Biomaterial considerations for the Vegan patient and others with cultural and lifestyle concerns.

There is now a growing trend across all generations towards a Vegan or vegetarian diet, as well as the many with considerations affected by matters of culture and faith. Consequently, it becomes essential to offer treatment options that enable procedures to be carried out without confliction for the patient.

The use of biomaterials in Guided Bone Regeneration (GBR) has become an essential part of implantology and the treatment of cases where there is a lack of supporting bone, which result in the need for grafting procedures. The principal of GBR is to create a space between the bone defect and the soft gingival tissues in order to promote bone remodelling. A membrane is applied on the inside of the gingival flap to act as a barrier, in order to prevent the proliferation of epithelial cells. The membrane encourages the migration of bone cells within the blood clot to keep the bone graft and blood clot in place, as well as preventing bone loss by as much as 25% (Widmark et al; 1997).

With the expansion of cases treated due to developments in surgical techniques and approach, as well as implant design, the use of biomaterials, accompanied by an appropriate membrane has become ever more routine. Historically, these biomaterials have been xenografts derived mostly from bovine, porcine or possibly equine sources. There has been limited progress on synthetic options, although combinations of Hydroxyapatite and Beta TriCalcium Phosphate are becoming a more frequent choice, as a bone substitute. However, there has been very little choice when it comes to a resorbable synthetic membrane.

For the Vegan patient, a xenograft is totally undesirable, as it is for people of certain culture or faith. In the UK we live in a very cosmopolitan mix of cultures, faiths and lifestyle choices and so it is ever more important to understand how that might apply to your patient. Is a synthetic graft used with a porcine membrane acceptable to all patients? The answer is almost certainly that it is not ideal and possibly that it is not at all acceptable.

A synthetic membrane, which is free from animal derivatives will firstly avoid the risk of transmission of animal pathogens. It will widen the treatable patient group by being suitable for patients who avoid animal by-products for cultural reasons or lifestyle choices. The Tisseos membrane, developed by Biomedical Tissues in close co-operation with the University of Nantes, in France, is made of medical grade Polylactic-Glycolic Acid (PLGA), which provides excellent biocompatibility. A 100% biodegradable polymer, PLGA has a long history of successful use in a variety of medical applications and devices, such as resorbable sutures, pins, screws etc over many decades.

The Tisseos membrane does not require prior wetting and can be used with or without pinning or suturing. Whilst the micro-fibrous side absorbs biological fluids, the other side provides the necessary barrier qualities. Tisseos is easy to cut and if it becomes exposed, Tisseos will re-epithelealise in 2 weeks. The specially designed bi-layered structure prevents (gingival) epithelial ingrowth on one side, while promoting cell infiltration and guide bone healing on the other. Once wet, Tisseos respects the required form and shape that you create.

Prior to implant placement, it might be necessary to extract one or more teeth. The alveolar defect resulting from this can only be partially restored by bone neoformation and bone remodelling. While bone regrowth is observed at the base of the extraction socket, progressive irreversible and cumulative bone loss occurs in the alveolar bone crest. Studies show horizontal bone loss of 29-63% and vertical bone loss of 11-22% 6 months following tooth extraction (Tan WL et al, 2012). The variation observed being due to different factors including general metabolism, periodontal anatomy, functional constraints, reason for extraction and the technique employed. So, a question arises as to whether one should wait 6 months for full wound healing, when most of the bone loss will have already occurred?

A simple technique of guided tissue regeneration (GTR) would mean preserving the overall alveolar volume, particularly in light of a future implant placement to replace the extracted tooth. It has been shown that the best results in socket preservation are obtained using a bone substitute held in place by a membrane to prevent soft tissue ingrowth into the socket (Sanz et al, 2015). By using a resorbable membrane, second stage surgery to remove the membrane is avoided. The slow, but fully controlled resorption of the Tisseos membrane provides an optimal barrier effect and preservation of the socket guarantees optimal bone volume for future implant placement.

In a multi-centre study by Hoornaert et al, 2016, the Tisseos membrane, used together with bone fillers, performed well in GTR in all indications – immediate and delayed implant placement, socket preservation and alveolar crest augmentation after tooth extraction. The study confirmed that Tisseos is safe and performed well for guided bone tissue regeneration in various dental surgery indications.

In the UK, Tisseos is available from Saxon Implantology Ltd, who are also distributor for Bego Implant systems and Kohler Instruments. Kohler produce high quality instruments for most dental procedures, including implantology, tooth extraction and the maintenance of implants in the long term. For further information on Tisseos and any of the above products, contact Saxon Implantology on (+44) 7931-526595 or email [email protected]

References:

Widmark et al “Mandibular bone graft in the anterior maxilla for single-tooth implants. Presentation of surgical method” Int J of Maxillofac Surg 1997 Apr; 26(2): 106-9

Tan WL et al “A systematic review of post-extractoral alveolar hard and soft tissue dimensional changes in humans” Clin Oral Impl Res 2012; 23 Suppl 5:1-21

Sainz M et al “Key aspects on the use of bone substitutes for bone regeneration of edentulous ridges” Dent Mater 2015; 31:640-7

Hoornaert A et al “Biocompatibility, resorption and biofunctionality of a new synthetic biodegradable membrane for guided bone regeneration” Biomed mater 2016; 11:045012

CASE STUDY: Socket Preservation on the Day of Extraction (Hoornaert, Nantes

A 51 year old patient presented with a mobile bridge to replace the upper central incisors on a single support

Photo 1 - Upper central incisor is extracted and a temporary prosthesis is placed.

Photos 2 and 3 - Guided Tissue Regeneration at 6 weeks: placement of the Tisseos membrane between the flap and alveolar wall covering the bone substitute.

Photo 4 - Clinical situation 10 days after GTR with no sign of inflammation.

Photo 5 - Implant placement at 6 months in positions 11 (UR1) and 21 (UL1).

Photo 6 – Clinical situation at 14 months with final restoration.

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Date:

Posted on 02.07.19