#13 – Martina Stefanini - How to choose the correct combination of biomaterials

00:00:08: Welcome to the BOTUS podcast.

00:00:09: I am Jacek from BOTIS and today i'm bringing you a very special guest.

00:00:14: her name is Dr.

00:00:15: Martina Stefanini, she comes from the University of Bologna in Italy.

00:00:22: She is a periodontist, but she also works together in the research group of professor Giovanni Zucchelli and Bologna.

00:00:30: So we are really very happy to have her here.

00:00:32: Martina Stefannini will be today interviewed by my colleague Dr.

00:00:37: Arturo Robertazzi so I am now handing over the work to my colleague Arturo!

00:00:43: Thank you Jacek for the kind introduction and welcome Martina to the Botis podcast.

00:00:49: So for the listeners, Martina Stefanini is graduated from the University of Bologna and from the same university she received a PhD in medical sciences.

00:01:02: And She's been working a lot research within the group of Giovanni Zucchella at the University bologna.

00:01:08: so it really pleasure to have you here.

00:01:11: I mean your.

00:01:14: Your work at University of Bologna is probably the most interesting part, but you're also working on a private practice Martina right?

00:01:21: Yes.

00:01:22: I share my private practice with my family and Let's say my daily routine is in the morning, I spend time at university doing researches and also treating patients because we have a pre-dental clinic.

00:01:42: We are obviously specialized in soft tissue management around teeth and implants And this department treats our patient and performs clinical trials.

00:01:57: And this is the morning side of Martina's life.

00:02:01: In the afternoon, I share my private practice with my families in particular with my father and with my uncle... ...and basically periodontists.

00:02:13: ninety percent and ten percent implantologists.

00:02:17: So these are my daily routine.

00:02:23: And so cool.

00:02:24: I mean, at University of Bologna you have several research lines.

00:02:29: can you comment a bit about that?

00:02:32: Yes our main research focus is regarding biomaterial especially.

00:02:39: we are working on the connective tissue substitutes in both periodontal and implant field.

00:02:50: As you know, our surgical specialty is regarding the soft tissue management.

00:02:57: And in this way we would like to find the best substitute for the connective tissue grafts in order to reduce patient morbidity.

00:03:08: So are trying focus on research especially clinical trial using these new biomaterials both around teeth, but also around implant.

00:03:21: And working on biomaterials we are using some bone substitute in the implant placement because for us soft tissues set the tone but also the bone play an important role in this field.

00:03:42: So especially, in immediate implant placement... ...in order to fill the gap we are trying use different biomaterial associated with connective tissue substitute.. ..to obtain as much as possible only one surgical procedure that best results in terms of hard and soft tissues.

00:04:03: These are mainly our research topics at the moment in our department.

00:04:10: Okay, so going back a little to the soft tissue management you mentioned that your working on a lot of biomaterials and connective tissues.

00:04:19: So one question could be what are looking exactly in a bi-material?

00:04:25: To replace or substitute the autologous tissue?

00:04:30: So let's back to the characteristic of the connective tissue graft.

00:04:33: The main important characteristics of the connected tissue graft, deriving from the palate of our patient are mainly true!

00:04:42: The Connective Tissue Graph helps the flap remain stable in a final coronal position when the flap is not stable by its says.

00:04:52: This is one of most important aspects... The second important aspect is that when we use the connective tissue graph, it's because we want to change patient phenotype.

00:05:02: The soft-tissue phenotype of our patients... Because a thin phenotype is a risk factor for gingival recession recurrence.

00:05:12: So if you treat a gingival recessions and don't want the patient will experience this problem again.

00:05:17: You have to change thickness of the soft tissues aspects that we would like to have exactly the same way in a connective tissue substitute.

00:05:28: And I think regarding increasing soft tissues thickness, for example with the Mochoderm reached very high level of increased soft tissue thickness because this material is able to incorporate blood clots which became with time connected tissue grafts.

00:05:47: so it works as well but takes to achieve the same goal.

00:05:55: Regarding the flap stability, we are still conducting some researches because this is a characteristic which it's very difficult to reproduce in bio-material and so we're working on each to improve quality of material that we have now available.

00:06:16: But basically these are the two aspects, yes.

00:06:18: Increasing soft tissue thickness and add the flap stability in the coronal position.

00:06:24: And regarding the thickness how much would you say is necessary to increase when using a soft tissue substitute like Mucoderm or CTG?

00:06:38: When you are treating teeth, it's different with respect to when you were treating implant because... ...when you're treating implant and need to increase soft tissue thickness around the implant.

00:06:49: You'll need at least two millimeters of increased soft tissues thickness Because the supracrestal soft tissues around implants aren't attached to the implant thread like around teeth where the soft tissues are strongly attached to the root.

00:07:08: So when you speak about implant, we need at least two millimeters of thickness.

00:07:12: why do you need less thickness?

00:07:14: When you talk about teeth let's say one point five millimeter is more than enough.

00:07:21: Going back maybe into our initial question The question could be Why Do We Need A Substitute.

00:07:28: I mean, why are you looking for biomaterials that can mimic the properties of the autologous tissue?

00:07:34: What is the problem with that.

00:07:36: Why do we want to solve this problem?

00:07:38: The problems... mainly the problems are true.

00:07:41: one problem related to the morbidity in patients because obviously when they need to harvest a connective tissue from their palate You have two surgical sides.

00:07:51: these increase risk of complication increase the morbidity, increased post-operative risk for your patient.

00:08:04: And on the other side, the availability of the palate is limited to the amount of the palette of patients.

00:08:09: so if you have to treat only one single recession defect it's not a problem.

00:08:15: but when you have a patient affected by multiple gingiva recessions in four quadrants The pilot from your patient.

00:08:25: so you need an alternative material to substitute the connective tissue

00:08:31: and then staying with the recession coverage.

00:08:34: Do you think you found this material?

00:08:38: I think yes, yeah.

00:08:44: Yeah I have a lot of experience in the use of mucoderm around teeth and i'm really happy with the result that was able to obtain.

00:08:54: And for sure, In the upper jaw we were able to solve every kind of defects.

00:09:01: The only area which cannot be used is when you are treating the lowering scissor.

00:09:13: In this specific area, we still have some limits that I'm pretty sure with time will overcome.

00:09:23: And what is the problem of the lower jaw then?

00:09:26: Why it's more difficult...

00:09:27: The problem for a lower jaw is related to the specific anatomy in these areas.

00:09:33: Most times you have very shallow vestibule depth and a lot of muscles, phrenola.

00:09:43: you need to have the connective tissue wrap that act as a barrier, to prevent early muscles reinsertion.

00:09:52: So the collagen substitutes still don't have this capability... ...to delay the muscle's reinsertions in these areas.

00:10:04: It is related with really cool and difficult anatomy of specific area.

00:10:12: But lying things with time, we will also try to solve this problem.

00:10:18: You're optimistic and let's say that we are in the upper jaw can you uh... In simple words because we don't have the visual aid work us through.

00:10:27: what do from opening a package of for example Mucrodom to their actual surgery in multiple recessions For example

00:10:37: It is when I have to treat micropore recession.

00:10:39: i never use either connective tissue graph or the collagen matric for treatment of all included teeth.

00:10:47: It's completely different, the corollary-advanced flap with a tunnel technique from this point of view because when you perform a tunneling technique You have to use the connective Tissue Graph Or the Collagen Matric For the treat of All Included Teeth While When performing a Corollary Advanced Flap You can Use The Connective TISSUE GRAPH OR THE BIOMATRIAL cytospecifically, in a cytos-specific way.

00:11:11: So before this surgery I always evaluate carefully every included tools and i decided which one would need to apply biomaterial or connective tissue graph.

00:11:26: so before using the blade you already know how many connected tissues we need or how many pieces of collagen matrix I will fix because otherwise if i would use too much material, let's say damage to impair the vascular supply from my flag.

00:11:53: So basically put the collagen matrix into the saline at the beginning of this surgery, because I really like to work with a collagen metric which is already wet and ready-to be used.

00:12:06: And it takes at least twenty minutes.

00:12:08: but if its also half an hour... It's perfect!

00:12:14: Usually i like add thickness especially in those elements that are backally displaced or which present a root concavity in order to avoid the flap to collapse inside this concavity, Or in elements where keratinized tissue is lacking.

00:12:39: So if I have less than one millimeter of keratinised tissue on my flag... ...I always apply collagen matrix.

00:12:49: So, basically the indication for use of collagen matrix when you are treating gingiva recession is when you have barcary displaced root, root concavities and lack of keratinized tissues.

00:13:06: And I mean... You performed a lot of surgeries with Mukoderm.

00:13:10: What's the long-term results?

00:13:14: Are you satisfied by the long term result in recession coverage using Mukodem?

00:13:18: Yes, absolutely.

00:13:20: You know that after six months the Mocoderm is completely degraded.

00:13:24: so the result you evaluate at six month of their surgery it's a true connective tissue formation.

00:13:33: So its' the true final results and usually I always experience very nice result.

00:13:39: that then would be maintained over time if the patient obviously will follow us and we'll not start again to brush after all magically.

00:13:48: And usually, we have very nice results.

00:13:53: I'm young so i don't have a long term result but We had cases with more than five years of follow-up showing the stability of the result obtained at six months.

00:14:07: So it was good Very good.

00:14:09: I mean recession coverage is.

00:14:12: we've seen a lot of evidence from Mukudem and a lot clinical evidence also form your group, I suppose.

00:14:19: by adding an implant And so trying to increase the soft tissue around an implant We are increasing also the difficulty off the whole procedure.

00:14:29: So what is this relation with that?

00:14:32: What do you when there's a deficiency around an implement where it is your workflow

00:14:39: When there is a buckle lingual deficiencies around implant, meaning that there's lack of soft tissue thickness around an infant already placed.

00:14:51: I had lots experience with the Mocoderm and we have also published case series studies on this in which were able to demonstrate it was possible to obtain increasing soft tissues thickness upto two millimeters which is a successful result from all points of view.

00:15:11: In the included cases in our case reports, the gingival margin was already at an ideal position.

00:15:20: so we didn't include patients with apical coronal soft tissue degenesis because these cases are starting now to work on the use of substituted material but still don't have evidence on that.

00:15:36: Why?

00:15:36: If you have to increase the soft tissue thickness, which is lacking in an implant already placed with a gingival margin.

00:15:45: Already on the ideal position I can recommend use of mucoderm instead of connective tissue graft.

00:15:54: always would be idea to reduce as much as possible the morbidity for patient.

00:16:00: In this case how do we use Mucoderma and Do You mix it with Amelogen and Salso?

00:16:08: The main indication, in my opinion to mix mucoderm with endogene is the treatment of infrabony defects for periodontal reasons.

00:16:20: This another important topic and I have some very nice results on the treatment hopeless prognosis, treated with the periodontal regenerative technique that combines a coronary-advanced flap.

00:16:47: And under this coronar-advantaged flap I place the mochoder which acts as wall to avoid risk of flap collapse inside the infrabonic component.

00:17:01: because in most of these defects, we have the lack of the Bacal Bonnie wall.

00:17:06: So you know that to keep the blood clot stable inside the infrabony component and avoid the flap collapse, the Mocoderm fixed at the papilla anatomical disapitalized papilla or adiacea and LCTus is something he's able to term a non-contenitive defect into a contentive defect which I simply apply amylogeny And I really obtained very, very nice results in terms of clinical attachment level gain radiographic bone defect field and a static outcome.

00:17:40: This is for me one of the most promising indication.

00:17:48: Of course,

00:17:53: there are some cases in which unfortunately you cannot save the tooth.

00:17:56: So in that situation You have to restructure the tooth and what would be your procedure?

00:18:01: I mean we're moving a tooth.

00:18:03: then What happens

00:18:07: when i remove it?

00:18:08: It's such A large question If we were always speaking of the aesthetic area because i like The speed of aesthetic area Because its more challenging because you need to obtain an aesthetic result.

00:18:24: When you are speaking about posterior area, You need to provide your patient function.

00:18:30: when they speak about anterior area we need obviously function but also aesthetics and I have two extract tools if it is possible.

00:18:41: for me the The best solution for the patient is to provide immediate implant placement in order to reduce the number of surgical procedures.

00:18:54: And obviously, if I perform an immediate implant replacement... ...I want to elevate the flap because i want to extract as much as possible into a chalmage tally way with the O-plus tools that I place my implant with a guided implant procedure and if there is a Baccal bone degenesis, I placed some biomaterial.

00:19:24: Let's say I play some Cerebon in the implant thread that are exposed from the Bacal bone And...I Place The Bone In This Area Which Corresponds To Exposed Implant Thread.

00:19:42: because then there is the area from the implant edge to the gingival margin that is, the area for the soft tissues.

00:19:51: So in this area I place a connective tissue graph in order to increase the soft tissue sickness and obviously In cases of very deep bachal bond agencies i also like to head between The connective Tissue Graph And the Cerebon adjacent matrix in order to protect the biomaterial and to obtain better stability of the material above exposed implant threads.

00:20:25: Then I completed coronia vaster flap, And applied also a provisional restoration that will help me stabilize the flap around the abatement.

00:20:41: So usually, this is my first choice.

00:20:47: I need always to plan the case on the CBCT because i want it be sure to place the imp and in the right way to obtain primary stability for immediate provisionalization obviously.

00:21:07: so basically when you have a small defect we will just Cerebon, for example and cover it with CTG.

00:21:14: And then that's if you have a larger defect will also use the membrane.

00:21:19: so what is the advantage of using just some membrane there?

00:21:22: Why do you need in this cases?

00:21:25: You needed to stabilize the bone graft in these huge defects since its very easy to fix and very-very easy to handle.

00:21:36: This matrix can be fixed at the periosteum lateral to the bachal bone defects in order to stabilize the particle of the biomaterial that are placed above the exposed thread on the implant.

00:21:53: And it will act, let's say like a matrix which protects the particles from the cerebone and then I can place my connective tissue or attached to the inner aspect of the flat.

00:22:14: Okay, so I think we covered a lot of topics from recession coverage to bone regeneration and period effects.

00:22:23: So i would like to thank you Martina for your time.

00:22:26: Thank you really For your time with us with BOTIS And...

00:22:32: Thank You for inviting me.

00:22:33: it's always a pleasure to discuss with you about our surgical procedure and our use of biomaterial because you know it's our research topics, we need to improve and try make the more possible experience on that.

00:22:51: So thank-you!

00:22:51: And

00:22:52: I hope see you soon around somewhere in the world.

00:22:54: so Thank You Martina!

00:22:57: Bye!