Sorry, its bone…

19

Ich bitte um Verständnis, dass ich diesen Beitrag etwas ironisch betitel. Aber ich werde immer wieder mit Disksussionen über Augmentationen mit xenogenem Knochenersatzmaterial, wie z.B. BioOss, konfrontiert, die sich jeder praktischen und evidenten Basis entziehen (Quellen siehe unten). Dabei  erlauben sich häufig immer wieder diejenigen ein pauschalisierendes und verherendes Urteil, die selbst kaum Erfahrung mit Knochenersatzmaterial  haben, weil sie diese Engriffe in dieser Form entweder gar nicht oder einfach zu selten durchführen. Fatalerweise assoziiert Knochenersatzmaterial ein einfaches Handling. Doch ein Eingriff am Sinus ist und bleibt ein chirurgischer Eingriff. Treten Komplikationen auf, dann ist häufig das Knochenersatzmaterial und selten der Behandler schuld. Und genau diese Fälle werden dann als subjektiver Beweis für das Versagen von Knochenersatzmaterial heran gezogen. Mittlerweile haben einige genau das als Marktlücke für sich erkannt und propagieren wieder rein autologe (körpereigener Knochen) Knochenaufbauten, in Bezug auf die Augmentation im Sinuslift wider aller wissenschaftlichen Studien. Aber warum tue ich mir überhaupt den Stress an und mache mich hier öffentlich angreifbar?

Weil bei der Diskussion der ethisch moralische Ansatz für mich persönlich zu wenig Beachtung erfährt. Was ist eigentlich mit dem Patient? Darf er nicht selbst entscheiden? Meine Erfahrung ist, wenn man den Patient objektiv aufklärt, dann wird er sich immer für das medizinisch Notwendige und nicht das Machbare entscheiden. Übrigends sind wir Ärzte nicht nur ethisch sondern auch rechtlich dazu verpflichtet. Auch wenn ich eine Augmetation allein mit BioOss im Sinuslift meinen Patienten empfehle, kläre ich immer über die Möglichkeit einer rein autolgen Augmentation auf. Bei wöchentlich 3 bis 5 Sinuslifts entscheiden sich 99,9% für das Knochenersatzmaterial. Verständlich, denn die Entnahme von Eigenknochen vom Kiefer oder gar vom Beckenkamm entfällt und damit auch zwangsläufig die physische Belastung des Patienten während und nach dem Eingriff. Man muss kein Mediziner sein um zu erkennen, dass jedes zusätliche (in diesem Fall meiner Meinung nach unnötige ) OP Gebiet die Komplikationsrate erhöht.

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Bekanntlich sprechen Bilder mehr als tausend Worte. Der hier gezeigte Fall ist in unserer Praxis ein Klassiker. Wie man auf dem präoperativen DVT erkennen kann, ist der Oberkiefer hochgradig atrophiert. Im Molarenbereich imponiert eine Restknochenhöhe von 1mm und weniger. Die Patientin kam mit der Aussage zu uns, dass ohne umfangreiche Augmentation, u.a. auch Beckenkamm, keine Implantation möglich sei. Meiner Meinung nach ist hier nicht die Atrophie entscheidend, sondern die Tatsache, dass der Kiefer in seiner Form noch gut erhalten ist, und die Kieferrelation noch stimmt. Selbstverständlich ist hier ein zweizeitiges Vorgehen zwingend notwenig. Durch das präoperative DVT war vorhersehbar, das ein Septum den Lift erschwert. Die Augmentation erfolgt allein mit BioOss L und einer Biogide auf dem knöchernen Zugang.

Da sich nach einer umfangreichen Augmentation die knöcherne Ausgangsituation grundlegend ändert, machen wir vor der geplanten Implantation in der Regel erneut ein DVT, allerdings mit 0,3 Voxel als Fast- Scan mit einer Strahlenexpositionsreduktion um 50%. Die Interpretation des post-augmentations DVT´s überlasse ich dem Leser.

Denn entscheidend ist letztendlich die Implantation, die heute erfolgt ist. Und auch hier überzeugt mich einfach das, was ich sehe. Zwar fehlt mir an dieser Stelle der histologische Beweis der Bohrspäne die aus dem Sinuslift heraus kommen, aber es sieht so aus wie Knochen und noch viel wichtiger, es blutet und ist vital. Bedenkt man das ursprüngliche vertikale Knochenangebot Regio 26, so bestätigt das Bild der fertigen Implantatbettpräparation den Erfolg der Augmentation allein durch BioOss. Auch ein Drehmoment von mehr als 20nm zeigt, dass das partikuläre Ersatzmaterial jetzt fest ist.

Wer genau hinschaut, der wird bemerken, dass ich vorerst nur die linke Seite des Patientenfalls zeige. Durchaus beabsichtigt, aber dazu mehr im Teil 2 dieses Falls…

to be continued!

Dr. med. Oliver Zernial // myimplant.de // Kiel

References

  • Schlegel KA1, Fichtner G, Schultze-Mosgau S, Wiltfang J. Histologic findings in sinus augmentation with autogenous bone chips versus a bovine bone substitute. Int J Oral Maxillofac Implants. 2003 Jan-Feb;18(1):53-8. PMID: 12608669.

  • Valentini P1, Abensur D, Densari D, Graziani JN, Hämmerle C. Histological evaluation of Bio-Oss in a 2-stage sinus floor elevation and implantation procedure. A human case report. Clin Oral Implants Res. 1998 Feb;9(1):59-64. PMID: 9590946.

  • Klein MO, Al-Nawas B. Für welche klinischen Indikationen in der dentalen Implantologie ist die Verwendung von Knochenersatzmaterialien wissenschaftlich belegt? Eur J Oral Implantol. 2011;4 Suppl:73-92. PMID: 22328984.

  • Jensen T1, Schou S, Stavropoulos A, Terheyden H, Holmstrup P. Maxillary sinus floor augmentation with Bio-Oss or Bio-Oss mixed with autogenous bone as graft in animals: a systematic review. Int J Oral Maxillofac Surg. 2012 Jan;41(1):114-20. PMID: 22000958.

  • Esposito M1, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2006 Sep-Oct;21(5):696-710. PMID: 17066630.

  • Klein MO1, Kämmerer PW, Götz H, Duschner H, Wagner W. Long-term bony integration and resorption kinetics of a xenogeneic bone substitute after sinus floor augmentation: histomorphometric analyses of human biopsy specimens. Int J Periodontics Restorative Dent. 2013 Jul-Aug;33(4):e101-10. PMID: 23820714.

  • Jensen T1, Schou S, Stavropoulos A, Terheyden H, Holmstrup P. Maxillary sinus floor augmentation with Bio-Oss or Bio-Oss mixed with autogenous bone as graft: a systematic review. Clin Oral Implants Res. 2012 Mar;23(3):263-73. PMID: 21443592.

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About Author

Dr. med. Oliver Zernial // Facharzt für Mund-, Kiefer- und Gesichtschirurgie // zertifizierter Implantologe // Praxis für Implantologie, Kiefer- und ästhetische Gesichtschirurgie // Willy-Brandt-Ufer 10 24143 Kiel // http://www.myimplant.de

19 Kommentare

  1. Hi Oli,
    1.) Glückwunsch zum Relaunch von „I love Implants“
    2.) zum Fall: ich praktiziere es genauso / ähnlich. Durchaus erreichst du eine Primärstabilität auch bei 2mm Restknochen und dann wird ein 1-zeitiges Vorgehen meinerseits durchgeführt. meine Frage: Welchen Zeitraum favorisierst du als „Umbau-Zeit“ zwischen den operativen Eingriffen (SinusLift-Augmentation – Implantation) ?

    Viele Grüße aus Leipzig

    Stefan Ulrici // http://www.dentale.de // Leipzig

  2. Ja bei 2mm implantiere ich auch einzeitig, siehe auch den Artikel „dont´t drill“. Bei Zweizeitigkeit warte ich 4-5 Monate nach Sinuslift mit dem implantieren. Sind zusätzlich horizontale Augmentationen nötig (Anlagerung etc.) dann warte ich noch etwas länger und füge hier auch autologe Späne hinzu. Die Implantate heilen dann nochmal 5-6 Monate ein. D.h. die Overall-Downtime für die Patientin ist ca. 9-10 Monate.

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