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.
