Discussion Topic: Long-term Functionality of Bone Graft Materials

The fact that a material is resorbed , IS the most important aspect as we do not need donor HA type material for long term retention unless a pontic site of a bridge . The functional presence of an Implant retains and can improve the bone in line with Wolffs law ( Over 150 years ago ) We need to work with the body by using fully bio-absorbed materials to return it to its former healthy state which we can then monitor by merely using x-rays as there will be no residual graft material to take the space require by the new host bone nor will there be a "false" reading of density on the x-rays. We have noticed over a 9 year period that the grafted sites routinely have a better long term retention than the adjacent host bone sites often gaining bone height after the first years loading ! Have we been possibly misled of the need for donor HA by the financial interest of som?. Do We have evidence , sure , Cores , Micro CT , scans Etc .... Kind Regards Peter

Peter where do you get all these laws???? Anyway in my experience the graft gets turned over or resorbed or replaced by the patient's own bone so as far as the graft is concerned you are done. The old hydroxyapatite stays forever and Bio-oss stays forever. I can't believe I'm that old. What you need to understand is that the graft is only a scaffold for replacement with the pt's own bone. The only organic graft that stays forever is a free fibula graft used in mandibular reconstruction It has its own blood supply like the osteo-flaps. Even ribs resorb. Use a quality product like a cortical-cancellous cadaver product with or without growth factors. The calcium products, bioglass etc just don't work well to give you decent bone in the alveolus. I don't even like the dynablast type products the collagen filler doesn't give me a decent result. However that said just about anything works in the sinus even bio-oss. I think you should not cut corners with the graft product since it will affect the bone quality for the implant. Also the "gold standard" auto graft actually works better with allograft and growth factors, go figure! Just my thoughts and experience.

Julius Wollf German anatomist ( 1836-1902 ) the father of of understanding Bone and is functional role . and of course common sense with combined Implant experience dating back to the early 60s. Like yourself just what we see in extensive cases . Regards Peter

This is a great question and it will become more important as the implants placed in the last few years begin to age. I think we can all agree that the best for long-term functionality of a dental implant is normal healthy bone. Therefore any graft that produces normal healthy bone is the best for long-term functionality. Anything that is nonresorbable does not produce normal healthy bone and cannot be considered the best for long-term functionality. The worst bone grafts for long-term functionality are bone grafts that are nonresorbable and produce sclerotic bone. With these grafts you have a significant amount of retained graft material that takes the place of normal healthy bone and in addition you have bone that cannot remodel (the definition of sclerosis). Autografts are good for long-term functionality because they are fully resorbed and produce normal healthy bone. Allografts and xenografts are nonresorbable and produce sclerotic bone and the way these grafts fail has been elucidated. The future of bone grafting is in graft materials that are fully resorbable and produce higher vitality(more osteoblasts) and higher density than normal healthy bone and therefore are the best for long-term functionality. Greg Steiner Steiner Laboratories

I would have to agree in some things with Greg, healthy bone is the best you can aspire to. I would have to disagre in other like the use of long term resorbable materials. There are some that allow you to get bone, real healthy living bone arround and encasing the particles, hence it keeps the volume in the long, long term with full osseointegration capabilities.The biological, microscopical and functional studies are there for the reviewing

Peter and Greg make great points which seem to be overlooked by an industry and profession which sometimes prefers to see things differently. It seems to me that before practitioners consider the quality of a bone grafting material they should asses thier patients health state and be realistic about thier skill levels. Get the these two right and the first must be less important. As was said the best place for implant ant is healthy bone and ANY procedure or material which achieves sufficient bone to support a functional implant and appropriate soft tissue to give the patients desired appearance is a successful one. When considering materials it seems to me that the ideal is the one that either accelerates bone healing or supports it and then resorbs at the same pace as new bone is formed. Anything that does not do this is "squatting"....

I completely agree with greg opinion. The material you are going to use will depend on procedure. For example if you need to place bone under a pontic you will.need to seek a very slow material like a bovine bone or biooss. There is a common mistake that a lot of practionner do is to graft bone in all the extraction sockets because they want to prevent bone resorption, which is true. But the problem is they go and place an implant 2 months later in the grafted bone thinking they are placing it in a native bone. Dont even graft bone if you are willing to place an implant this early. I use nowadays a combination of dfdba and fdba (encore bone) which i consider as the best choice for osteoinduction and conduction. The dfdba is a slow resorbing material while the fdba is considered to have some osteoi duction activity and is resorbed more rapidly. This mix is great for gbr.

To Kong, Peter and others, bone will regenerate about dental implants. You are correct that there is usually a loss of bone around dental implants. Ralph Roberts, DDS reported in The JOI XXXI No. 2, 2005 (A Twentyfour Year Retrospective Study of Bone Growth After Implant Placement) thisnis a study of ramus frame implants and Fisch and Misch Report in The JOI, XXVI, No. 4, 2000 of bone regeneration in a subperiosteal implant. I have personally seen this in a small number of my cases ranging from blade to root form implants.

Greg, I thank you. Yes, autografts are the gold standard,allografts have questionable late induction and questionable resorption, alloplast are safe, synthetic, osteoconductive, sometimes they resorb to fast or to slow, they do produce lamellar bone, xenografts have a questionable efficacy and are somewhat osteoconductive but they are a strain on the RES over time. Xenografts are space fillers. I do question just how strong are they over time at supporting implants in function. I also would like to see more studies on where all these different graft materials go and the end organ effect.

Dear John just something we have noticed in a few thousand synthetic graft cases between 3 surgeons with a combined implant experience of over 80 years. As I said then ,not evidence based but very well documented , I have shown cases here already. We are doing some research into this and will be showing two papers at the EAO this week. We are as suprised by this observation as yes all the ( now dated as most done when polished collars were de riguer ) evidence suggest bone loss post loading. Anytime you are over this way I can show hundreds of cases as it is interesting. We feel it may be due to the funtional re-modelling and remant graft material and have thus adopted an early loading (10 weeks) protocol even with initial IOS ( Osstell ) readings in the 20s . Kind Regards Peter

Sorry, ISO , needed to change as typos seem to be unforgivable We must also remember that any decent high level research ( RCT etc ) ) will cost hundreds of thousands of $ . Regards Peter

To John Kong I understand your frustration about allograft osteoinduction but you need to have a bit of understanding because of the amount misleading information put forth saying that allografts are osteoinductive. Most of the allografts are sold by companies that buy the material from a bone bank and they have no knowledge of the graft material. All of these products have statements in bold about "proven osteoinduction". You will most often find an insignificant asterisk that refer to the osteoinduction as "proven" in a rat assay model. Allografts are osteoinductive in rats but not in humans. The companies can get away with this misleading information because allografts are considered transplants and not regulated by the FDA and therefore they can say anything they want about the material. In addition you have legions of paid lectures touting how the allograft they represent is osteoinductive. To make things worse you have professors from major US universities publishing papers on allografts in respected journals that talk about allografts as being osteoinductive. I politely called out one such prominent professor and he replied that there is no research that supports allografts as being osteoinductive in humans because the research is impossible to do in humans and that his statements were theoretical. He does not say his statements are theoretical in his papers! When I sent him a literature review of the research that has been done in humans and it shows clearly that allografts are not osteoinductive in humans he refused to communicate with me further. So, have some understanding of those practitioners who hold to the belief of allograft osteoinduction but when someone claims that allografts are osteoinductive based on a rat model just tell them you have not treated many rats lately and ask them to provide support for their claim in humans. By the way osteoinduction in a bone graft is a bad thing but I have already droned on long enough so that discussion will need to wait. Greg Steiner Steiner Laboratories

I obtained my ct scanner two years ago and had my staff recall about 50 bigger reconstruction cases with and without implants. All but one required a large bone graft and all were grafted with autogenous bone( sometimes mixed with dfdb ) . One case was grafted with bmp and dfdb only, because harvesting bone in the 80 year old was contraindicated. All grafts, with the exception of the bmp case, are impossible to discern from the adjacent native bone, with a high quality ct scan. One orthognathic case from 19 years ago, where I used an ha block, with a large downward move in a lefort 1 osteotomy, is frankly embarrassing . Fortunately the patient was young and grew bone next to the blocks . Harvesting autogenous bone is simple, very cost effective and safe. The suggestion of second surgical site issues, especially in implant cases, was conjured up by those not proficient in the technique or companies trying to suggest it is unnecessary. Our grafts need to be inductive, in my opinion. Bvinci. Vinci Oral and Facial Surgery. Baton Rouge, La.

To Richard, Peter, Greg and Khoudry, There are tons of articles on bonegrafting in the literature. Some excellent, some absolute garbage. It's up to the reader to sift though the garbage (hate to generalize, but generally case studies and studies in journals with weak editors) and be able to call out bs when you see it. Then, if the evidence is there for a product you like and it makes sense to you, try it in your hands. If it works on a consistent basis, good for you. Some on this forum like synthetic grafts while some tout autogenous or allografts. If in the end, if you end up with regenerated bone of sufficient quality to serve the needs of your patients, does it matter how you got there? There is ample evidence in literature that shows autogenous bone, allografts, xenografts and alloplasts all can assist in regenerating bone. In my opinion, it's up to the dentist to choose which works most consistently in their hands, the key being consistent. Anyways, thanks all for your inputs.

To Baker k. Vinci and Student Urist who discovered and performed most of the original research on BMP's found autografts to not be osteoinductive in humans. J Periodontol. 1996 Oct;67(10):1025-33. After all dental autografts are necrotic with no living cells. Numerous human studies have found allografts to not be osteoinductive in humans. Osteoinduction is the ability of a substance to grow bone outside of bone. In other words an osteoinductive substance can convert muscle, fat, nerves etc into bone. This is why there is a legal industry built around suing BMP products and practitioners for severe adverse events when bone is growing where it should not and causing serious complications. Osteogenesis good. Osteoinduction bad. Greg Steiner Steiner Laboratories

Baker, the point I'm trying to make is this, the Xenografts are large particles, they are sintered when processed, the sintering makes them impossible for the body to resorb. Look at chapter 18 of Jensen's book "The Sinus bone Graft". On page 224, look at the photomicrografts and the chart. BioOss is 27% of the grafted site, newly formed bone is 23% and connective tissue is 50%. XENOGRAFTS DO NOT RESORB!

Greg, the few events that have occurred with BMP have been blown out of proportion, however I don't feel as if this stuff is what Marx and several hundred other big names have suggested. Just as PRP was the next big thing, it still has some practical applications.I am not an academic, so my responses from personal experience are anecdotal with evidenced based support. In my opinion, autogenous bone is still the " gold standard". The reason so many of our colleagues are attempting to suggest our grafts need to be vascular based is because they are trying to bring more viable cells into the bed. While i agree with the philosophy, it is impractical in this forum. I will continue to use and suggest what works and what the majority of our current literature suggest. I don not consider advertisements as "scientific reading". Our neurosurgical and orthopedic colleagues, still continue to suggest the same. Bvinci

Greg, I hope you don't take my latest responses as offensive, but rather, passionate with an insatiable thirst to gain more acumen. I don't believe anyone is suggesting that our autografts are always "viable", just as the landmark case of islet cells that were transplanted into the young girls pancreas, temporarily curing her of type one diabetes, were not supported by a vascular flap, or transplanted fat in facial soft tissue deformities does " the job ", despite their lack of true viability. I'm not certain I can buy the suggestion that Urist proved soft cancellous bone is not inductive. To many others have proven otherwise, but again, I am here to learn. Sincerely b Vinci

Greg and Baker, you both make valid points. There are dentist that use graft materials solely upon the advice of the salesperson. This is nuts. At least you two, Bob Miller, Peter Fairbairn, some others and myself are trying to get the word out there.

i think we should try to put implants when we have enough healthy bone and to reduce the use of bone grafts as much as possible !!! PhD. Dr. SAAD BOJI

Dear Saad , we feel that placing the implants where it is optimal and grafting will always be a better solution in the long term for the patient . We need to be working to a better future for our patients with more ethical lower pain solutions in regeneration. Having just come back from the EAO it is dispiriting to see the power of money and the control it imposes on thought which could possibly be holding us back in progress to better regernerative protocols. Kind Regards Peter

I am going to share a clinical experience I had a few years ago with an onlay graft, I used an allograft with a long term resorbable membrane, a new product for me. The patient returned a few months later with a good sized buccal exostosis(maxilla).I actually biopsied it I was shocked at what I got, the graft really took off. The reason I 'm sharing is that our clinical experiences are so important. I think that sharing what works in your hands and what products seem to work well can really help clinicians. However I really do appreciate the researchers even though we can spend a lot of time discussing the research. Frankly I 'm not that smart just practical. And my patient was very pleased with her ability to grow so much bone in such a short time period, I just wanted to make sure it was normal bone.I did not charge for the biopsy!

You biopsied your graft? I have heard of allografts working in block form. I would not do it, however. Did you not believe it was gonna work? I'm sorry, just a bit confused! Bvinci

Dear Peter Would you please comment further on the EAO and the power of money?