I have a question for discussion, I sincerely hope some of you will have time to share your insights regarding GBR.
I met a lot of people from different countries and it seems all people use different protocols regarding GBR.
Some people use only allografts, some xenografts, some both, some mix all of mentioned biomaterials with autogenous bone chips and vice versa.
I often used autogenous bone chips with small xenograft particles covered by collagen membrane either with periosteum sutures or tacks.
I find very unpredictable results with auto/xeno mix, as sometimes in cbct bone looks alright, but clinically bone is either soft or xenoparticles are totally unincorporated - almost by reflecting the flap you can scoop out majority of bone grafting biomaterial.
When used only allograft, it seemed that majority of graft resorbed with bone growth being very little as opposed to previous situation.
Once again, I am talking in majority with lateral GBR, as Sinus lifts are very forgiving if done correctly in my opinion.
My question is - what type of bone material do you usually use? Do you also find that using xenograft in lateral GBR looks only good in CBCT, but clinically bone is very poor, if any bone forms at all?
would you share some insights in what technique (and materials) you find the most predictable for lateral GBR?
Hey! Thanks for your response:) I know this is extremely wide topic, I am only asking Your opinion and/or Your preference on bone grafting materials if thats okay I hope you will find some time to respond, but thank you in advance!!
I have had the same experience and actually gave up doing cases that require large volumes of GBR and instead refer to someone who has either mastered it or is still willing to be frustrated. Having been doing and studying it for over 20 years I will say that the folks that present the best “eye candy” from the podium are using xeno/auto/ or xeno/allo combinations. I think their secret is membrane stabilization with “passive” primary closure and 9+ months healing before implant placement. Again I don’t even mess around with it anymore because neither me nor my patients are patient enough to wait for what has been an unpredictable outcome. I think that you are on the right track but if you stick around a pay close attention you will discover that while everyone has “A Case” very few actually have a “Collection of Cases”, most likely because it is a difficult and often unpredictable procedure. There are a lot of really good guitar players in this world but not everyone can sound like Glen Campbell or Jerry Reed so its probably best if we concentrate on our own sound that we can predictably reproduce. There are folks who can do it and do it well but the consumption of a lot of humble pie has convinced me to stay on the sidelines and look for lower hanging fruit.
Based on what I read, it looks like particulate graft technique(s) did not work for you. To take deep dive and analyze the “why”question, you can provide us more info such as surgical site pictures, that includes flap design, volume of graft augmented, how it is stabilized, how the primary wound closure is achieved.
If particulate grafting techniques did not work out for you, you may want to think about Block grafting or only grafting such as autologous or allograft blocks in the line of Khoury technique.
Hope this helps from a brainstorming point of view
I agree that predictability is not great for many bone graft protocols. Success begins with case selection and knowing what works in your hands using the materials and methods you are confident using. Vertical ridge augmentation is at best highly unpredictable or minimally successful in my hands using the techniques I use. Lateral augmentation is about all I’m comfortable performing. If a ridge is really narrow, 3 mm and less and remains narrow for greater than 5 mm vertically, it will be difficult to convert to a 6 mm ridge width acceptable for placing a 4 mm diameter implant. If the top several mm of a ridge is mostly cortical bone buccal and lingual, again its hard to graft predictably.
My best results come in ridges that are 3 plus mm width in the top 2 to 4 mm but widen quickly further apically. It is also helpful if the ridge length to be grafted is limited to about two teeth size and is bordered mesially and distally by teeth, leaving a graft site that’s bordered by supportive width everywhere except at the ridge crest.
I have largely stopped using xenograft except in sinuses, and there its mixed with allograft. My go to for lateral ridge augmentation is cortical/cancellous mineralized allograft, possibly supplemented with locally obtained autogenous bone if available. Cover the graft with a collagen membrane that’s soft and readily adapts securely to the graft bone and adjacent anatomy, such as Ossix Plus. I also sometimes will add something like Bioxclude membrane or Emdogain which seems to hasten early healing and flap closure over the graft. Tension free flap closure is essential and avoid a temporary partial that places pressure onto the grafted area. Allow it to heal and mature without overlying disturbance from a temporary for 6 months or more.
Grafting is a journey. I would recommend visiting SteinerBio and read some of their educational material. Consider mixing autogenous with Beta Tricalcium phosphate. With that combination you will have no remaining graft materials after 6 months or so of function. You would do better with a PTFE titanium re-enforced barrier to maintain space and shape.Good luck.
in USA we can use ALLO and XENO but i think EU can only use XENO, NO allo is allowed. So deciding what BG to use and available depends on where your office is located. Also some patients, such as vegans and Jehovah’s witnesses, does not use human or animal products, which means XENO and ALLO is not an option. Only can use ALLOPLAST and AUTO graft, which i have experienced these types of patients before. Also I’m a traveling dentist, which means i’ll just use any BG available at the office. i’ll request allo or xeno both usually works 95% in my experience. failure is very rare.
Your technique for horizontal GBR sounds like Dr Istvan Urban’s method. Which i have also been using and i have only encountered mushy bone once. But i have also encountered mushy bone after using allograft. it makes me think if just patient healing is an issue. just too many variables to consider.
Sinus lift is very forgiving because there’s no movement of the BG, blood supply from top and bottom, and 100% isolated from oral cavity. horizontal and vertical GBR is by far the most difficult technique, most unpredictable treatment modality.
for socket preservation i usually use mineralized cortical
for sinus GBR usually use XENO/ALLO mix. i noticed xeno/allo mix has less resorption.
for horizontal/vertical GBR i use AUTO/XENO/ALLO mix. or just XENO/ALLO, 50:50 mix.
membrane i use bio gide or KONTOUR for horizontal and PTFE-Ti for vertical. these two seem to stretch and hold up to tacts and screws best.
the reason why GBR has so few cases. because when my patients hear way more money and more time for growing bone, they usually option for cheaper and simpler treatments. or if they have no teeth, no bone and no budget i’ll recommend zygo and pterygoid implants.
The worst part is when you have been doing this so long that you get to see your success stories from 10 years ago turn to crap… I have seen enough of my own and other docs “Successful GBR Cases” not do so well long term that I will spend the rest of my career foraging for lower hanging fruit so that I don’t sell my practice to some sucker to deal with my future failures. I have learned that implants are only as permanent as the permanent teeth that they are intended to replace and if permanent teeth were really permanent than we would not be having this discussion. About 5 years ago I realized that even the immortals who present eye candy “sexy cases” from the podium rarely show results past a few years. However, Danny Melker, Bill Strupp, and Howard Chaslon have shown me enough 30+ years follow ups on their non-implant retained cases that I will calm my ego and at least suggest other options. Talk to me 10 years ago and I was the best surgeon in the world and could produce all of the “success to the point of loading” cases you can imagine but oddly enough not all of that success was permanent… hence my attitude as it relates to “big GBR cases”. To make matters worse these folks end up going in debt to finance these cases and very few people around the globe can demonstrate true success beyond the point of attaching a tooth to the screw! Just my experience after 25 years of pounding my own chest and performing ego driven procedures…
we are all trying to do our best dr scotty. but being pessimistic and jaded regarding GBR is not productive to us (i would like to learn from you also) and a disservice to your patients. most patient will take the “low hanging fruit” approach as well. but every now and then i’ll get a stubborn patient that refuse to extract periodontally involved teeth and want to keep natural teeth as long as possible and only want to replace just a few mobile teeth. then i have to “BIG GBR” that site and place implants. which i have done in the past as long it’s clinically sound.
I believe you are an excellent clinician. dr scotty. im not naive, i know nothing last forever. but i perform GBR and implants with the intention to last longer than me and the patient’s lifetime. I noticed i usually have failure when i push the limits of implant placement, ie very thin bone. or large vertical GBR. but i would like to challenge myself to improve on my surgical technique and results. it’s not an ego issue. but trying my best to help the pt achieve what they want.
i also suffer failures and have plenty of pictures to show other clinicians what not to do. But i believe my intensions are good, trying my best to help patients achieve a better quality of life through a good set of teeth (having teeth is more about form then function no one needs teeth to survive). I learn new surgical techniques because i encounter lots of patients who needs GBR and w/o GBR it will be difficult to place implants most of the time. i dont take ortho courses because i have no interest in ortho. I’m sure every field, endo/perio/pedo have their hail mary treatments.
like everything inside the mouth, natural or fake are only as good as how the patients take care of them.
My apologies for the offensive nature of my remarks. My intent was to admit to myself and to others who might be struggling to get consistent results with GBR that I have struggled as well. It has been my experience, along with many of my fellow residents and alumni that I keep in touch with, that seemingly few of these cases demonstrate consistent results over time. While I and the fellow docs that I keep in touch with have been able to grow bone and place fixtures in this bone it has not always maintained well… that is unless adequate soft tissue is present to protect the grafted site. As a result of the inconsistent long term results observe by myself and the many clinicians (clinicians much more skilled than myself) that I stay in touch with I have opted to limit how often I perform these procedures and instead opted to at least offer my patients other options. The individual who initially posted this question is not alone!!
