxillofac Implants.
2008 Jan-Feb;23(1):56.
2. Pugel A, Simianu V, et al. Use of the Surgical Safetey
Checklist to improve Communication and Reduce Complications.
Journal of Infectionand Public Health. 2015
May-Jun;8(3):219-225
3. Benavides E, Rios H. et al. Use of cone beam computed
tomography in implant dentistry: the International Congress
of Oral Implantologists consensus report. J Implant Dent.
2012 21(2):78-86
4. Garber D, Belser U. Restoration-driven implant placement
with restoration-generated site development. Compend
Contin Educ Dent. 1995 Aug;16(8):796-804
5. Pikos M, Miron R. Bone Augmentation in Implant Dentistry.
Batavia, IL: Quintessence Publishing Co Inc, [2019]
6. Dohan Ehrenfest DB, Del Corso M, Diss A, Mouhry J, Charrier
JB. Three-dimensional architecture and cell composition
of a Choukroun's Platelet rich fi brin clot and membrane. J
Periodontol. 2010;81(4):546-55
7. Kawazoe T, Kim HH. Tissue augmentation by white
blood cell-containing platelet-rich plasma. Cell Transplant
2012.;21(2-3):601-7
8. Miron R. Understanding Platelet-Rich Fibrin. Batavia, IL:
Quintessence Publishing Co Inc, [2021]
9. Greenstein G, Tarnow D. Using Papillae-Sparing Incisions
in the Esthetic Zone to Restore Form and Function. Compendium
2014 May;35(315-321)
10. Tay J, Lu X, Lai W, Fu J. Clinical and histological sequelae
of surgical complication in horizontal guided bone regeneration:
a systematic review and proposal for management. Int J
Implant Dent. 2020 Nov 26;6(1);76
11. Nishimura I, Shimizu Y, Ooya K. Effects of cortical bone
perforation on experimental guided bone regeneration. Clin
Oral Implants Res 2004;15:293-300.
12. Verdugo F, D'Addona A, Ponton J. Clinical, tomographic,
and histological assessment of periosteal guided bone regeneration
with cortical perforations in advanced human critical
size defects. Clin Implant Dent Relat Res 2012;14:112-120.
13. Surapaneni H et al. Antibiotics in dental implants: A review
of literature. J Pharm Bioallied Sci. 2016 Oct;8(Suppl 1):
28-31
14. Nguyen K, Liu Y et al. A Randomized Single-Blinded Trial
of Ibuprofen-versus Opioid-Based Primary Analgesic Therapy
in Outpatient Otolaryngology Surgery. Otolaryngol Head
Neck Surg. 2019 May;160(5):839-846
15. Department of Scientifi c Information, Evidence Synthesis
& Translation Research, ADA Science & Research Institute.
Oral Analgesics for Acute Dental Pain. American Dental
Association October 2016:286
16. Sheridan R, Decker A, Plonka A, Wang HL. The role of
occlusion in implant therapy. A comprehensive review. J
Implant Dent. 2016 25(6);829-838
17. Pikos M and Miron R. Bone Augmentation in Implant
Dentistry
18. Resnik R. Misch's Contemporary Implant Dentistry 4th
edition
19. Miron R, Choukroun J Platelet Rich Fibrin in Regenerative
Dentistry
20. Journal of Oral Implantology
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