Archived Newsletter Re-Post.
The AOX Newsletter • February 2024 #9
First of all, I’d like to say that it is rare that I am doing any significant grafting during All-On-X surgery.
However, in about 10-15% of cases, I will do low volume particulate grafting around an implant that may have slight thread exposure due to an adjacent bony defect.
While I don’t graft “every socket” or “every implant site” – I don’t hesitate to graft around an implant that I feel will truly benefit from increased bone coverage.
Why?
Well, I normally have a surplus of gold standard, free bone on hand.
During use of the barrel bur for bone reduction, excess particulate bone debris is created and typically collects on the retractor, the patient’s inner cheek and hard palate. This bone debris is scooped up with the malleable retractor on hand and stored in a sterile container on the mayo stand.
There is almost always more than enough particulate bone debris collected in this manner for any/all grafting needs. On an average double jaw case I am able to easily collect ~1-2 cc of bone. While more bone debris may actually be created, it often finds its way into the suction or throat pack etc.
This gold standard autogenous graft material is then combined with PRF. Honestly, you can’t ask for a better graft option – and it’s all right there for you and your patient at no cost.
The only time I will avoid using this technique is in patients with severe periodontal disease and/or existing pathology such as multiple granulomatous lesions.
However, even in these patients, I assess if the pathology is confined to one jaw and/or one area of the jaw. I then focus graft collection only on the “healthy” part of the jaw bone. Since I am not normally doing extensive grafting, this will usually provide enough bone for any intra-operative needs.
This graft technique has been extremely effective for me over the years. In addition to the above benefits, I have also noticed that the use of this very fine particulate autogenous bone creates less inflammation at the graft site than commercial allograft options. And because of this, the particulate autogenous debris creates less risk of wound dehiscence at your All-On-X graft site.
The next time you reach for that bottle of allograft, ask yourself if you’re passing up a treasure trove of autogenous All-On-X bone that’s literally right in front of you.
Matthew Krieger DMD
“Sometimes the best things are right in front of you; it just takes some time to see them.”
Gladys Knight
Q & A with Dr. K
“Your implant placement is really close to the sinus without perforating it. How do you consistently do this without a guide?” |
First, I always look to identify a landmark I can correlate on the panorex image with the location of the sinus – relative to my planned implant placement. This could be a socket, a bone defect, or a tooth root etc. I then use this landmark intra-operatively to guide the placement of my sterile graphite marking as part of my Graphite-Guided Surgery protocol.
Second, I drill slowly – utilizing the Low RPM Osteotomy Technique. This gives me confidence to be very close to the sinus because I can actually “feel” if the tip of the drill perforates and I can easily re-direct the drill if needed.
Third, I utilize a perio probe to provide tactile feedback that a true bony stop has been maintained at the apex of the osteotomy. I can also drag the tip of the probe (if necessary) along the distal osteotomy wall to ensure there is no perforation into the sinus.
Finally, my goal is to match the angle of my posterior implant to the angle of the sinus. I do NOT attempt to angle at a perfect 30 degrees. In order to maximize A-P spread, rather than focus on a pre-determined angulation, I mimic the angle of the sinus itself (*within reason) and then correct as best as possible with the MUA.
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