SynthoGraft™ Clinical Presentation

Hello, my name is Shadi Daher and we’ll be talking today about SynthoGraft. It is a synthetic bone graft substrate. SynthoGraft is formed, of pure phase beta tricalcium phosphate. The porosities however are formed in a way that makes them interconnected. This is helpful for us in grafting and it has been proven by different analyses and microscopic studies. Cores of the SynthoGraft bone have shown that the material itself is replaced with bone very efficiently and effectively. Histological slides show that in as little as three months you see significant replacement of the graft particles. In six months time you see significant ossification of the osteoid around the graft particle and in fact there are few of the graft particles remaining with active resorption with osteoclasts happening all around them. The literature on the topic is quite thorough. Beta tricalcium phosphate has been studied for decades and the SynthoGraft type of beta tricalcium phosphate which is the purest has also been studied extensively. What I would like to discuss with you today are four different ways of using the beta tricalcium phosphate SynthoGraft for replacement of missing bone. The first one would be the site preparation procedure after extractions followed by implant placement. The second one would be grafting with an implant concomitantly after an extraction and large bone defect and also repair of a large defect in conjunction with implant as well and finally restoration of the integrity of a crest with a sinus elevation procedure preceding that. The first patient is a fifty seven year old female. The maxillary right central incisor has had a root canal and a failing restoration. This is evidenced by the constant drainage and the puffy and rolled gingiva. The tooth is removed in an atraumatic fashion using luxators and appropriate forceps and the socket is curetted. This quickly reveals the missing buccal plate. All of the remnants of the soft tissue, be it from the infection or the, periodontal ligament are curetted thoroughly out and then irrigated. A resorbable, membrane, a collagen membrane is chosen and trimmed to fit over the defect. Blood is collected from the socket and mixed with fine grit SynthoGraft. The mixing has to be thorough and long until we obtain a consistency of putty that is easy to handle and contain and inject into the expected site. The membrane is then placed against the, buccal wall defect and the mixture of SynthoGraft and blood is injected filling the socket. The graft is contained with a collagen plug and sutured in place. After the socket is left to heal with a bonded temporary for approximately five months, The patient is brought back and another radiograph is taken showing good incorporation of the graft. A conservative flap is then raised allowing for the placement of a Bicon implant. Initially a high speed drilling with the pilot bur under external irrigation using approximately eleven hundred rpm allows us to establish the location and angulation and length of the implant. We check that with the use of a paralleling pin. After that we reduce the speed to fifty RPM or less and use latch type or hand type reamers. Two and a half and in sequence in half millimeter increment all the way up to the final size. In this case we went to three, then three and a half, and we always check the presence of buccal walls as well as mesial distal and palatal and the floor. We don’t want to be surprised at the very end of the procedure with a missing wall. So throughout the process the buccal wall, presence is verified. We go all the way up to four and a half millimeter and that is a hand reamer which allows a greater control and better angulation if necessary as well as selective carving of one side of the osteotomy versus another and as you can see the hand reamer allows us to harvest and collect bone as well. And the final size in this case was five millimeter width and a five by eight millimeter implant was placed at a depth of approximately two millimeter from the crest of the bone, which placed it up roughly five millimeter from the crest of the gingival margin. The black healing plug is then inserted to ensure that no bone grows inside the well of the implant. And the proof of success of the bone grafting with the SynthoGraft is in this slide where the collected bone from that osteotomy, since it wasn’t washed away with irrigant, shows that the bone contains very little uncoalesced particles of the SynthoGraft. Rather, particles of newly formed bone are evident. And we place the bone over the shoulder of the implant, pack it, imbibing away some of the liquid blood or otherwise, and then close the incision with a figure of eight suture. After a healing of four months, the patient is brought back for uncovering, and as you can see, is no radiolucency, and there is quite evident adaptation of bone to the surface of the implant. The bonded temp is then removed, revealing a healed gingiva. An incision that preserves the papillae is made and the black healing plug is removed. After verifying the integration of the implant with a guide pin, an impression reamer is used to remove some of the, excess bone over the shoulder of the implant and an implant level, impression post is inserted and, finger pressure is used to place it fully within the implant. Then an impression sleeve is draped over that impression post and an impression is carried with a closed tray in the usual fashion. After the fabrication of an integrated abutment crown, it is inserted roughly about four weeks after the uncovering. The contacts are checked, the well of the implant is cleaned and dried, and the final seating of the integrated abutment crown is achieved using a specially made jig with several taps from a surgical mallet. It is important that the force of the impact be directed against the long axis of the implant abutment assembly. The next case is a fifty three year old male who had lost the second bicuspid of the maxillary right and after a period of healing of approximately three months, he came back for grafting and if possible implant placement. As you can see the buccal wall is slightly deficient however there is no complete loss of the actual architecture. But a full thickness flap revealed a large defect. When the defect is fully exposed and all of the soft tissue, that is intervening between the sides of the bone is removed, the true size of the defect becomes, evident The preparation did not need to go through the initial pilot hole phase rather we could go directly to the four point five millimeter reamer that was used, with hand straight handle. From four and a half to five to five and a half and six allowing minimal contact between the reamers and the native bone, mesially and distally at the level of the crest. The level at the apices of the roots, the, bone was very deficient and the defect was large. A five, excuse me, six by eight millimeter implant was tried and found to be, with no significant contact rather a SynthoGraft, mixed with blood, was introduced into the defect the area was thoroughly packed, and then the implant was seated with contact only with approximately two to three millimeter area in the mesial and the rest of the implant in contact entirely with the SynthoGraft. After placing the healing plug, a membrane was draped over the buccal and the retention suture was placed and the flap was closed with 4-0 chromic gut suture. The post op radiograph shows the proper positioning of the implant as well as the grafted material around it. At the uncovering approximately four months later the implant appears to be still in the proper position and the true test of the grafting technique is in this slide where you see that the crest is completely regenerated, that the implant is not only integrated, but it is completely within the crest of, the newly formed alveolus, like it is supposed to be with the Bicon technique. And the final restoration is with an integrated abutment crown. The next case is a seventy three year old male who presented to us for the treatment of failing dentition, especially in the maxillary anterior right side. Removal of the teeth showed several carious teeth but it really revealed the extent of the periapical pathology which was then curetted and a significant granulation tissue lesion was removed. Post operative film demonstrated the extent of that defect. The area was not primarily treated as the infection was relatively active. It was allowed to heal for roughly two months and then the patient was brought back in for placement of a graft and implants. A full thickness mucoperiosteal flap with releasing incisions at the mesial and distal that were papilla sparing was open and upon elevation the true extent of the defect was evident the buccal plate was missing and the periapical void was exposed. All of the scar tissue and the granulation tissue was again removed and the area cleansed with an irrigant. In this case we used sterile water. Finally implants were then placed in the locations of the missing teeth in the canine lateral and central incisors. The standard Bicon placement technique was followed with pilot bur at high speed and irrigation followed by low speed reaming in half millimeter increments. The final size was reached using hand reamers as the bone was soft and to provide better control. Final size was four and a half millimeters to five millimeters. After the completion of the osteotomy a template was selected which was the sterile paper wrapper of the Bicon resorbable membrane it was then trimmed and used to trim the membrane, excuse me, the collagen membrane to the proper size. The implants are introduced, seated at the proper depth from the crest and the SynthoGraft is then placed and controlled in place with the collagen membranes that are held in place with retention sutures and the tissue is sutured. Post op film showed the proper adaptation of the bone graft and upon uncovering and placement of temporary abutments we see that the implants were thoroughly integrated solid with proper level of papillae. The final restoration was in the form of integrated abutment crowns as well, which were placed after a period of healing of approximately one month for the soft tissues, four months for the bone. And this is the final x-ray. The final case I will share with you today is a thirty seven year old female who had had a failed sinus graft in the area of the maxillary right bicuspids resulting in a chronic oral antral fistula that required a long time for healing and at the time of repeating the sinus lift we were forced to open a window in the periosteum to regenerate or recreate the continuity of the sinus mucosa. After doing so we were able to elevate the remnants of the sinus mucosa lining and using a kerrison rongeur to protect the neighboring roots, we’re able to widen the osteotomy or the window adequately to complete the dissection of the sinus mucosa. Once that elevation is complete out of the alveolar process, We ensured that the, palatal wall or the palatal slope is also free of all of the sinus mucosal lining and, again we placed a mixture of SynthoGraft in this case because of the size of the graft we used a mixture of thin or fine and coarse SynthoGraft. The, mixture is also with blood and it was packed thoroughly to fill the whole, void created underneath the sinus mucosa which is elevated. Backfill with metal or glass syringes is necessary and because we had to recruit some of the periosteum to complete the or to achieve the continuity of the sinus mucosa we have to protect the graft from the connective tissue and for that we place a membrane which is also held in place with a, it’s a resorbable membrane so it’s held in place with a retention suture, that’s also resorbable and the wound is closed. And this is the post operative film. Approximately four months later the patient is brought back and upon opening a flap, a full thickness flap, see the proof of the success of this technique with the unquestionable recreation of this bone, bony crest and the success of the sinus graft. Again a paper template is used to measure against a titanium mesh, this is a point two millimeter mesh that is trimable with surgical scissors that is then shaped to recreate the ideal contour of that crest and then it is secured in place with tacks and or screws and underneath it a, resorbable membrane is used. Before all of the procedure is continued, it is, checked that the flap will close without tension. If necessary, horizontal releasing or Buerger incisions are made in the flap so that we have the closure without any tension. And again, a mixture of SynthoGraft with blood, in this case entirely fine grit, SynthoGraft is placed and packed over the crest and with the, collagen membrane directly in contact with the graft and the, titanium mesh draped over the crest we’re able to recreate the contour of this alveolar crest and then suture the area without tension. This is the post operative film. In this case we waited five months after the placement and when the patient was brought back. We open the full thickness mucoperiosteal flap. We see that the tacks are intact as well as the titanium mesh which is then removed after removing the tacks and it is immediately evident that the new osteoid bone is present. The bone is soft but it is there. Two Bicon implants were placed in the usual, fashion using hand reamers and expanders as necessary and as you see the bone graft is largely resorbed. A four by eight millimeter implant is placed in the area of the first bicuspid and a four point five by eight millimeter implant is placed in the area of the second bicuspid. These implants were restored approximately five months after placement. Before closure we always check the positioning of the implants in case anything needs to be changed. It can be before integration takes place. The black healing plugs are cut at the level of the bone and the harvested bone graft is packed over the shoulder and the flap is sutured. Thank you for your attention for any further information, please visit SynthoGraft.com.