Membrane exposure: complication or not?
“Treating dehiscences requires time and patience.” Amely Hartmann | Germany Oral surgeon, Private Practice Dr. Seiler and colleagues, MVZ GmbH, Germany Interview conducted by Marjan Gilani
Amely Hartmann is an oral surgeon who has contributed to the clinical development of Yxoss CBR® since its early days.¹ She answered our questions about membrane exposure after major bone augmentation with 3-D printed mesh. Dr. Hartman, let’s start with a frequently asked question: how predictable are implants placed in regenerated bone with 3-D mesh technique? Dr. Hartmann: The implants are very predictable. Different studies show implant placement is possible in 100% of cases,²-⁵ with an implant survival rate of almost 98% after 5 years of follow-up.³ And this is no surprise – implants are predictable since we place them in the patient’s own, regenerated and vital bone. In practice it is easy to see the stability and vitality of bone volume when the implants are inserted.
“Membrane exposure doesn’t necessarily mean complications.”
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Does the etiology of the defects affect the success rate? In my experience, etiology does not play a major role, though scars from previous surgeries may lead to more difficulties when handling soft tissue.
Still, dehiscence is a complication that can occur during major bone augmentation with Yxoss CBR®… No therapeutic approach in such a difficult area is without disadvantages. But morbidity is lower with Yxoss CBR® compared to harvesting bone blocks from intra- and extraoral donor sites or the iliac crest. Exposure occurs in 20–30 % of cases with Yxoss CBR®, but we have shown this doesn’t have an impact on the survival rate of implants and long-term clinical outcomes.
What does this mean? One factor is time – when exposures occur.⁵ Early exposure happens within the first four weeks after surgery, mostly due to wrong surgical handling of the soft tissue and putting too much tension on it.
To avoid this, wound closure should be without tension. I always insert additional deep sutures with resorbable materials. Early exposure may also happen when the soft tissue edges are not well protected by the dressing template (suck down splint), so the patient can play with their tongue in the area. It is why using a dressing template has positive effects. When the early exposure happens, we visit the patient in closer time intervals, e.g. weekly, and clean the area with the saline solution without disturbing wound healing. On the other hand, the exposures which happen later are often due to mechanical factors e.g. when the patient has no pain, feels good, and gets careless during the healing period. In this scenario, I prescribe 0.05–0.1 % Chlorhexidine solution which patients can use for disinfecting the area on their own.
Once exposure occurs, when do surgeons need to wait and see, and when do they need to intervene? We should remember that exposure doesn’t necessarily mean complications. Of course, we hope no exposures occur, but I personally do not panic if they do. When we panic we may immediately want to re-suture or remove the mesh, which are more harmful. Instead, we should have the patience to wait. But, of course, we must deal with infections.
How do you discuss exposure with your patients? Well, you must talk to them in advance – tell them that there is always a risk of
