Redness on the check after failed bone graft: any input?

Which graft material did you use?

Yes scary looking senario , as said what graft materials used ,never seen something like this in many a year but then we do not cross species graft . Another thing is the possibilty of the patient being on Bisphosphonates or a history of their use? Peter

how does it matter of what graft material was used .if it was placed in an infected socket or over a granulation tissues .

It does as some graft material are bacterio-static ( can shown one to bee bacterio-scidal ( in perti dish tests ) and some may even have organic components which may retain and infection becoming infected themselves . So I guess that it is in fact a critical question. Peter

You may consider using Ceftriaxone along with Flagyl . also inject the Ceftriaxone directly into the infected site. The patient should rinse with Peridex. Ask the patient again about dietary habits, re-review the health Hx. Something was missed or omitted.

Could you please post a panorex, you could be developing an osteomylelitis. Any history of Bisphosphonates?

Soft tissue will not heal over necrotic bone, is that the graft or the basal bone?. Is there a tiny metal tac? under the flap. I would not have the patient on steroids if there is active infection. I think it would be prudent to refer this case to an OMS before it develops into a serious osteomyelitis. The redness of the overlying cheek is due to the increased vascularity from the mandibular infection. I'd debride this and place the patient on iv antibiotics. I like to get a culture/sensitivity and I also rely on my infectious disease colleague. This infection /non-healing wound is going on two months, not good.

Is anybody else confused? If a bone graft incision opens, you cannot just re-suture it. Where did you learn this?? "I have attempted several times to replace the sutures" ?????? What does this mean? If a wound opens up at two weeks, its due to infection. At this time, the graft needs to be removed as it is all contaminated. You can't just sew it up again! An infected graft has no blood supply. It is a foreign body and the body is trying to get rid of it. Thats why your wound opened. You may as well be trying to sew a dead cat into your patients jaw. This is not a question of graft material. It is basic biology. Your choice of antibiotics is strange too. Flagyl alone in the mouth is not appropriate for an infection. In combination it is excellent. Why a steroid? Your patient is infected. Why are you trying to inhibit their immune response? Your treatment up to this point has been a recipe for osteomyelitis. This may be a large sequestrum. You should refer this patient right away to an oral surgeon. This needs to be scanned and have a definitive debridement with culturing. Your patient may have a deep seated infection and need long term antibiotics. Don't sit on this any longer. Get help ASAP.

debridement and good curettage of the infected area has to be performed immediattly with systemic antibiotics in combination with metronidazole for 10 days sounds good start to treat this pt. never attempt to suture a wound again after its opened

I agree this is a bit of a nasty infection. Open this up and remove every drop of graft remaining as well as any suspicious looking native bone. IV may be necessary. This could be MRSA based on that redness of the cheek. ( or it could be frostbite from the ice pack). I agree refer this to a hospital based OMFS.

Looks like it could be cellulitis at this point. I would refer to OMFS for culture and appropriate treatment of infection at this point.

Could the redness simply be from the ice burn from prolonged application on the area?

I do agree that u should have never sutured again as the graft was infected and definately contaminated. We never use the graft even during procedures when it comes in contact with saliva. So considering suturing again should never have been done but debrided the first instance itself , suitable antibiotics administered and referred to a specialist asap. It didn't matter what the graft material was.

Dr T, you are correct as per the antibiogram, however that takes time fir the culture, identification of bacteria and the sensetivity test. One should culture first and initiate empirical treatment and adjust if necessary after the C&S results.

Did you use autogenous bone harvested from the ramus or bone substitute material? Did the patient have any other signs of infection, such as painful cheek swelling , local heat or bad smell? You have removed all the grafted material and curetted those granulation tissue, the infection should heal without using any special antibiotics unless the patient is on the medication of Bisphosphonate. The patient had an ice pack on her cheek for a prolonged time and that could cause ice burn just like a frost bite on her facial skin. The redness of skin has nothing to do with the wound infection and it may disappear itself .

Has the patient been checked for undiagnosed diabetes? Is there a history of Bisphophonates?

Hi, looks nasty! never try and resuture necrotic bone under a flap, it will never work. In reality why are you particulate grafting on the edentulous posterior mandible. Typically fraught with problems no attached tissue / ridge is sloping so how is a particulate graft going to stay??! Patient will eat on teh ridge no doubt! Always always sort soft tissue first! SEBCTG or alloderm still v difficult. Then augment the ridge using - block or ridge split Then 6/12 place implants plan: idb and mental and long buccal clean all that junk out and irrigate with corsodyl .2% and then saline and then close. Refund patient and refer to omfs. I have to say it sounds like poor execution and planning of treatment: Do you have records from your ct ; prosthetic guide; models; written consent? if not you must learn from this case-if you dont i would conclude that your are actually harming your patients. Harsh but fair.

Where does one start, with this. First, there is NO NEED for primary closure at small graft sites. You are robbing Peter to pay Paul, when you lift such an aggressive flap. Once something has opened up intraorally or extra orally, there is a reason and the last thing you need to do is re close the wound. Please take a good guided tissue regeneration course. Why did you not refer this to a surgeon. In my geographic area, that would be standard of care. Personally, I would have left the wound open and observed it. Continuous trauma, is the wrong answer. A single medrol dose pack is not going to hamper the immune response. You have to ask the question; if you needed this done to you, would you go to a doctor that does a few of these or one that does a couple of hundred a year? Yes, everyone has a bad experience at some point in their career, but you are operating out of your "comfort zone". Bvinci

I read with great interest the responses to this question. It seems that most of the answers have missed the magnitude of this problem. what is shown here is a large amount of necrotic bone. This is either Bisphosphonate necrosis or an Osteo. This patient needs to be in the care of an OMS who may well end up refering to an ID doctor to treat in conjunction. The longer you treat the case the deeper the hole you are digging. To be fair to your patient you need to move this case along. If not don't be suprised if there is a letter from a lawyer in the future. I review cases like this all the time ,and this is fertile ground.

Dear Dr. : It would be helpful if you show the pre op xray, treatment plan and medical history. Age, diabetes, bisphos. , could be big factors in your reasoning and choice of graft. Was this a socket graft of an infected #20? #21 appears on your photo. Were you trying to get width or vertical heigth? Was this an overlay particulate, for what reason? Width and depth of bone to NVC? Primary closure w/scoring of periosteum or tension to close? This looks like a serious necrosis and I would like to see how it all developed in order to truly help me and others here. Sincerely Leonard

Redness on the check - 1st degree frostbite(frostni) the area affected by frostnip usually does not become permanently damaged as only the skin's top layers are affected.

Okay poster what was the final outcome? It's not the materials or technique. I hope the realization is when referral is indicated. One does not want to be guilty of negligence or failure to refer. Omsk are here to help that's what we are trained for. I see these cases often and treat them without judgement.I hope you take the good advice and continue to learn and grow

Cabe exame clínico e/ou laboratorial para esclarecer sobre Diabetes, Bifosfanatos, coagulograma e se necessário Raio X Panoramico para esclarecer a extensão, remoção de todo materiail de enxertia, tecido de granulação e tecido duro ou mole suspeitos de necrose, aguardar cicatrização por segunda intenção, lavagem e irrigação com soro fisiológico, antibioticoterapia sistêmica padrão se possível com Amoxicilina 500mg 3x dia por 7 dias, Nimesulida 100mg 2x dia por 3 dias, colutório indicado Periogard em bochechos por 7 a 10 dias e acompanhamento.

My first impression was Bisphosphonate necrosis , (midle age female) I don't think that has to do with the type of graft but what was there prior to bone grafting. Before you do anything make sure there is nothing on the medical history that migth complicate this case further.Take a PANX to evaluate the extension of the lesion, i believe is greater than is showing. DO NOT SIT ON IT. Don't be afraid to ask some of your local Oral Surgeon for help and guidance most of the ttime they are willing to lend a helping hand. Good Luck and do not get discourage just get ready.