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Contraindication for augmentations?


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Not all patients on anti-resorptive therapy have a high risk of osteonecrosis of the jaw. When is implantation possible, and what should a dentist consider?

Prof. Bilal Al-Nawas | Germany

Bisphosphonates and other antiresorptives have been used in various bone diseases for many years. All bisphosphonates, which accumulate in the bone, have a common feature of significantly slowing down or reducing bone remodeling.

This also applies to some more recent active substances which are currently on the market or being tested. These effects must be taken into account when planning therapy.   

The mandibular vestibular flap is released with a scalpel blade (15c). The tip of the blade should contact the superficial inner face of the flap starting from the vertical releasing incision and moving distally or mesially (Fig. 2A-D). The blade works with the cutting face upside down and the non-cutting area facing the flap. Once the periosteum is interrupted, the flap can be elongated with an elevator or dissector, avoiding vascular damage. It is important to work where the flap reaches the fornix, so as not to weaken the flap itself. Consider the position of the mental foramina and the mental nerve, maintaining a safe distance of six mm from these anatomical structures. 

The maxillary vestibular flap is released in a manner similar to the mandibular vestibular flap, except that usually, once the periosteum is interrupted, the flap is elongated with a blade (instead of elevator or dissector) because the density of elastic muscle fibers inhibits coronal advancement.

Avoiding the killer loop effect

The surgeon should keep in mind that a released and elongated flap does not necessarily result in a correctly released flap. When the flaps are not optimally released, the suture lines, which are usually composed of horizontal mattress sutures and single sutures, may make the marginal part of the wound ischemic, which can result in necrosis. This “killer loop effect” of horizontal mattress sutures is amplified by increasing the residual flap tension at the end of the surgery. The application of a breaking force suture seems to reduce the marginal flap tension prior to the horizontal mattress.8 Two suturing technique employ a breaking force suture – one in the maxilla and one in the mandible. 

The maxillary suture involves the entire thickness of the palatal flap and just the coronal periosteum layer of the vestibular flap. The needle engages the palatal flap seven to ten mm apical to the flap margin, then moves to the vestibular side and engages the periosteum on the coronal margin of the releasing periosteum incision. It then moves palatally again through the entire palatal flap. After the suture is tied, the vestibular flap slips coronally (Fig. 3A-D). Then mattress sutures and single sutures are applied with no or minimal residual tension.

The mandibular suture involves the inner part of the flaps. The needle engages the periosteum on the coronal margin on the lingual flap, then moves to the vestibular flap, engaging the coronal margin of the released periosteum in the same manner. After the suture is tied, both flaps move coronally and will usually come in contact with one another. Then mattress sutures and single sutures are applied with no or minimal Tension (Fig. 4A-D). 

The breaking force suture involves just the periosteal layers without creating any killer loop effect, while leaving the vascularity intact. This suture can reduce the residual flap tension prior to wound closure by about 87%.8

Prof. Bilal Al-Nawas

Prof. Bilal Al-Nawas | Germany

University Medical Center of the University of Mainz
Clinic for Oral and Maxillofacial Surgery

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