Thursday, January 19, 2017

Radiowave Radiosurgery and Bone Regeneration Techniques

Centers for Oral Care
No. 10 -- 19Jan2017
A BLOG by DH DeForge, VMD
Fellow of the Academy of Veterinary Dentistry

Radiowave Radiosurgery and Bone Regeneration Techniques 
Over a decade ago, veterinary dentists began a journey in the study of modern bone regeneration techniques in companion animals. In the Journal of Veterinary Dentistry, 1997, in the manuscript, Bioglass®-Perioglas® Synthetic Bone Graft Particulate, data from the CT and NY Oral Care Specialty Centers on bone graft particulate in the treatment of osseous periodontal defects and in post-extraction sites, to maintain vertical height and width of the alveolar ridge, was unveiled. Eleven years later much progress has occurred in Bone Regeneration Techniques [BRT] and additional usages of bone alloplast have been identified.
Veterinary periodontists regenerate missing bone and attachment around teeth affected by long-term periodontal disease with BRT. Guided Tissue Regeneration [GTR] usually refers to regeneration of all or part of the periodontal attachment apparatus [i.e. bone, periodontal ligament, and connective tissue attachment]. Guided Bone Regeneration [GBR] is specifically designed to regenerate bone. These procedures should never be attempted in general practice without an understanding of simple periodontal flap creation with oral radiology prior to and as a follow-up diagnostic testing procedure.
Grafting Selections:
The autograft is tissue transplanted from one site to another within the same patient. Choosing an intraoral grafting site to place in another oral area is very difficult and can cause additional pain and healing time to the veterinary patient. This is not a common treatment selection in our companion animal oral care patients.
The allograft is a tissue graft between individuals of the same species. The source is most often cadaver bone. Treatment to prevent cross contamination and immune reactions make this an uncommon grafting material in veterinary medicine.
The xenograft is the sharing of tissue between two different species. Bovine is the common bone origin. This material has been utilized in veterinary grafting. This author has no source of up-to-date information on the success of such clinical trials.
The bone alloplast is any synthetic grafting material made in the laboratory. Consil®, a bone alloplast by Nutramax Labs, has been tested at The CT and NY Specialty Centers for Oral Care and by other clinicians and is being used with great success. Consil®-Bioglass® Synthetic Bone Graft is a particulate composed of 45% Si02, 24.5% CaO, 24.5% Na2O and 6% P2O5. The particles are surface active amorphous glass materials composed of calcium salts, sodium salts, phosphates, and silicon dioxide. The Consil® becomes a collagen-driven mechanical barrier that inhibits epithelial down growth. When augmenting an osseous site, there is the formation of a calcium phosphate layer that is equivalent to the naturally occurring hydroxyl-carbonate apatite of bone. This surface layer promotes the attachment of osteoblasts and connective tissue. Consil® is now available in the traditional granule form or the new Bioglass® putty. The putty has shown excellent results in treating the infrabony defect seen in advanced periodontal pathology.
Any veterinary surgeon can utilize bone graft material. It is strongly recommended to x-ray prior to surgery and post-extraction. If, after taking dental intraoral x-rays, the veterinary surgeon feels uncomfortable with the extraction they should refer to a veterinary oral specialist for this treatment.
Pathologic fractures of the mandibular symphysis and the distal mandible are common in older dogs. Forceful extractions without intra-oral examination of the site can turn a pathologic fracture into a complete fracture necessitating oral orthopedics to repair.
Augmentation Guidelines:
  • Oral radiograph all sites to be treated
  • Use Radiowave Radiosurgery to create full thickness mucoperiosteal flaps
  • Radiowave Radiosurgery produces an essentially blood free surgical field that is easy to visualize with minimal tissue trauma
  • Utilize alveoplasty and osteoplasty to remove pathologic tissue before grafting
  • Immediate post-treatment dental x-rays must be taken of all treated sites
  • Follow-up oral radiographs in 6-12 months are essential
  • Laboratory sessions to develop an expertise in Radiowave Radiosurgery, periodontal surgery, and oral surgery are recommended
Other uses of Consil Bone Alloplast:
  • Oral Orthopedics
  • Post-oral oncology excisional biopsy
  • Treatment of Periodontal Defects
  • Post Oral Surgery treatment of the Dentigerous Cyst
  • Orthopedic surgery - non-oral
  • Treatment of the unstable mandibular symphysis with and without orthopedic stabilizer
  • All extractions in the canine and feline
PHOTO ESSAY: Exodontia of An Abscessed Retained Incisor Root Utilizing Radiowave Radiosurgery [RWRS] and Guided Bone Regeneration [GBR]
After utilizing Radiowave Radiosurgery to create a full thickness mucoperiosteal flap, the abscessed incisor root is separated from it alveolar attachments with a surgical length small round bur on a high speed handpiece.   Because of ankylosis of the root to the alveolus, these teeth will not easily lift from their attachments in the alveolus. If a forced expulsion with a root elevator is used, the result is most often a root fracture with a retained root remnant. Oral radiology must be utilized at this time to identify the root fragment and to create parameters for surgical removal.
After the root has been freed of its attachments, osteoplasty is performed to remove all abnormal alveolar bone with a diamond bur or a cross-cut fissure surgical length bur. The alveolus is irrigated with normal saline after the osteoplasty is complete. Lastly, the bone alloplast, [i.e. Consil®-Nutramax Labs], is placed into the extraction site. The alloplast should not be forced and packed but just placed to the level of the original bone. The flap is replaced and closed with 4-0 Maxon® or a comparable absorbable suture. The patient is placed on antibiotics for two weeks and pain control medicine for 2 weeks. An E-Collar is utilized to stop the patient from rubbing or disturbing the surgical site until healing is complete.



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