Condensing Osteitis: Can I Place An Implant in this Situation?

Condensing osteitis is produced when bone is formed in a inflammatory environment resulting in an increase in mineralization and a decrease in vascularity and vitality (fewer osteoblasts) as the body tries to isolate the lesion from the rest of the body. Consider it scar tissue. Histologically it is called sclerotic bone. The same histology and healing process occurs when allografts and xenografts that contain proteins are grafted into bone. Allografts and xenografts produce sclerotic bone as a result of the presence of foreign proteins and the histology of these grafts cannot be distinguished from condensing osteitis. So if you are willing to place implants in bone that has been grafted with foreign proteins you should have no reason to not place an implant in an area of condensing osteitis. Personally I remove sclerotic bone prior to placing an implant whether it be from condensing osteitis or from an allograft or xenograft. I then graft with a material that will produce normal vital bone. If you can provide a radiograph it would be helpful. Greg Steiner Steiner laboratories

If you look at "sclerotic bone" microscopically you will generally see vital bone, usually with little to no inflammation. I would feel no compunction about placing an implant at such a site. (I am a periodontist who has placed implants for 25+yrs and have a masters in Oral Path)

Greg, Please can you advise us as to what sort of graft material that will produce normal vital bone? Thanks.

Hello Dr. Chow That is a good question that most don't ask and I will try to not bore you. First, if you do not graft you will get poorly mineralized bone with poor vitality plus you are likely to get significant shrinkage of the site. So you need to graft but the graft needs to be resorbable or the site will be filled with inert foreign material that at best will provide no vitality for integration. Ever wonder why allografts and xenografts are nonresorbable? If you heat these grafts high enough to remove all proteins it turns into a ceramic that is too hard to resorb. If you don't heat allografts and xenografts they have residual proteins that cause an inflammatory reaction (sclerotic bone). The previous Dr. is correct, you do not find inflammatory cells after healing is complete with these grafts because the body has mineralized the area and retracted vascularity to isolate the foreign proteins from the body. We call this process mineral encapsulation and vascular isolation. In this case, you end up with high mineralization but poor to no vitality. So, you need a resorbable material that stimulates osteogenesis if you want normal vital bone. I try to not be commercial in my comments but our graft material Socket Graft and Regen Biocement were designed to produce normal vital bone in a short period of time. I have only placed one implant in condensing osteitis and it failed and when I removed the implant I removed the condensing osteitis, grafted, and the second implant was successful. Greg Steiner

Thanks Greg for such an informative response. If what you say is true, it means many of our grafts if infected will rapidly be lost because of the lack of vascularity. The gold standard then must be a graft that is rapidly resorbed and replaced with normal bone, which will omit many of our favourite brands. I am hazarding a guess that Regen Biocement is calcium sulphate or some derivative of it. If so, why are we not all using that instead, since it is easily available and it even sets to boot! Sincerely.

The problem with diagnosing condensing osteitis is that it is not an all or nothing phenomenon. All of the above comments are true; however, one important element has been left out. When an implant is placed, success depends on early angiogenesis, not necessarily related to the number of osteoblasts in the bone immediately adjacent to the implant surface. Angiogenesis is directly related to the rate of bleeding when the osteotomy is prepared. Osteoblasts can then be recruited from the deeper bone areas. Our decision to place an implant into dense bone (sclerotic bone being one type) is directly related to the amount of bleeding present. If it is insufficient, all that is necessary is to decorticate the inner part of the osteotomy, much as you would do to mandibular cortical bone when an onlay graft is placed. RJM

Dr. Chow Histology shows calcium sulfate to be a mediocre graft material. Socket Graft and Regen Biocement are calcium phosphate graft materials formed by molecular bonding in the graft site. Allografts are promoted to be osteoinductive and osteogenic due to the activity of the grafted proteins which research has shown to be false when these products are used in humans. These statements can be made because allografts are considered transplants and have no FDA oversight. You can say anything you want about unregulated products. With the advent of tissue engineering we now have the ability to produce normal bone that may actually surpass normal bone in vitality. I am currently putting together a "How bone grafts heal" paper that will allow us to have a discussion on what is happening in the graft site and what we are creating with the various graft materials. Greg Steiner

"Is it advisable to place in implant in an area of condensing osteitis?" No, condensing osteitis means there is a serious chronic infection in the bone.

Dr. Greg Steiner, When & where will your be published?

Sorry for the missing word, Dr Greg Steiner. So when & where will your paper be published? Thank you.