Vertical bone augmentation with Itsvan Urban | Tell Me More About

Added: 2026-05-08

[00:00:10]Joining me in this tell me more about session is Istvan Urban from Hungary.

[00:00:14]Istvan, welcome. Thank you so much for having >> You did a session here in the Monaco Congress earlier today where you talked about vertical bone augmentation and delayed implant placement. A very relevant topic in this theme of timing in implant dentistry.

[00:00:28]What is the latest scientific insight that you brought to our audience?

[00:00:32]Well, number one, I dived into some of the new research which is mainly pre-clinical first about the importance of the communication of the graft and potential growth factors with overlying soft tissues and the periosteum.

[00:00:47]Let me see if I get that. So, the communication of the graft with the overlying >> growth factor to overlying tissue, yeah.

[00:00:54]And what what did you dive into? What did you find? So, we we we we we looked at like a completely occlusive device, then when you have the blood clot and when you have a surface of the bone and you have [snorts] something in there.

[00:01:06]Or you have a device that has certain size of opening and we want that size to be communicative, but not soft tissue ingrowth. We can talk about that, too.

[00:01:16]So, then you have a graft that can communicate with the blood clot, with the surface of the bone and bone and overlying soft tissues. So, we looked at that. Mhm. And we found that So, first we wanted to understand that is mesenchymal cells outside in the soft tissue, how important they are.

[00:01:33]And so, we started to stimulate any mesenchymal cells and used a growth factor to BMP2.

[00:01:40]And um so, in the occlusive area, they can communicate with the blood clot and the bone. In the perforated area, they can communicate with the bone, the blood clot, and the soft tissue. And now, indirectly from the result, we can tell how important the soft tissue was. It looks like it was very very important.

[00:01:59]So, you say the soft tissue or the connection with the soft tissue has an effect on the growth of bone. Exactly.

[00:02:05]How can that be? Did you Were you able to determine that? Yes.

[00:02:09]So, because in the soft tissue that like the periosteum has two layers. One is the cambium layer and the outer layer is the fibrous layer. Membranes were developed to exclude cells which are in the fibrous layer, fibroblast. But in the cambium layer which is closer to your bone graft, there are blood vessels. Blood vessels, we know where they're important for bone regeneration and there are progenitor cells.

[00:02:31]And we know that progenitor cells, if somebody tells a project like a like growth factor can tell progenitor cell, "Okay, well, you know what? Let's you become a bone cell." Mhm. And then they become a bone cell and that would help.

[00:02:42]Yeah. And so, but we don't know like exactly like how important they are. The Is there a potential? Are they talking to us for the last 30 years, "Hey, we want to help, but you guys Yeah, yeah, yeah, but you excluded us. Yeah, yeah.

[00:02:53]What what type of magnitude of effect do you see when we when you say improve?

[00:02:59]Gigantic. I mean, it's like crazy.

[00:03:02]It's like Define crazy. Crazy is like we figured out that there's not in the blood clot there's like no mesenchymal cells. I mean, this poor growth factor which is very expensive and only communicating with these progenitor cells didn't find anybody.

[00:03:15]>> [laughter] >> Okay? So, under the membrane there was no bone. Mhm.

[00:03:18]From the from the bone there's some apposition of bone that like very slowly growing up. So, a big gap, but then, you know, this device is not perfect. So, some probably some growth factor seeped that was seeping out touching the bone graft, touching the soft tissue, and above the membrane there was bone.

[00:03:37]There was bone above the membrane, there was no bone under the membrane. So, and the and the perforated device, there was bone all over the place. We could barely find that the membrane. Was this specific for the device or the membrane used in this study or is this a generic phenomenon you see when there's membrane used?

[00:03:54]>> is a biological principle. Mhm. Okay, which we obviously exaggerated because we used something that can only communicate with mesenchymal cells. So, this study shows the importance of mesenchymal cells. And then, I also looked at the next study we did Yeah.

[00:04:09]based on this we said, "Look, okay. So, that means that maybe when we do a bone graft and we put some growth some growth factors that we put or there's some growth factors inside the bone graft then maybe the location is important of of the growth factors or the biological factor. Whether they are close to the bone or close to the soft tissue.

[00:04:31]>> Whether whether in the middle bone soft tissue. So, we again used a micro dose of growth factor, but again, not because of growth factor, because of to to see if I put something which has an effect on mesenchymal cell. Mhm. So, we chose this because we know that this has a perfect effect. And we started to position it in the middle of the graft, we called it the sandwich. Yeah, of course.

[00:04:52]>> Okay. Yeah. And we put it outside just like just a normal like a graft which has no biological effect, just a simple like cellular graft which has just a stabilizing effect for the growth for for the blood clot. So, when we put it outside we called it the lasagna. Yeah.

[00:05:09]Okay. Okay, I feel I >> Yeah, it's easy. You need to make science communicable.

[00:05:12]>> Yeah, I put the lasagna over the sandwich. Over the lasagna, yeah. And then we had two, you know, control groups. Yeah. And what we found is what exactly what we predicted.

[00:05:22]Number one, we used a very very small dose, so like a micro dose. And what we found that when we put in the middle, many of the samples had no bone in the middle. There was a big void. But then, some growth factors came out because now we used the perforated one. Yeah.

[00:05:36]Touched the soft tissues, above the membrane there was perfect bone, below again a void.

[00:05:41]When we did the lasagna which was directly communicating Yeah.

[00:05:45]those cells which we're talking about Yeah. talking to us for 30 years Yeah.

[00:05:49]and they performed not bone only on the top, but the entire graft became bone.

[00:05:54]The entire graft all the way to the original bone level. Yeah, and we waited on for two months only for in these animals which is like they're healing faster.

[00:06:01]>> That was my next question. This is an animal So, because I was wondering how how many cases were you able to do this?

[00:06:06]I like it. Control group, everything, but this is difficult in real patients, right? It's difficult in your patients because it's like >> study. It's an animal study, but it's not so difficult in your patients because for example, in in North America, this is on the market. Mhm.

[00:06:19]Now, you talk about the specific growth factor. A specific growth factor. And in in European Union, it's on the market, but for different indications for neurosurgery and things like that.

[00:06:27]And we are in we are we have submitted ethical approval with Professor Windisch, a good friend of mine, the two of us to do a randomized clinical trial to repeat the lasagna effect on the vertical augmentation. So, I I I um actually in my lecture, I showed this is a biological phenomena. Yeah. And then I showed cases when we used a micro dose of this device and we created like we had patients who were like it's very difficult like patient who had lost the mandible and had a >> entirely entirely and they had like a fibula like this little bone transplanted in here Yeah. with fat and all that and usually for for the bone graft on it, they they they don't work very well. So, what we did, okay, poor host, we did a bone graft, lasagna, stimulated the overlying soft tissue and we got perfect bone.

[00:07:16]So, it looks like it's going to work very well on humans, but this is just it was one of the the insights that I in terms of biologically >> And does it mean from what I understand correctly, this case for example, you have to do in the Americas.

[00:07:28]You have to do it in America or it depends where which country you do. Like in America, it's it's off label to do it because it's, you know, like the FDA there's different indications. Okay, let me give you one example what is like off label. Off label would be like you use uh there is a there is a medication called Tegretol.

[00:07:47]Swiss medication. It's all over the world.

[00:07:49]It's very good for um like neural neurotic pain. Mhm. It's also very good for epilepsy.

[00:07:57]Okay. Okay, in some countries, you open it, it's it's licensed for neuropathic pain. But what if you have a patient which would be this would be the perfect medication for epilepsy. It's not illegal to use, but it's off label to use. Got you. Got you. So, but usually what they do then those countries, they register it for that indication. Yeah. Okay, now in the European Union, it's registered for neural and all that. So, micro dose you could use off label.

[00:08:22]So, it's but it's off label everywhere so far. I think but the next BMP will come in that I don't want to talk about BMP, but next BMP will come in hopefully with another BMP, I think it's BMP7 or BMP, you know, BMP5 or 4. Anyway, so it's going to be licensed hopefully everywhere.

[00:08:40]>> [snorts] >> Istvan, would you say if all limits are off? So, it's FDA or it's ethically approved all all licenses are on green.

[00:08:47]This would be the new standard of care.

[00:08:49]Would you always do a vertical bone augmentation [clears throat] like this?

[00:08:53]Uh let's let's see. Let's wait for the >> This is interesting. You doubt. Why the doubt?

[00:08:57]>> No, no, no, because I would say I only would say yes once you have a randomized clinical trial. Ah. Yeah, yeah. Okay, so the scientist in you is still a bit cautious.

[00:09:06]>> I would be extremely surprised if not.

[00:09:09]Yeah, I can imagine.

[00:09:10]>> you can do a micro dose, you need micro dose which would cost like 200 euros.

[00:09:14]Okay? So, I I mean, the the results what we see is much better.

[00:09:19]Based on what you've seen now, would would this work in any area where you want to do a vertical augmentation or are some areas better fit than others?

[00:09:28]I would say anywhere. No restrictions on that. But again, low dose Yeah. not to not to have a lot of swelling and just, you know, improve the healing.

[00:09:37]Exactly. Any other takeaways from your session on stage today? Well, this was not my my main takeaway was not even this. My main takeaway was This was just the news, right? This is the news. Yeah.

[00:09:47]It was, you know, what you do when you have cases, young patients who had previous problems. Like imagine somebody who had implants failed, you know, they removed the bone the implant and somehow the canal got exposed. This is a big defect. Canal is exposed. The or the mental nerve is almost on the crest. So, we have very short flap. You have scar tissue. You have to put in a much bigger bone graft and close it with a flap that is this short down. How do you do that without damaging the nerve?

[00:10:14]That was one of my topic.

[00:10:16]And um You got my curiosity, Yishai. How do you do that without damaging the nerve?

[00:10:21]>> So, because if Let's imagine you have a 4-mm flap.

[00:10:26]How do you advance a 4-mm flap to 20 mm without damaging the nerve? Cuz nerve is right there. Well, you know, I wish I could tell this to myself 20 years ago.

[00:10:36]Well, tell us now then. But now I can tell you.

[00:10:37]>> Yeah.

[00:10:38]So, basically, um you go through only the periosteum. You cannot cut deep Mhm.

[00:10:43]because the nerve [clears throat] is right there. And you have a very short flap. You want vascularization of the flap.

[00:10:48]That means you you go very close to the mental foramen. So, you cut on top of the nerve. Mhm.

[00:10:54]And once you cut on top of the nerve, I mean, I put in on the other side a bite block to make sure the patient's not chewing on it or closing immediately when I'm doing that. Then [snorts] I cut on the periosteum.

[00:11:05]Then after I cut the periosteum, then I very I have a blunt instrument that I very carefully start to stretch the flap. But I can stretch only 2 3 mm.

[00:11:14]>> going to say, you're still not far away from 20, yeah?

[00:11:17]Okay, under the periosteum, usually there's little collagen fibers, little bundles that we debundle, that we rotate the blade and we we say we play the guitar on those strings. Dong dong dong.

[00:11:28]And then stretch 2 3 mm.

[00:11:30]Then what we do is call the gradual stretch.

[00:11:34]We stay patient. So, we stretch 2 3 mm, debundle, 2 3 mm, debundle. And once is in these 2 3 mm segments, we bypass the entire nerve. And that's when we start to pull a little bit more force. And the whole thing is like beautifully coming up. You may see through the nerve, but the nerve is completely intact. You see the fiber, the big branches of the nerve. And now you have a long flap. Plus, you have the lingual flap that I also talked about, you know, the three zones and how you advance the lingual flap. And then you can close these flaps all of a sudden.

[00:12:06]And this young patient is 45 years old is going to have um A good restoration, yeah. And bone again. However, Yishai, I've seen you many times in these congresses. You are a very, very experienced surgeon. I can imagine this is not for everyone, right?

[00:12:22]I think this can be for everyone as a concept, the the stretching? who is serious about this, wants to learn.

[00:12:29]Okay? And you have to be very serious about it. Because you're super close to the nerve.

[00:12:33]>> But it's not about, you know, how talented I think. It's I think how serious you are.

[00:12:37]And then how dedicated you are in terms of Okay, let's go through this. Okay?

[00:12:43]And we we we have published an article, but I want to I want to publish a decision tree. Okay? I have a patient.

[00:12:49]Short flap, long flap.

[00:12:51]Okay? Decision one. Okay, then.

[00:12:55]Native tissue, fibrotic tissue, scar tissue. Okay? Worst would be very short flap and scar tissue. Mhm. Okay? What are the little details you have to do?

[00:13:03]So, first you make a diagnosis in your mind. I'm going to have this patient have five bone grafts, a lot of scar tissue. This patient has super super short flap. Before I'm going to get a heart attack, I have to make a decision what I'm going to do. Okay?

[00:13:15]>> what are your alternatives except not treating? Okay, you could put an extra short implant in some of them, but what I showed you can't. Okay. Because they were very narrow and it was like 1 or 2 mm from the nerve.

[00:13:28]And imagine a 45-year-old patient who's coming to my practice. I'm looking at it. The nerve is exposed.

[00:13:35]You know, it's like, do I need this? Do I really want to do it? I mean, I want to do it.

[00:13:38]>> yourself as a professional surgeon.

[00:13:40]>> I didn't need it. The patient's looking at me.

[00:13:42]Yeah, of course I want to do it.

[00:13:44]>> Yeah. And so, somebody has to do it, but I think, you know, and again, so, if you have this decision tree in your mind, you have the training, you're dedicated, Okay, I also Okay, let's say I have a short flap, native tissue. This is what I'm going to do, what I just explained.

[00:13:58]>> Yeah. Okay? And you sit down like that.

[00:14:01]Is different. And it sounds like the room for error is zero. Zero.

[00:14:06]For for this particular but it's an extreme example. There's not much of a room. But you're not going to do make a you're not for error. You're not going to make an error because you know exactly what you're going to do. And when you mentally prepare yourself, this is what I'm going to do or you're just going into a surgery, let's see what happens and I'm going to That's not working. I don't know if there's any surgeons out there who would try to do a surgery like that, but uh No, no, but if you Yeah, if you have no idea, don't do it. Yeah. Yeah. Great example. So, that's something you also shared in your session. But what is the key takeaway?

[00:14:34]What do you hope people take into the clinic tomorrow morning?

[00:14:37]>> [snorts] >> I think um the number one patient prepa- select patient preparation is very important.

[00:14:42]So, everything has to be super clean when you do surgery.

[00:14:45]You know, how you approach a flap design and a flap advancement is very important. And we talked about the anterior maxilla. Mhm. You know, how important that is that you do it as a compre- comprehensive that comprehensively looking at it. That means that you have a defect.

[00:15:02]Usually it comes with a soft tissue defect.

[00:15:04]>> Mhm. What are you going to do with it?

[00:15:06]How is that going to look?

[00:15:08]So, how many you know, how much time is going to take? Um and because you Once you start to do it, you have to go from A to Z.

[00:15:17]Yeah.

[00:15:18]There's no way back. There's no There's like in the middle you say, "Oh, this was good enough. Okay, that's good enough." You know, no, no. You have to go until until Z. Yeah. Okay, or don't start. Yeah.

[00:15:27]So, planning is key, patient selection.

[00:15:30]Any other thing you hope people do more carefully or take away from your session?

[00:15:35]Patient prepa- Again, patient preparation. What does that mean in your >> Here's the problem. It means like that I see that they do, let's say, somebody's doing a bone graft and the neighboring tooth has a crown with an open margin like this. Mhm. Why? Oh, patient didn't want to change it. No, but now you have an open margin. Do you know what's in there? Bacteria. Mhm.

[00:15:53]>> [clears throat] >> You know why do you have pus and an infection? Because that you suture the flap up under the the margin and now it is infection. You do this beautiful surgery for nothing. Yeah. So, before you do this beautiful surgery that you learned, you have to prepare the patient for it. Has to be If that crown is not good, change the crown.

[00:16:10]Yeah, yeah.

[00:16:11]So, that's why you don't use the word selection, but preparation.

[00:16:15]>> Preparation. So, that might mean you first go to work at the adjacent teeth.

[00:16:19]You have to clean everything, to clean everything, treat periodontal disease.

[00:16:24]So, have a mouth that is really ready Yeah. for you to do the bone Do you feel that's often overlooked? I think it's very often overlooked. Very often overlooked. Too much focus just on the implant then.

[00:16:33]>> my god, this is what I'm going to do.

[00:16:34]And then it's like, okay, but you didn't prepare the patient. Mhm. So, patient preparation. And then, of course, you have to learn this. Mhm. Once you learned it, then and you prepare the patient, of course, very important, the post-operative management, provisionalization.

[00:16:48]So, there's a there's a lot of little things, but I think the two most I mean, seriously, the most overlooked is the is the preparation for a patient. Exactly.

[00:16:56]And then the surgery.

[00:16:58]Interesting, very interesting findings.

[00:17:00]Thanks for your passionate sharing of those. And uh it was an honor to talking with you about this. Thank you for being here with us. Thank you so much for having me. And thank you for watching this episode all the way to the end. I can imagine you get excited, you want to learn more. Make sure you check out all the other episodes of Tell Me More About and all the other educational, scientific content here at Monaco Online.