The Inverted Periosteal Graft™ for the Regeneration of Osseous Defects Around Dental Implants in a Smoker

The following series of photographs will outline the materials and methods to regenerate failing implants in a smoker. The patient was counseled on the negative effects of her smoking habit and the patent reported that she would not quit smoking. Significant probing defects were located on all implants. Probings on the mesial surface of #14 implant were to the apex of the implant with possible sinus involvement.

Pre operative radiograph showing osseous defects with alveolar loss to the apex of implant #14.

Pre operative periodontal probing. > indicates greater than 9 millimeters

 Pre operative view of buccal gingiva


Pre operative view of palatal gingiva

Initial incisions are sulcular with a split thickness flap only extended to allow for access to the lesions. At this stage flap is only reflected to gain access to the lesions. The flap has not been extended to expose the palatal periosteum that will be inverted.  The granulation tissue is now removed and the implant surfaces are gently instrumented with a metal curette and treated with saturated citric acid.

This photo shows the root surfaces have been detoxified and the palatal flap has been extended to expose the connective tissue that will serve as the lingual inverted periosteal graft.

The buccal flap is raised with sulcular incisions. The flap is full thickness to the mucogingival junction where the periosteum begins. At the mucogingival junction the flap becomes split thickness leaving the periosteum over the bone. This photo shows the periosteum that will serve as the buccal inverted periosteal graft.

At this point the periosteum is incised at the apical extent of the flap and freed with a curette (a 13K works well for lifting off the periosteum). The buccal and lingual periosteal grafts are elevated to ensure they will cover the bone grafts and suture interproximally. The bone graft material is LD hydroxyapatite mixed equal volume with REGEN BIOCEMENT and wetted with Hydrase. Any hard particulate bone graft material should suffice for this procedure. The preparation of the bone graft material begins prior to surgery. The estimated amount of hard bone graft material is dispensed into a mixing bowl. Hydrase is used as a wetting agent. Using a mixing bowl, wet the hard particulate bone graft material with Hydrase and allow to soak until needed. When the bone graft site is prepared mix REGEN BIOCEMENT and the particulate hard bone graft material in equal portions by volume. Add Hydrase as needed to achieve a thick paste. Carry the bone graft/REGEN BIOCEMENT mix to the graft site, fill the defects and shape the surface for any additional appositional bone regeneration if needed. This surgery was successful using a particulate bone graft material, however, currently we are only using REGEN BIOCEMENT wetted with Hydrase and achieving equally satisfactory results.

The bone graft in place mixed with REGEN BIOCEMENT with the buccal periosteum inverted over the bone graft prior to suturing to the lingual inverted periosteal flap. The exposed bone shows the periosteal donor site.

The inverted lingual periosteal flap is covering the bone graft material and is sutured interproximally to the buccal periosteum.

 Primary closure of the palatal flap

 Primary closure of the buccal flap

 One month radiograph showing ossification of the periimplant defects.


Post operative probings

 One month post op palate

 One month post op buccal.

ARMAMENTARIUM

Hydrase wetting agent from SteinerBio

low density hydroxyapatite from Calcitec

REGEN BIOCEMENT from SteinerBio

Saturated citric acid for implant conditioning

4-0 vicril sutures

5-0 plain gut suture 1/2″ needle

250 mg Amoxicillin and 250 mg metronidizole tid for 10 days

Peridex bid sans manual oral hygiene for two weeks

The inverted periosteal graft is the intellectual property of SteinerBio. Anyone using any of the SteinerBio bone graft products during this surgery is granted licensee rights to the procedure.