Bone graft failure: any ideas?
I have a 35-year old female patient, medical history is non-contributory, non-smoker, non-drinker. I did a simple extraction of 3 mandibular anterior teeth with no periodontal issues or bone defects. I placed bone graft material in the extraction sites, released tissue and sutured via primary closure. I prescribed clindamycin, dexamethasone and Vicodin. Post-operative visits, 1st at 2 weeks (suture removal) and 2nd at 3 months when radiographs were taken. Soft tissue and bone graft looked healthy and “normal”. 4 months after the surgery, I accessed the area to place the implants and the bone graft sites were soft. Seems as if “hardened” bone had not formed. Any ideas as to what went wrong in my technique? Thank you in advance for your help.
42 Comments on Bone graft failure: any ideas?
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greg stiener
1/29/2014
Growing body parts is never entirely predictable and there may be nothing wrong with your methods or materials. It sounds like you have fibrous encapsulated granules but if only the sockets were grafted that means either the graft was pushed out of the sockets or the sockets resorbed around the graft material. Please let us know what type of graft was used and if a membrane was used what type of membrane. Does the tissue appear to be inflamed? Greg Steiner Steiner Laboratories
George
1/30/2014
tissue appeared healthy for the most part at the 3 month appt. slightly inflamed around 22 and 27 due to what I assumed was some light plaque build up.
Sb oms
1/29/2014
Was there a flipper or interim partial?
Did it have any tissue contact?
George
1/30/2014
patient had a flipper. was instructed not to wear it and she stated she did not
Richard Hughes, DDS, FAAI
1/30/2014
If you did everything correctly! Then give the area more time (2-3 additional months) to turnover and make bone.
George
1/30/2014
Im afraid/embarrassed to say I panicked. I curetted the sites, added the same graft material and membrane and closed. same med regiment. Its been about one month since the second procedure. Nervous as heck about seeing the same result.
thank you everyone for the responses!!
Richard Hughes, DDS, FAAI
1/30/2014
You may want to revisit the site and degranulate and decorticitate. I use a thin laboratory acrylic bur. it is about the width of a .22 cal bullet. I use this to remove all soft tissue inside the socket, next detoxify with tetracycline for 3 minutes by the clock, irrigate with saline, now decorticitate with a 557 surgical bur on the lingual aspect of the socket. In Europe they recommended to chop up most of the lamina dura. I like to at least preserve the mesial and distal portions of the lamina dura. This way you can check on the radiographs when the lamina dura has disappeared. This denotes about the same time when the graft has turned over. Yes use a resorbable membrane.
If the patient has some sort of sucking habit, they could of sucked out the graft material and then you will get fibrous tissue ingrowth.
Don't feel bad, we all have had a learning curve.
I like to use OsteoGen for the particulate graft material.
I would change the antibiotic. Think about Ceftin 250 mg 1 tab BID
George Sinnis
2/3/2014
thank you for responding. will look into your suggestions further.
CRS
1/30/2014
What graft materiel did you use?
George
1/30/2014
dynacore allograft 70:30 Cort/Can and dynamatrix.
greg steiner
1/30/2014
You have a lot going on with this graft protocol. Cadaver bone with pig intestines as a membrane. These materials contain human or animal proteins that elicit an immune response and it is the inflammatory reaction that determines the degree of mineralization. The host response to these materials will vary from fibrosis (your result) to dense mineralization to intense inflammation which most practitioners diagnose as infection. If the replacement graft material was harvested from the same human and animal you can expect the same result. If the donors are different you may get what you want. You were smart to remove the material because these materials are not resorbable and therefore you would not expect the clinical picture to change over time. Greg Steiner Steiner Laboratories
CRS
1/30/2014
I don't like graft materials with fillers, I prefer human cort/cancellous light but firmly packed to allow blood into the spaces. I allow 16 weeks minimum for healing. I don't allow flippers to put pressure on the graft. I would not use that particular product.
George Sinnis
2/3/2014
thank you. what is your materials of choice for these instances?
CRS
2/5/2014
Any human cortical/cancellous two brands I like are Maxxeus and Allosorb, the price points are good.
Peter Fairbairn
1/31/2014
I am with Greg and Richard on this one we need to use materials that turn over at the correct pace to result in true host bone being restored with no foriegn remnant material. As I have said before membranes may a hinderance to healing not only restricting blood supply to the graft site but also the periosteal induction of BMPs ( Stromal cell derived factors ).
If you break a leg skiing you would not be happy if the Doc walks in and says he is going to wrap it all up in pig intestine with some other material and you have to wait 6 months to walk ..... Lets think about materials and the benefits of early placement and loading . 10 weeks should be more than enough if you work with the bodies healing process
Peter
CRS
1/31/2014
Great post, I like the humor. I would just be careful with the comparison to orthopedic healing of long bones which are different in regards to osteointegration in the oral cavity. I feel dental implants need to be fixed during osteointegration but that is my take.
George Sinnis
2/3/2014
thank you for your response. what is your materials of choice for these instances?
George Sinnis
2/3/2014
so in other words, extraction, bone grafting and primary closure only? ive used oraplugs where i cant obtain primary closure-thoughts?
could you relay your materials of choice in this situation?
peter Fairbairn
2/7/2014
HI CRS , agree morphologically more like a pelvis ...... But Histologically and physiologically bone is bone unless there is a non resorbable remnant material , then it becomes ''bone like " .
There is a lot of research done with Osstell showing some very interesting things about how fast integration ( merely healing of the bone close to an Implant ) can be .
As to even primary Stability actually not necessary again only if certain graft materials are used which fully turn over .
Have 50 or 60 cases all well recorded with Osstell , just need time to write it all up as starting another animal study next week .
Regards
Peter
Dean Licenblat
1/31/2014
I agree with CRS, only difference is sometimes for aesthetics/phonetics the patient needs a prosthesis in which case I have the lab fabricate either a maryland bridge from resin or a denture which is 3-4 mm relieved from soft tissue and reline it on the day with soft reliner. I also rehydrate my graft material with a combination of antibiotics and patients own blood.
George Sinnis
2/3/2014
thank you for your contribution
Robert J. Miller
2/2/2014
Curious as to why you would extract three teeth with "no periodontal issues or bone defects"? But assuming there was a valid rationale, let's pose the following questions:
1. Following extraction, was there bleeding from the osteotomies?
2. If the bleeding index was poor, did you decorticate the walls of the osteotomy prior to placing the graft?
3. What type of graft did you use and was it of high or low crystallinity? What is the recommended resorption time?
4. Was there any tissue movement or microtrauma to the flap during healing?
5. Why did you use a corticosteriod immediately post-operatively, what was the dosage and for how long was the patient using it? If you want to interfere with the early inflammatory phase and resorption of the graft, then you chose the right drug.
6. Why did use mix clindamycin with the graft rather than metronidazole and what was the dosage?
I know I have been critical of these types of cases on this site in the past, and have received my share of "hate" mail after my posts, but this is just basic biology guys. Without a respect for basic pathways of healing, you can expect to see these results routinely. But these "empirical" cocktails have no longer have a place in implantology. Take a good bone augmentation course and get caught up with current protocols.
RJM
CRS
2/2/2014
Hey Robert, quick question I use decadron routinely it wears off in about three days. Can that effect bone resorption over the course of several weeks? I give it for soft tissue swelling after surgery and patient comfort. I like your post, but I don't use antibiotics with my graft either. As always could you post some resources? I like the thought process in your post and and open to learn more. Thanks
George
2/3/2014
THANK YOU FOR TAKING THE TIME!
Curious as to why you would extract three teeth with “no periodontal issues or bone defects� But assuming there was a valid rationale, let’s pose the following questions:ANSWERED BELOW
1. Following extraction, was there bleeding from the osteotomies? GOOD BLEEDING DURING. PRIMARY CLOSURE, NO BLEEDING UPON RELEASING PT. PT DID NOT NEED THE GUAZE.
2. If the bleeding index was poor, did you decorticate the walls of the osteotomy prior to placing the graft? I DID, BUT PERHAPS NOT VIGOROUSLY ENOUGH? I REMEMBER THINKING I SHOULDVE BEEN MORE AGGRESSIVE BUT I HAD SUFFICIENT BLOOD, IN FACT I USED IT TO MIX THE GRAFT INSTEAD OF SALINE.
3. What type of graft did you use and was it of high or low crystallinity? What is the recommended resorption time? DYNACORE ALLOGRAFT 70:30 Cort/Can and DYNAMATRIX MEMBRANE... CRYSTALLINITY?
4. Was there any tissue movement or microtrauma to the flap during healing? NO
5. Why did you use a corticosteriod immediately post-operatively, what was the dosage and for how long was the patient using it? If you want to interfere with the early inflammatory phase and resorption of the graft, then you chose the right drug. (2) 4 MG TABS. 1 THE DAY OF, 1 THE NEXT DAY
6. Why did use mix clindamycin with the graft rather than metronidazole and what was the dosage? CLINDAMYCIN 300MG X30 WERE GIVEN FOR PT TO TAKE ORALLY. I DIDNT MIX WITH THE GRAFT.
I know I have been critical of these types of cases on this site in the past, and have received my share of “hate†mail after my posts, but this is just basic biology guys. Without a respect for basic pathways of healing, you can expect to see these results routinely. But these “empirical†cocktails have no longer have a place in implantology. Take a good bone augmentation course and get caught up with current protocols. NO HATE MAIL HEAR, I ASSURE YOU. JUST APPRECIATION
ezgator
2/4/2014
robert...define good bone grafting course...I feel there are so many it is hard to know which ones are good and which are not.
Robert J. Miiler
2/2/2014
CRS; There have been several studies on the role of anti-inflammatory drugs and the inhibition of COX-1 and COX-2 pathways and the role of PGE2 in early bone formation. Whether you are using NSAIDS or more powerful corticosteroids, the effects are similar. Early markers for bone regeneration are substantivley reduced when inflammation is inhibited with some studies showing increased numbers of implant failures with excessive use of NSAIDS. Here is a good paper on the biologic pathways.
"Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing"
Jessica Cottrell and J. Patrick O’Connor
Pharmaceuticals 2010, 3, 1668-1693; doi:10.3390/ph3051668
We limit NSAID use to only ONE day post-operatively and administer that dose in the chair when surgery is complete. I find it rare that patients need anything more than Tylenol (if anything at all) after this early drug dose. The only time we have used decadron previously (sublingual) was following subperiosteal implant surgery and big flaps.
RJM
George Sinnis
2/3/2014
thank you for the link!
CRS
2/3/2014
Thanks so much!
Richard Hughes, DDS, FAAI
2/3/2014
Why would you extract three sound teeth?
George Sinnis
2/3/2014
why would you assume that?
I didnt think itd be relevant, perhaps I was wrong in not painting a clearer picture. my apologies. the patient was very crowded, with #24 being approximately 80% lingually displaced. #s23 and 25 had deep carious lesions extending subcrestally.
extractions and a bridge between 22-27 was discussed but the pt was adamant that she did not want another bridge.
ortho, endo, crown lengthening, cast post/cores, and crowns were given as a treatment alternative. Looking back, I was probably guilty of favoring (and relaying that opinion) extractions/implants as the treatment of choice, but the pt WAS given the aforementioned options.
Richard Hughes, DDS, FAAI
2/8/2014
Ok, thanks for the clarification. I'm not throwing stones. I was curious. I tend to favor the six unit bridge in these cases.
George
2/3/2014
Again, I want to thank you ALL for your time and input.
my dex regimen was (2) 4mg tabs, one the day of surgery and one the following day.
ive taken 3 bone grafting courses, 2 implant courses and a sinus lift course. I have been instructed by all to use antibiotics starting a couple of days prior to the surgery and extending until the completion of the prescription. clindamycin 300mg, 30 tabs, 1 tab tid has been the protocol in my limited experience. will read up on the ceftin. thank you for the suggestion.
Choukroun
2/4/2014
Georges, your protocol is right! If your patient has not the capacity to build bone, it comes, may be from a biologic disorder. Please check the LDL cholesterol and Vitamin D level..
Two Neglected Biologic Risk Factors In Bone Grafting And Implantology : High LDL Cholesterol and Low Serum Vitamin D.
Choukroun J, Khoury G, Khoury F, Russe P, Testori T, Komiyama Y, Sammartino G, Palacci P, Tunali M, Choukroun E.
J Oral Implantol. 2013 Oct
Das
2/4/2014
Interesting and lengthy discussions I follow a very simple and predictable protocol For ridge preservation you can use any graft material , I preferably use Mineross lightly packed and always cover using a dense PTFE membrane like cytoplast Covering the graft site is very important for predictable graft containment and epithiliasation.(barteee).Possibly the softness of the graft site was due to the exposure of the graft material and fibrous inclusions
Dennis Muse D.D.S.
2/4/2014
Always decorticate to encourage osteocytes into graft framework, not tissue cells. It's a race, you know, osteocytes v.s. tissue cells. Tissue will always win unless you get rid of all of it and seal area from any tissue with a GBR membrane. Good luck and God bless!!! Dennis
SFDIndy
2/6/2014
Unless theres an undisclosed medical issue, Im leaning towards this. I recall thinking I shouldve been a bit more aggressive.
Donald Rothenberg,DMD
2/4/2014
In our practice we use Synthograft by Bicon...
it is always mixed with the patients own blood which we take from an IV ...
we don't not use blood from the mouth... assuming it is always contaminated.
We get good regeneration of bone in 3-6 months...depending on the patient and the volume of graft placed.
SFDIndy
2/6/2014
thank you for your reply. ive debated on taking a phlebotomy course in the past. i may have to revisit this.
Osbert Usher
2/5/2014
I love the aspect of getting blood through an IV method instead of from the surgical site. Thanks.
CRS
2/7/2014
I just let the socket fill with blood unless I'm using PRGF growth factors. Remember these are clean contaminated oral cases using iv blood is probably not necessary an exposing a patient to a blood draw. Unless you do these all the time probably not worth the hassle. I did stop using bone gathered from the suction too icky!! I agree that grafting in the mandibular anterior is tricky but so is any oral grafting I just don't think the fillers work well.
Richard Hughes, DDS, FAAI
2/8/2014
Using IV blood for a socket graft is absolutely unnecessary. You will obtain all the blood with stem cells if you decorticitate the socket from the bone marrow. You do not obtain stem cells from venous blood. This blood will permeate the graft material, which acts as a scaffold for new bone to form. You can use the clot but I like to stack the odds in my favor. I have seen the buccal resorb rapidly, so now I graft. It's a good service for the patient and makes subsequent implant placement easy. Just do not use a nonresorbable material.
greg steiner
2/8/2014
In regard to the use of antiinflammatory medications and bone healing. The anti-inflammatory medications only affect bone healing processes that require an inflammatory process to heal. The idea of not using anti-inflammatory medications comes from endochondral bone formation after fractures which have a signification inflammatory process associated with them. All maxillofacial bone heals by why of intramembranous bone formation which does not have an inflammatory process associated with it. So anti-inflammatory meds will affect your healing leg (endochondral) but will not affect your healing mandible or maxilla (intramembranous). We all know prostaglandins cause bone resorption. So blocking prostaglandins with anti-inflammatory meds promotes intramembranous (maxillofacial) bone healing. Our bone grafts reduce prostaglandin production by design. So anti-inflammatory medications will have no effect on maxillofacial healing when no graft is placed and will not affect autografts or our grafts because these healing processes do not have an inflammatory mechanism. However allografts and some xenografts which require an inflammatory process for mineralization will be affected by anti-inflammatory medications. I prescribe medrol to my patients and advise switching from narcotic pain meds to NSAID's as soon as possible and my failure to integrate is next to never. Greg Steiner Steiner Laboratories
