Ridge Preservation Particulate Grafting Materials
Marshall Wade, DDS | Danny Holtzclaw, DDS, MS | Eric Pulver, DDS | David Lee Hill Jr., DDS
Marshall Wade, DDS
is in private practice with Maplewood Oral and Maxillofacial Surgery in Maplewood, Minnesota. He is a diplomate of the American Board of Oral and Maxillofacial Surgery and a fellow of the American Association of Oral and Maxillofacial Surgeons. He is also the founder and director of True North Professional Studies.
Danny Holtzclaw, DDS, MS
is a periodontist at the Austin Dental Implant Center in Austin, Texas. He is board certified by both the American Academy of Periodontology and the International Congress of Oral Implantologists.
L. Eric Pulver, DDS
is in private practice at Pulver Oral Surgery in Highland, Indiana. He is a diplomate of the American Board of Oral & Maxillofacial Surgery, and a fellow of the Royal College of Dentists of Canada. He is also an adjunct clinical instructor at Indiana University Dental School.
David Lee Hill Jr., DDS
is an oral and maxillofacial surgeon at Chapel Hill Implant and Oral Surgery Center in Chapel Hill, North Carolina. He is also an adjunct clinical instructor in the Department of Oral and Maxillofacial Surgery at UNC–Chapel Hill.
Inside Dentistry (ID): What is your “go to” barrier product when covering ridge preservation particulate grafting materials if primary closure is not possible?
Dr. Marshall Wade: The two things that I tend to use are a cytoplast titanium-reinforced membrane or a resorbable bilayer collagen membrane, such as Bio-Gide® (Geistlich, http://shop.geistlich-na.com). While the company represents them as being able to be exposed, primary closure is always the most desirable. I have had really good success with the cytoplast membrane especially. The downside about that membrane, however, is that it can only be left in for a month, but when you remove it, a pseudo-membrane has been formed underneath it, which continues to act as a barrier over the graft material, so it’s been really successful.
Dr. Danny Holtzclaw: Undoubtedly my choice would be human-amnion-chorion barriers (BioXclude™, Snoasis Medical, www.snoasismedical.com). While these have only been used in dentistry for about the last 10 years, similar placental-based products have been used in medical procedures since the early 1900s. Studies have shown these barriers to contain dozens of different growth factors and proteins that provide this barrier with natural immunoprivileged properties, anti-inflammatory and antibacterial properties, pain-reduction properties, and enhanced wound-healing properties. These barriers can be left fully exposed to the oral environment. Some other barriers, such as polytetrafluoroethylene (PTFE), also have the ability to be left intentionally exposed, but they are non-resorbable. Unlike some barriers that must be retrieved at a future appointment, amnion-chorion barriers are fully resorbable. Studies have also shown that when used for ridge preservation, exposed areas that were covered with amnion-chorion barriers healed with keratinized gingival tissue, which is a definite benefit in terms of future implant health.
Dr. Eric Pulver: If I’m removing a free-end posterior tooth or teeth in an area that also requires edge and socket augmentation, I design and release my flap to achieve primary tension-free closure to avoid exposed membranes. If a very small area of the socket remains exposed, I will use gel foam and tissue glue. This acts as an artificial scab/protective barrier for the particulate graft material during the initial healing stage.
For an edentulous area, there are a number of different types of membranes. There’s usually collagen type I (from a tendon) cross-linked, and non-cross-linked membranes. Each one is treated with a slightly different chemical process which alters the time it takes for the membrane to break down. I like to leave my particulate bone graft in place for 4 to 5 months before placing an implant, and there are lots of different graft materials that you can use. I prefer allografts. I sometimes will use a xenograft in combination but most of the time, 90% of the time, I would say that I use just alloplastic material.
Dr. David Lee Hill: The “ideal” dental membrane for socket grafting or a bigger osseous reconstruction allows for preservation of that soft-tissue architecture, so that stealing, borrowing, or manipulating tissue unnecessarily does not happen. Can you get the ideal result by preserving soft-tissue architecture, keratinized tissue width, and the inherent anatomy? Does it require non-surgical removal? The membrane must be able to withstand exposure if there’s not going to be primary closure.