Hi everyone! After placing bone graft and covering it with resorbable membrane I noticed the gingiva was not able to completely cover the membrane. The membrane was visible.I was doing a procedure to repair the buccal wall defect around the implant. Made sure the membrane is secured . Took the stitches through the membrane and then into the gingiva. Can this result into bone graft failure?
Thanks
Thanks for your question. Please upload some photos, so someone can help.
Sure when patient comes back for suture removal I will take a picture
Thanks
if you are using a collagen membrane. you need to have no tension primary closure. if not, saliva will dissolve any exposed membrane prematurely and your particulates may have partial to full lost depending on how much of the surgical site is open. If you can’t get primary closure. you can always place a PTFE membrane on top of your collagen membrane and allow secondary closure. you can remove the PTFE membrane at 6 weeks. which by that time. granulation tissue would have grown under the PTFE and cover the graft.
however, i recently read Amniotic Membranes can be left open. which i haven’t tried yet.
but in your case. since you’re repairing a buccal defect at an implant. definitely should have primary closure to avoid graft lost and avoid bacteria to colonize the implant (biofilm) which will cause graft failure also.
good luck.
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Resorbable membranes need to be covered up during healing or they will dissolve and the bone graft is apt heal less than optimal. You need to release the flaps and suture in layers to ensure primary closure.
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We did a quick search with OsseoNews AI, and actually while it is recommended to achieve primary closure with collagen membranes, they do not necessarily require primary closure according to a recent study (link below in reference section). Granted this is only one study, but in our experience depending on the type of collagen membrane used, some are “forgiving” in that they are designed to withstand some degree of exposure. So it really depends on the type of membrane used and the extent of the exposure. In any case, the study compared open healing to complete closure for collagen membrane coverage during immediate implant placements with simultaneous guided bone regeneration (GBR) found that open healing achieved outcomes similar to those of complete closure. In cases where the initial wound widths were ≤6 mm, soft tissue healed completely after 16 weeks without any wound dehiscence. However, for wider wounds (≥7 mm), some exposure of cover screws occurred, but this did not negatively impact the final restorations. This suggests that, at least, for immediate implant placements requiring bone grafting and collagen membrane coverage, it may not be necessary to release gingival flaps or use tissue grafts to achieve full coverage, as open healing can lead to comparable results with potentially less discomfort.
REFERENCES
- Healing outcomes of open versus closed flap procedures for collagen membrane coverage following immediate dental implant placements with simultaneous guided tissue regeneration. Journal of dentistry. Volume: 141, Issue: , 2024 - Qianrong Zhou , Fei Yang , Ni Li , Yan-Fang Ren , Youcheng Yu
- Membrane durability and tissue response of different bioresorbable barrier membranes: a histologic study in the rabbit calvarium. The International journal of oral & maxillofacial implants. Volume: 20, Issue: 6, 2005 Nov-Dec - Thomas von Arx , Nina Broggini , Simon StorgĂĄrd Jensen , Michael M Bornstein , Robert K Schenk , Daniel Buser (Note: This study did report that 1 of the chemically modified collagen prototype membranes exhibited prolonged membrane integrity in the absence of an inflammatory tissue response.)
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I was always taught, 20+ years ago, that while we should always try to get passive primary closure it is not always necessary if using a collagen membrane. I sincerely hope that it is not necessary when utilizing collagen products because if it were then the whole idea of collagen plugs would be a joke. At the time I trained we were using Gor-Tex for our non-resorbable option and it absolutely had to be completely covered or else the results would be ugly. We didn’t have the newer teflon products so collagen membranes were our go-to in the event that primary closure was not possible and they seemed to do just fine. I honestly think that the introduction and the simplicity of the Cytoplast teflon membrane allowed the goal posts to shift and “we” in the industry started throwing shade on collagen membranes in favor of the incredibly forgiving and easy to teach profit center of the teflon membrane socket graft procedure… There has never been an issue with collagen membrane exposure only a more aggressive market strategy by the makers of plumbers tape.
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On another note and “why” I always lean in favor of a collagen membrane over teflon even in the event that primary closure is not possible. The whole premise of the pin hole procedure is to utilize collagen membranes to augment the soft tissue and it somehow surprisingly works. This same soft tissue augmentation occurs around a ridge augmentation if a resorbable collagen membrane is used and I am convinced that the condition of the surrounding soft tissue is far more important than the bone when it comes to long term implant, and teeth, stability.
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Thanks for your detailed explanation.