Popcorn effect from granules following GBR?
I have started using tricalcium phosphate for bone grafts and cover the site with a resorbable collagen membrane. The grafts and soft tissue seem to heal well and look normal. However, recently I have started noticing a ‘popcorn’ effect, by which I mean that you can see small granules beginning to exfoliate. Patients are not in any pain or discomfort and no pus or swelling has been noted. How would you manage this?
19 Comments on Popcorn effect from granules following GBR?
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greg steiner
6/6/2017
Popcorn
You will get popcorn even if you do not graft. For approximately 35 days you will get bone chips exiting the gingiva when you don't graft(they are necrotic pieces of the socket wall).
If you use cadaver bone you will get popcorn for at least 2 months. The difference is that you can see the white bTCP but you cannot see the bone chips. You are to be congratulated on you move toward biocompatible materials and I am sure your patients appreciate it. The only thing you should consider changing is to move from a collagen membrane to a synthetic membrane. The collagen membrane is resorbed via attack by the patients immune system to the foreign proteins. The problem with this is that the immune cells are drawn to the collagen and migrate through the graft material and and will interfere with mineralization of the graft producing more popcorn than usual and possible completely stopping mineralization if the immune response is severe. Greg Steiner Steiner Biotechnology
Gary
6/16/2017
Hello Greg,
Which synthetic membrane are you referring to? Like cytoplast?
greg steiner
6/16/2017
Yes the cytoplast membrane works well and cost effective. I advise it over any of our materials for a predictable result. However when I have very thin buccal bone and gingival esthetic concerns I use a Socket Seal because with this technique you don't raise a flap and remove that blood supply to the bone. The Socket Seal works extremely well over grafted immediate implants but is more challenging for molar sockets because it is less stable than a membrane.
Emery Cole
6/6/2017
Is a membrane necessary with TCP?
Peter Fairbairn
6/6/2017
It depends but I have not used one in my daily graft cases for 15 years but always used a material that sets due to CS ....
greg steiner
6/6/2017
Peter
You say you do not use a membrane but you don't add that you never place a graft at the time of extraction. That is a big difference in technique.
greg steiner
6/6/2017
Emery
If you are grafting a socket at the time of extraction you need to isolate the BTCP from the oral cavity and protect it from washing out. The only other option is to do primary closure but if you do that you lose the keratinized gingiva. With primary closure a membrane is not needed. Greg Steiner
Peter Fairbairn
6/8/2017
Hi Greg no I do in about 5% of cases ...... just that in the modern world predictability is paramount .......... so we make protocols to ensure the highest success rate...it is hard to clean a site well and get a level of closure in a fresh extraction site
regards
greg steiner
6/12/2017
Peter
I graft every extraction socket and many if not most of those extraction sockets contain an immediate implant. I never get post op infections and 99% of the time I have a great foundation for a delayed implant if that was the treatment plan. My long term implant success rate is 99% plus over the last 9 years of implant placement. Socket grafting and immediate implant placement when a tooth is removed is one of the most predictable things I do in the clinic. There is no lack of predictability with these methods. Greg Steiner Steiner Biotechnology
Peter Fairbairn
6/6/2017
Interesting Greg , in thousands of grafts using BTcP over a 15 year period and have yet to see this "popcorn " effect .....
But I have never used a Collagen membrane , ever so your idea may make sense ...
Have seen xenograft particles coming out over a number of years but you can just remove them ...
greg steiner
6/6/2017
Peter
Your comment about xenograft particles coming out over years is a good observation that very few have made. What I see with both xenografts and allografts is they move coronally over years and out the gingiva. A canine grafted with cadaver bone will fill the entire socket a few months after grafting. However 10 years later only one half of the graft is still present and it is located in the coronal portion of the socket. You will find graft particles breaking off and graft particles in the gingiva and exiting the gingiva. My assumption is that the body slowly is trying to ride itself of the nonbiocompatible material. Any thoughts? Greg Steiner Steiner Biotechnology
Peter Fairbairn
6/8/2017
Yes possibly simple foreign body host response .......
Rand
6/6/2017
I often use a PTFE membrane without primary closure and leave it in place for 4 weeks. It eliminates almost all graft loss and preserves attached gingiva. At 4 weeks it is easily removed without local anesthetic.
Phil Mathers
6/7/2017
No one has commented of the resorbability of the graft material. This varies greatly from
for example High temperature processed Xenografts which are virtually unresorbable down to simple CS that is virtually resorbed in a few weeks. The pop corn effect will surely be proportional to that characteristic.
Phil Mathers
greg steiner
6/13/2017
Hello Phil
It is good to hear from someone who understands bone grafts. I agree with all of your statement but I would go further and state that there are no xenografts that are ever resorbed. I think there is also another factor in the popcorn effect and that is biocompatibility. If a graft material produces an inflammatory response in the host I think it is more likely that the graft material will be pushed out by that inflammation. Greg Steiner Steiner Biotechnology
Lukasz Palka
6/7/2017
Hello,
From my experience and bone biology observation I think that well mineralized bone like crestal cortical or cribrosa from socket is the outer layer and our body will do everything to keep it that way. In order to remodel bone in the extraction socket the cortical must be resorbed or removed. If we use graft material based on the same bone it will be resorbed or removed as well. The small particles are resorbed the big ones are removed by osteons remodeling and periosteum transport (like in a case of amalgama tatoo)
Bill M
6/7/2017
Peter
Because you wait and graft after, I assume, soft tissue 'closure' do you use a collaplug over your graft/suture or not
Greg which membrane would you use if grafting immediately
Peter Fairbairn
6/8/2017
If doing a rare extraction and graft case , just use a fleece over the site and the graft is stable .... have published and had many posters on the topic ..... some stuff on Pubmed ....but have a poster case were we photographed it every day for 3 months to monitor this soft tissue healing by secondary intention over a stable graft ......... we use both CS and poly-lactides to stabilize the graft
Peter
greg steiner
6/15/2017
Hello Bill
As I do not want to compromise the gingiva and aleolus by raising a flap I use a Socket Seal.
