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M643: Esthetic Soft Tissue Management “A to Z”
Surgical Mini-Lectures References Wolford LM: The Use of Porous Block Hydroxyapatite. Chapter 28, Part II, in Modern Practice in Orthognathic and Reconstructive Surgery (Editor Bell WII) W.B. Saunders Co., Philadelphia, 1992 Wolford LM, Chemello PD, Hilliard FW: Occlusal Plane Alteration in Orthognathic Surgery. J Oral Maxillofac Surg 51:730-740, 1993 Cottrell DA, Wolford LM: Altered Orthognathic Surgical Sequencing and a Modified Approach to Model Surgery. J Oral Maxillofac Surg 52:1010-1029, 1994
M643 Esthetic Soft Tissue Management “A to Z” Daniel R. Cullum, DDS, Coeur d’Alene, ID Synopsis: As surgeons, our ability to predictably produce soft tissue quality and quantity at implant sites is critical for a successful outcome. We will discuss assessment and management of a continuum of treatment challenges from inadequate attached tissue, thin biotype and immediate implant sites through more complex defects using: • Modified flap design for apical or lateral repositioning • Free connective tissue grafting with closed donor site harvest • Split and full thickness recipient site preparation • Pedicle flap design and modifications • Vestibular flap fixation • Combination procedures • Role of growth factors and hard/soft tissue lasers Attendees will be challenged to advance their soft tissue techniques with progressive skill development in situations that present every day in our practices. A minimally invasive approach to predictably manage defects at the time of extraction and with combined procedures will be discussed.
M644 Clinical Applications of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) Robert E. Marx, DDS, Miami, FL R. Gilbert Triplett, DDS, PhD, Dallas, TX Human Bone Morphogenetic Proteins (BMP) are a group of bone inductive proteins that determine and form the human skeleton. In the adult, they reform bone after osteoclastic resorption as part of the normal bone turnover cycle. The concentration of BMP in human and animal bone is exceedingly small negating its clinical usefulness for bone induction via xenogenic or allogenic bone grafts. However, molecular biotechnology has cloned the BMP-2 genes to produce clinically effective concentrations in a recombinant form. Recombinant human bone morphogenetic protein-2 in an Acellular Collagen Sponge (rhBMP-2/ACS) is cur110
rently FDA cleared for lumbar spinal fusions and fresh tibial fractures, ridge preservations of the jaws, and maxillary sinus augmentations. In addition, the authors’ off label use of rhBMP-2 indicates its ability to regenerate bone de novo in other oral and maxillofacial surgery procedures such as horizontal and vertical ridge augmentation, naso alveolar clefts, cystic defects, and as an enhancement to or replacement of autogenous bone grafts in large continuity defects. The ability of rhBMP-2 to regenerate bone de novo in facial and jaw defects is limited only by the scaffolding matrix, the dose of rhBMP-2, and the availability of mesenchymal stem cells that can respond to it. To date, the initial clinical experience in small bony defects has now also shown good de novo bone regeneration in extended applications such as those noted above.
M645 Periodontal Plastic Surgery for the Implant Patient Anthony G. Sclar, DMD, South Miami, FL With recent biotechnological developments and the widespread employment of implant dentistry periodontal plastic surgery has become synonymous with “oral plastic surgery” and “implant site development” having applications in both cosmetic dentistry and implant therapy. Traditional periodontal plastic surgery procedures were used to manage vestibular insufficiency, aberrant frenum, marginal tissue recession, excessive gingival display and lost interdental papillae. The realm of contemporary periodontal plastic surgery continues to expand with the evolution of procedures and technologies used to preserve and reconstruct alveolar ridge tissues in preparation for conventional or implant restorations. In order to provide optimal care for their patients, the implant surgeons should qualify themselves by obtaining additional education to keep abreast with the rapidly developing fields of oral plastic surgery and implant site development. Prerequisites for the successful “oral–plastic-implant” surgeon includes: an in depth knowledge of the anatomy and biology of periodontal and peri-implant soft tissues and a clear understanding of the anatomic basis for the successful application of periodontal plastic surgery techniques around the natural dentition and dental implants. To begin with, the peri-implant soft tissues lack a connective tissue attachment to the permucosal implant structures, and do not enjoy the blood supply normally derived from the periodontal ligament. In addition, the peri-implant connective tissue is acellular when compared to its periodontal counterpart and lacks the sophisticated organization of connective tissue fibers designed to provide mechanical protection and stability for the natural dentition. Furthermore, the peri-implant soft AAOMS • 2009
M643 Esthetic Soft Tissue Management “A to Z” Daniel R. Cullum, DDS, Coeur d’Alene, ID Synopsis: As surgeons, our ability to predictably produce soft tissue quality and quantity at implant sites is critical for a successful outcome. We will discuss assessment and management of a continuum of treatment challenges from inadequate attached tissue, thin biotype and immediate implant sites through more complex defects using: • Modified flap design for apical or lateral repositioning • Free connective tissue grafting with closed donor site harvest • Split and full thickness recipient site preparation • Pedicle flap design and modifications • Vestibular flap fixation • Combination procedures • Role of growth factors and hard/soft tissue lasers Attendees will be challenged to advance their soft tissue techniques with progressive skill development in situations that present every day in our practices. A minimally invasive approach to predictably manage defects at the time of extraction and with combined procedures will be discussed.
M644 Clinical Applications of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) Robert E. Marx, DDS, Miami, FL R. Gilbert Triplett, DDS, PhD, Dallas, TX Human Bone Morphogenetic Proteins (BMP) are a group of bone inductive proteins that determine and form the human skeleton. In the adult, they reform bone after osteoclastic resorption as part of the normal bone turnover cycle. The concentration of BMP in human and animal bone is exceedingly small negating its clinical usefulness for bone induction via xenogenic or allogenic bone grafts. However, molecular biotechnology has cloned the BMP-2 genes to produce clinically effective concentrations in a recombinant form. Recombinant human bone morphogenetic protein-2 in an Acellular Collagen Sponge (rhBMP-2/ACS) is cur110
rently FDA cleared for lumbar spinal fusions and fresh tibial fractures, ridge preservations of the jaws, and maxillary sinus augmentations. In addition, the authors’ off label use of rhBMP-2 indicates its ability to regenerate bone de novo in other oral and maxillofacial surgery procedures such as horizontal and vertical ridge augmentation, naso alveolar clefts, cystic defects, and as an enhancement to or replacement of autogenous bone grafts in large continuity defects. The ability of rhBMP-2 to regenerate bone de novo in facial and jaw defects is limited only by the scaffolding matrix, the dose of rhBMP-2, and the availability of mesenchymal stem cells that can respond to it. To date, the initial clinical experience in small bony defects has now also shown good de novo bone regeneration in extended applications such as those noted above.
M645 Periodontal Plastic Surgery for the Implant Patient Anthony G. Sclar, DMD, South Miami, FL With recent biotechnological developments and the widespread employment of implant dentistry periodontal plastic surgery has become synonymous with “oral plastic surgery” and “implant site development” having applications in both cosmetic dentistry and implant therapy. Traditional periodontal plastic surgery procedures were used to manage vestibular insufficiency, aberrant frenum, marginal tissue recession, excessive gingival display and lost interdental papillae. The realm of contemporary periodontal plastic surgery continues to expand with the evolution of procedures and technologies used to preserve and reconstruct alveolar ridge tissues in preparation for conventional or implant restorations. In order to provide optimal care for their patients, the implant surgeons should qualify themselves by obtaining additional education to keep abreast with the rapidly developing fields of oral plastic surgery and implant site development. Prerequisites for the successful “oral–plastic-implant” surgeon includes: an in depth knowledge of the anatomy and biology of periodontal and peri-implant soft tissues and a clear understanding of the anatomic basis for the successful application of periodontal plastic surgery techniques around the natural dentition and dental implants. To begin with, the peri-implant soft tissues lack a connective tissue attachment to the permucosal implant structures, and do not enjoy the blood supply normally derived from the periodontal ligament. In addition, the peri-implant connective tissue is acellular when compared to its periodontal counterpart and lacks the sophisticated organization of connective tissue fibers designed to provide mechanical protection and stability for the natural dentition. Furthermore, the peri-implant soft AAOMS • 2009