Placement of Dental Implants in Grafted Sites

Jack Hahn comments: Placing implants into grafted sites does not have to be questionable. Depending on the material used for the graft, this can be a predictable, dependable procedure. Socket grafting should always be practiced to maintain the bony architecture which is essential for the proper fit, function and esthetics of any restoration and is crucial to implant placement. Since implants are the main focus of my practice, I am keenly aware of the importance of utilizing a graft material that will predictably provide new, vital bone and will accept an implant in the shortest amount of time. I have learned that a combination of PepGen P-15 and FLOW materials provide the new bone I need in as short a time as four months. This mixture, which I call "The Marshmallow" because of its consistency, has been my graft material of choice for over 5 years with undisputed success. I have published several papers reporting the histological evidence of healthy, vital bone with the "Marshmallow" and consider it to be dependable and predictable. Also, I have found a very useful technique regarding sinus "bump" procedures. After elevating the inferior cortical floor with the blunt end of an osteotome, I inject 2 ML of FLOW. This will form a new "halo" of bone at the apex of the implant as well as seal any perforation that may have occurred.

Please explain what you mean by FLOW.

It means that its full of filler that helps the material to be injected thru a syringe, but does nothing to help grow bone.

I have to disagree. FLOW does have quite a bit to do with bone growth.Particulate material aone, will compact and impede cell transport through the grafted site. FLOW is PepGen particulate in a carboxymethylcellulose (CMC)hydrogel.This hydrogel acts to properly space the particulate PepGen and, importantly, permit faster transfer of cells throughout the graft.Also, this CMC carrier will also expand when introduced to blood. This is an extreme benefit when grafting extraction sockets. The expansion will occur to the depth of the defect and provide intimate contact between the graft material and the socket walls while "sealing" off any minute cracks or small fenestrations in the bony housing. Dr. Hahn published an article in IMPLANT DENTISTRY journal in 2003 (Vol 12 No 2) where same mouth case studies comparing sockets grafted with PepGen and his "Marshmallow" were compared clinically, radiographically and histologically. He reported that the Marshmallow (PepGen + FLOW) substantially enhanced bone formation and particle resorption compared to PepGen alone. Dr Hahn's article specifically showed histologic evidence of accelerated bone healing when FLOW was combined with PepGen particulate.

If the bone graft material is 'Osteoconductive', then the particulate is naturally spaced through a network of micro and macro pores. This matrix facilitates clot stabilization. Revascularization, migration of osteoblast and in-growth of woven bone is enhanced by the scaffolding.

I use Flow all the time for immediate extraction implants. Basicaly you squirt it in the site,push it down to the apex,thread your implant in the socket and it works like bathtub caulk-- it seals all space between implant and bone. If I have a facial dehiscence I stack the excess flow over the area and suture.It works every time.

DO NOT use the flow or the pg-15. It does not make bone grow. It is only osteoconductive. Hahn is pushing this crap just as he pushed the replace implant!!!!!!!!!!!!!!

I don't understand the push by prominent clinicians for “socket preservation”. Most if not all good studies show that this procedure does not reliably maintain the buccal bone. Doing a formal bone grafting procedure to replace the already missing or thin buccal plate is one thing, and just stuffing bone graft material into the socket and charging patients who are expecting enough bone for an implant in a few months is another. Where is the scientific rationale for this “hot’ procedure in implant dentistry? Is there an rational voice from dentists and oral surgeons who understand the physiology of socket healing after extraction?

I'm a patient and having an extraction 6/22/06 with implant to follow. What type of material is best - synthetic or cadaver?

I hope you chose a bovine or synthetic graft material.

I believe beta-tricalium phosphates have recently entered into this market as they recently were cleared by FDA for dental indications. Does anyone have information as to which companies have beta-TCPs out for dental surgery? What are the pros/cons of this synthetic vs. bovine bone?

A "true" or "perfect" technique does not exist, and to each clinician his own. This is the beauty of dentistry. Its trial and error and what works best in your hands. Do your own literature review and consult other practicioners on what works for them. As far as the bone grafting materials... Major differences are what the graft material will induce in the surrounding environment. There are three different types of bone stimulation, OSTEOGENIC, OSTEO-CONDUCTIVE, OSTEO-INDUCTIVE. Osteogenic is the gold standard, by which living bone cells are transplanted to a receipient site. Its termed autogenous bone grafting. Either cortical or cancellous bone can be transferred. Osteo-conductive are scaffolding grafts, as noted by a post earlier. It provides the "honeycomb" matrix of bone for cells to migrate from the recipient site or periosteum. These are just filler materials, they do not participate in activating bone formation. Materials include allograft, xenograft, synthetics such as Ca.Phos, Bone ceramic, etc. They all have a variety of "decay" times as well, some resorb quite quickly while other stay in graft sites for many years. Osteo-inductive describes the use of chemical mediators such as cytokines and growth factors to "induce" primitive or stem cells in the area to differentiate into bone producing cells. Allograft bone prepared in a special way, preserves the signaling while minimizing infectious disease transmission. Other agents that are popular are grafts with growth factors such as HGH of PDGF. Other additives to bone grafts that may serve a role in being osteoinductive are PRP and BMP. Beta-TCP alone is not an osteoinductive agent, but composite grafts with beta-TCP and BMP has shown good osteoinductive potential. I exclusively use allograft bone material for preservation of socket sites. I feel that the bovine material does not turnover and in almost every case after 4 months of healing, the center core of BioOss is still particulate. In my opinion and experience, I feel the quality and quantity of bone regeneration is greater with allograft over xenograft.

Dear SFOMS, a review published on JOMI (issue n°5, 2006) by M. Esposito et al. says that there is no reliable evidence that PRP has osteoinductive properties.

I would have to agreee with SFOMS. Having used almost every bone graft material to come down the pike in the past 25 years (including PegGen and PepGen Flow), the only thing that comes close to autogenous bone is allografts (ie PUROS or AllOss as examples) . The xenografts were not predictable in bone regeneration in my hands. At least when I reenter a site with an allograft at 4 months, it looks, feels and bleeds like bone. To be candid , I perfer allograft or allograft / autogenous combinations over pure autografts for most applications. I do not use PRP in my bone grtafts, but it clearly helps with soft tissue procedures. It may reduce swelling post op on bone grafts, so I have no objection to it's use on that basis-- you just can't say it improves bone growth in a graft.

I have used FDBA and DFDBA with excellent results. If the socket has 4 walls, either of these materials will function well. If the buccal plate is resorbed, it will need a futrure onlay graft procedure, prior to implant placement. I will place the graft and follow with implant placement in 4 months (when the growth factors are most present) After implant placement, I allow 4 months of healing before loading. Of course depending on socket size and adequate bone volume, immediate implant placement is the first choice. I think most of these materials function well as long as we do not expect miracles. If there is insufficient bone, We need to perform block procedures.

Look for published studies by Ron Nevins and Mellonig --show implants in regenerated bone do well Also Sasha Jovanovic and Massimo Simion publications show the results in regenerated bone

This board claimed less than a year ago, that natural bone( Tibia preferred) was the "Gold" standard

I can't believe pepgen P-15 is still on the market. It is like a lot of other poor products from dentsply that a re crap. I have cone into sties 12-24 months after placement and the p-15 is still there as it was the day I placed it. I think most clinicians have gone away from it. BioOss is a good material if you keep in mind that it resorbs very slowly and that is a desired quality of what you want. It works well in a sandwich technique where you have autogenous or puros underneath and the Biooss is maintainin the outer "cortical" dimension. Say for example you have an extraction site with a large defect fill in the internal area with pufoss and cover it where the cortical plate would be with bioss collagen - no membrane necessary.

Some good information- Publication: International Journal of Periodontics and Restorative Dentistry November/December 2006 Volume 26 , Issue 6 E-mail Abstract Back Comparison of Mineralized Cancellous Bone Allograft (Puros) and Anorganic Bovine Bone Matrix (Bio-Oss) for Sinus Augmentation: Histomorphometry at 26 to 32 Weeks After Grafting Stuart J. Froum, DDS / Stephen S. Wallace, DDS / Nicolas Elian, DDS / Sang Choon Cho, DDS / Dennis P. Tarnow, DDS The present blinded, randomized, controlled investigation histomorphometrically evaluated the vital bone formed following bilateral grafting with two different materials—Puros, a mineralized cancellous bone allograft (MCBA), and Bio-Oss, an anorganic bovine bone matrix (ABBM)—at 26 to 32 weeks following graft placement. Thirteen patients were selected who required bilateral sinus augmentation. Following elevation of the lateral sinus walls, one material was placed in the right sinus and the other in the left sinus, as determined by randomized choice. Twenty-six to 32 weeks after grafting (the same time frame was used for each individual patient), a trephine core was taken from the previously elevated lateral wall area and sent for histomorphometric analysis. Cores were obtained from 22 healed sinus augmentations in 11 patients. Eight patients provided bilateral cores, two patients had intact MCBA cores but inadequate ABBM cores, and another patient had an intact ABBM core but an inadequate MCBA core. Histomorphometric analysis of 10 MCBA cores and 9 ABBM cores revealed average vital bone content of 28.25% and 12.44%, respectively. The average percentage of residual nonvital bone was 7.65% in the MCBA cores and 33.0% in the ABBM cores. Significantly more bone was formed in the MCBA sites (n = 8 patients, paired t test). Histologically, both MCBA and ABBM particles were surrounded by new bone, osteoid, and osteoblasts. A higher average percentage of new vital bone was seen around the MCBA particles than around the ABBM particles. (Int J Periodontics Restorative Dent 2006;26:543–551.)

Nice study but the public is aware of the risk associated with human tissue. Similar articles have gone mainstream in such publications as People mag and Readers Digest. It just not worth it. .· Seven Plead Guilty in Stolen Body Parts Case ·. . Seven Plead Guilty in Stolen Body Parts Case By TOM HAYS, AP NEW YORK (Oct. 18) - Seven funeral home directors linked to a scheme to plunder corpses and sell the body parts for transplants pleaded guilty to undisclosed charges and have agreed to cooperate with investigators, prosecutors announced Wednesday. -------------------------------------------------------------------------------- . The unidentified directors secretly pleaded guilty in the probe of what investigators say was a plot to harvest bone and tissue and sell it to biomedical supply companies, Brooklyn District Attorney Charles Hynes said. "It is clear that many more funeral home directors were involved in this enterprise," Hynes said at a news conference. The seven entered their pleas in closed courtrooms and their names were withheld, but defense attorneys said that among those cooperating was the director of a funeral home that took parts from the body of "Masterpiece Theatre" host Alistair Cooke, who died in 2004. The four original defendants in the case pleaded not guilty on Wednesday to enterprise corruption, body stealing and other charges in the new indictment. If convicted, they face up to 25 years in prison. All remain free on bail. Prosecutors allege Michael Mastromarino, a former oral surgeon, and three other men secretly removed skin, bone and other parts from up to 1,000 bodies from funeral homes, without the permission of families. What The Corpses Fetch They were charged in February with counts including body stealing, unlawful dissection and forgery in a case a district attorney called "something out of a cheap horror movie." All the defendants pleaded not guilty before being released on bail. Mastromarino, owner of Biomedical Tissue Services of Fort Lee, N.J., allegedly made millions of dollars by selling the stolen tissue to biomedical companies that supply material for procedures including dental implants and hip replacements, prosecutors said. At the time, prosecutors said they had unearthed evidence that death certificates and other paperwork were falsified. In Cooke's case, his age was recorded as 85 rather than 95 and the cause of death was listed as heart attack instead of lung cancer that had spread to his bones. Other evidence includes X-rays and photos of exhumed cadavers show that where leg bones should have been, someone had inserted white plastic pipes - the kind used for home plumbing projects, available at any hardware store. The pipes were crudely reconnected to hip and ankle bones with screws before the legs were sewn back up. AP-NY-10-18-06 1939EDT Copyright 2006 The Associated Press. The information contained in the AP news report may not be published, broadcast, rewritten or otherwise distributed without the prior written authority of The Associated Press. All active hyperlinks have been inserted by AOL. .

I use Puros and Lifenet Oragraft. These are mineralised grafts and work well in my hands. All bone seems to be pink and pretty when I go back in. I harvest the osteotomy and repair any other little defects with the harvest. Sometimes the bone I place around a collar that may be 1mm short on the buccal from initial atrophy is not only there when I go back in but has grown over the healing screw and I have to plasty it off just to get the cover screw off. What we need to concentrate on as colleagues is what works and what doesnt and why. I thought PRP was on the way out at one time and the articles would possibly have you believe it. At the AAID sponsored bone grafting course in Dayton there was presented evidence that activated PRP may be far less effective than nonactivated PRP due to continued viability of some of the growth factors in the nonactivated form. I personally think this is very exciting and may have more far reaching effect than any of the other grafting materials that we currently are discussing. It definitely has merit for further investigation and the allograft and xenograft companies have every reason to counter these findings.($$$!!!) We will see some amazing bioengineering evidence in the next decade that may just impress us all. Thats for sure. Bill

... "DG, DMD Says: April 20th, 2007 at 10:17 am Nice study but the public is aware of the risk associated with human tissue. Similar articles have gone mainstream in such publications as People mag and Readers Digest. It just not worth it..." As long as surgeons buy human tissues in a dark corner, without any questions about the background of the source, without any responsible acting regarding the partner they buy from, these cases will occur. But these single cases give not at all any reliable and broad picture about all the transparent and responsible acting non-profit tissue banks in this field. The recommendation should not be to paint a devil on the wall. The recommendation should be to adress the good and safe working non-profit tissue banks with the best reputations in ethics and safety, to make detailed questions on them... I´m sure you would get satisfying answers. If a surgeon wants to find a safe human transplant from an ethical correct environment and without any doubts, he can find it.