What is the difference between all the types of allografts?
Considering that when it comes to allografts, one can buy cortical or cancellous chips or a mix of both or putty or whatever. But in general, besides the particle size, cancellous/cortical/or both and their consistency, how do the different products actually differ from each other? Is there all that much difference between one company’s brand and that of another company? Is cadaver bone essentially all the same regardless of who distributes it? Is cadaver bone = cadaver bone anywhere you get it from or does one company’s harvesting and preparation make its allograft more special over the other? In summary, if I am buying the same particle size of 50/50 MinerOss (BioHorizon) , how is it different from 50/50 of the same mix of allograft from other companies?
15 Comments on What is the difference between all the types of allografts?
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Blah
2/27/2013
Cost, school of thought, preference.
That's it!!!
If you go through literatures, you are going to find that everything works. How well it works depends on the case really.
If your "teacher/mentor/Ce course lecturer" recommend one brand over another then you are likely to use that brand. And what brand they recommend depends on what products is sponsoring the course instructor.....
In conclusion, everything works. How well they work for the case is a different story. Some will work better in your hands , some wont.
Jim
2/27/2013
Good discussion topic. You could ask 100 clinician's and probably get 100 different answers to your questions. There are differences in processing of allografts. You have Puros and its solvent dehydration and Lifenet and its Allowash XG freeze drying process as the primary processing ways of allografts. There are differences between brands but it really comes down to personal preference. All of the products will work if used correctly and with the right procedure. Using mineralized, small particle cancellous allograft will work in almost every occasion. This would include using membranes and getting primary closure whenever possible. If there is micromovement of the graft, no matter what brand it is, it will fail. Expecting to be able to build back huge buccal wall defects or increase the height of ridge will fail as well in most cases no matter what the product is. Cortico/cancellous mixes like Mineross are becoming more popular as Puros and Allo-Oss now have mixtures. Each company will argue that theirs offers "better" results but in reality it is up to each clinician to decide which product they prefer. There is no "best" product for everyone.
CRS
2/27/2013
All I can comment on is that I switched from Mineross to Allosorb due to cost. I interchange them and get comparable results. My experience was thru trial and error, I personally like the mix, just right as Goldilocks would say. I have had success with synthetics and xenografts I think one has to have a protocol that one is comfortable with. I don't like the pastes too much filler and soft bone. I think you have asked the million dollar question. I am looking forward to this discussion!
OMFS
3/2/2013
I'm surprised that no one has mentioned that where the tissue originates is a HUGE factor.
Personally, I feel this is the most important factor when deciding which tissue bank to use as my supplier of allograft tissue.
Let the buyer beware, there are serious and significant differences from tissue bank to tissue bank.
Quite frankly, it is disappointing to hear comments like, "they are all the same" and that "cost" should be a factor.
As clinicians, it is important to remember that biological products have a great deal of variability and that the donor and processing play a huge role in how they perform.
Lastly, let's not forget safety. One particular tissue bank that was mentioned here already has a horrible safety record/numerous tissue recalls and unethical business practices over the years.
Do your research!
greg steiner
3/8/2013
OMFS While I agree that biological products have a great deal of variability freeze dried allografts have no biological activity and therefore the donor is not a factor. Allografts heal by way of a type of heterotopic ossification I refer to as antigenic ossification. The donor cadaver bone is not matched to the host so this causes a foreign body inflammatory reaction that results in the formation of sclerotic bone. Normal osteoblasts and osteoclasts are not found in this process and mineralization is likely a result of endothelial-mesenchymal transition. Irrespective of the method of mineralization the problem is that you are left with pathologic bone that lacks the ability to adapt to change. Greg Steiner Steiner Laboratories
Dr. Bill Woods
3/11/2013
I respectfully disagree with the last post. All allografts are not the same and all bone formed is not the same. Different allografts have different responses and every patient is a host that doesn't respond the same either. I'm not sure what you are saying, but all bone formed is not pathological bone, not by a long shot and there are countless peer reviewed articles to substantiate good bone that has great lonjevity. Where do you base your information ? Please enlighten me. Bill
greg steiner
3/11/2013
Dr. Woods Allografts are transplants and for any human material to be considered a transplant and thereby avoid FDA regulation the material cannot be altered. Every allograft on the market is ground up human bone that is washed and sterilized and not altered in any way making them all the same. In fact many of the different allografts on the market are produced by the same bone banks and the seller just puts his brand name on the bottle. I agree that all hosts do not respond the same because it all depends on the degree of mismatch of donor and host antigens. A relatively good mismatch will provide sclerotic bone and a bad mismatch with produce granulation tissue with no mineralization that most clinicians think is an infection. Because you never know how the transplant and the host will interact is why you cannot predict what the result of your grafting will be. One thing for sure is that at best all freeze dried bone allografts produce is sclerotic bone which is pathologic. If you question this I invite you to take a few core samples of allografts and have you local pathologist describe what he sees. It will not be normal bone. Studies have proven conclusively that allografts are not osteoinductive and not osteogenic so doesn't that make you want to know what the mineralization mechanism is for allografts? I invite you to go the publications tab on our site and review the photos essays on allografts and sclerotic bone and get back to me with your comments. Greg Steiner Steiner Laboratories
OMFS
3/12/2013
Dr. Steiner,
Freeze dried allografts have no biological activity? Donors don't matter?
So when DFDBA is implanted in the muscle tissue of a mouse and bone formation occurs, how do you explain that one?
Furthermore, if the quality of the donor doesn't matter because the tissue is being ground up and freeze dried, please explain to all of us why the FDA and AATB has a set of guidelines pertaining to donor criteria.
I would like to impress upon you that it's not because they are trying to make life difficult for tissue banks.
It is known that the better the quality is of the donor, the less manipulation it has to be subjected to, hence, less chance of rejection.
With all due respect Dr. Steiner, you are misinformed and possibly biased.
greg steiner
3/13/2013
To OMFS
Yes, to your first two questions with a couple of clarifications. As stated earlier allografts cause an inflammatory reaction in the host and this could be considered biological activity. The only way donors matter is in what degree of inflammatory reaction they cause in the host.
In regard to osteoinduction in the mouse, I agree with you. Allografts are osteoinductive in mice but not in humans and you prove this to yourself every time you use allografts in your patients. Allografts have been placed around nerves and under muscles thousands of times and they have never turned those nerves or muscle tissues into bone. Osteoinduction is the ability of a substance to produce bone outside of bone and it is not a good thing. You will see your bone dealer make claims in bold print that their allograft is osteoinductive and there will always be an asterisk with a statement in fine print that the product is osteoinductive in the mouse model because they know it is not osteoinductive in humans.
The tissue bank guidelines you refer to are intended to make life difficult for the tissue banks because of the abuses in the past and these guidelines are only procedures to protect your patients from disease transmission and have nothing to do with product performance.
You mention rejection. Every host rejects the allograft and it is just a matter of degree of rejection. The body does everything to push out the allograft while the clinician is doing everything to keep it in. If allografts were osteoinductive or osteogenic you would place the allograft in a socket and bone would grow into the extraction socket. But that does not happen. If you have digital periapical radiographs you will see that the interradicular bone is resorbed and the graft material is forced into a rounded mass with a radiolucent border. Why does the body resorb the interradicular bone? Why is the lamina dura lost and why does the body ball up the graft material? The reason is that allografts are antigenic foreign material that the host is isolating. A graft material that is not antigenic but truly osteogenic (such as ours) will fill the socket with bone retaining the lamina dura and the interradicular bone.
A head of a major US periodontal graduate program published studies on allografts and he went off on the concepts of osteoinduction and when I questioned him here is his response.
"As you know, induction studies are generally done in animal models, as such studies are not do-able in humans. I know of no such human studies, which is why our discussion of this issue was more theoretical than evidence-based."
Ha! So here is a head of a major graduate periodontal program admitting osteoinduction in humans is completely theoretical! But he did not talk like that in his articles. When I sent him a literature review done in humans that clearly shows allografts are not osteoinductive or osteogenic in humans he refused to comment. There are no human studies that conclude allograft are osteoinductive or osteogenic but there is a significant list of human studies that prove they are not. I apologize for the length of this response and invite anyone with interest in this subject to communicate with me at any time. Greg Steiner Steiner Laboratories
OMFS
3/13/2013
All bone healing occurs via an inflammatory response. The graft merely accelerates and stimulates and guides healing.
Osteoinduction is not fully understood Dr. Steiner, but countless studies show improved bone healing with DFDBA and FDBA.
I think you are choosing to ignore those studies.
I've learned a lot from my orthopedic friends, their research is the basis for my argument.
Your posts are calculated and biased, try to remember that other surgeons come here for advice, not propaganda.
greg steiner
3/14/2013
Dear OMFS, You are making me feel like the myth buster here. Bone healing has nothing to do with an inflammatory response. In order to avoid another dissertation I will keep it short but your entire skeleton grew without any inflammation so why do we need inflammation to grow a bit more? If you extract a tooth without grafting you will have an inflammatory reaction present for about a month. If you extract a tooth and place an allograft you will have an inflammatory reaction from months to forever. The more inflammation, the worse the bone healing. If you extract a tooth and place one of our products you have no inflammatory response and you have just skipped the inflammatory phase of healing and have moved directly into osteogenesis. I have a refrigerator full of histology slides of our products and at no time frame is there any inflammatory response. In fact the FDA has approved our claim for our products to be labeled nonpyogenic. If you would like to see healing bone without inflammation you can click on the publications page of our web site and review Socket Graft Putty Histology or The Healing Socket and Socket Regeneration.
Do your orthopedic friends know more than we do? I belong to the American Society for Bone and Mineral Research and there are many DDS PhD's at the highest level of the most prestigious US universities doing the most advanced cutting edge bone research and I can assure you that orthopedists have nothing over us dentists. Your closing comment implied I should not be spreading such heresy because our fellow dentists are not sophisticated enough to be exposed to such information. The goal of my posts are to provide enough information for the reader to be able to ask the tough questions of those who lecture them and to empower them to be able to make their own decisions. This has been fun and I appreciate the opportunity to gore a few sacred cows. Aloha my friend, Greg Steiner Steiner Laboratories
Fernando
3/15/2013
So, I am the one who asked the original questions. I appreciate the comments and the debate.
Greg, I guess I can ask the same thing about B-tricalcium phosphate. How are they different? How is Cerasorb different from Bioresorb and from your product.
I have used b-tricalcium phosphate for many cases and frankly with average to good results but it has always played on my mind: "Man, when I see the "big dogs" lecturing, nobody uses b-tricalcium phosphate. They all use some sort of allograft or xenograft." And makes me wonder why?
Is it the same reason why people promote Nobel implants like crazy even though they are ridiculously overpriced and nickel and dime you for every little screw?? Or is there something else amazing about these graft materials that I am missing here?
This debate doesnt clarify much, as in the end, we may still wonder about the people writing in their bias. Doing the research yourself is not that clear as a lot of the research has its own company bias. So we are left trying things here and there at our pockets and patient's expense to certain degree.
greg steiner
3/18/2013
Fernando See what problems you have caused! You now have a front row seat to see how this will unfold. First you(or one of the readers) will begin to question the people marketing allografts and the "big dog" allograftistas and ask them if allografts are osteoinductive and osteogenic in humans and they will say of course they are look at my osteoinduction studies in mice. Then you will press them to know if they are in humans. They will say of course they are and you will then ask them for good science to support their statements and they will say they will get back to you but they won't. Then they will begin to ask and research on their own and they will not be able to find any support for their opinion but they will contend that allografts are osteoinductive and osteogenic theoretically. Then you will counter with a list of studies that conclude they are not osteoinductive or osteogenic in humans and they will then say well I don't know how they work but they are still the best bone graft ever. Then you will say they produce sclerotic bone that has no normal osteoblasts and pathologists consider sclerotic bone pathologic and the type of bone found in damaged joints. The will say they don't know what sclerotic bone is but they will get back to you and they won't. Then you will tell them that it has been claimed that sclerotic bone is a factor in implant failure and when sclerotic bone failure becomes a part of the differential diagnosis of implant failure you will sit there with a smile on your face having watched this whole story play out. Implants placed in sclerotic bone are implant dentistry's ticking time bomb.
In regard to Beta-Tricalcium Phosphate. They are all good bone grafts because eventually they are resorbed and leave vital bone and studies have shown that BTCP performs equivalent to autografts clinically in most applications. BTCP is slow to resorb but we want the stuff out of the way quickly so it is replaced with vital bone. That is why most BTCP has macropores which provide more surface area for resorption. However before I compare them we need a small diversion. What do dentists treat? Caries, periodontal disease and endodontic disease all need a dentist to treat because the offending pathogen is able to hide from the host's immune system. Macropores in either BTCP, allografts or autografts provide that hiding place and that is why these graft materials can become infected. Cerasorb is reported to resorb in 1 to 2 years. I don't know how long it takes to resorb Bioresorb but you can find out by asking the manufacturer when the FDA allows implant placement. The FDA will not allow a manufacturer to recommend implant placement until all of the graft material is resorbed. Our company has found a way to speed resorption without macropores which makes it antibacterial in a physical sense and our graft in fully resorbed in 6 months. Please understand that all of these products including ours are just gravel maintaining graft site volume until bone gets there. We advise mixing our BTCP with our putties. Our putties are osteogenic stimulating bone formation and we add our BTCP when we want to maintain graft site volume. Good questions. I hope that you are empowered and Bill is enlightened. Greg Steiner Steiner Laboratories
Hossam Barghash
3/17/2013
Dear Dr Greg steiner
I have few comments on few sentence you mention
first you said when you were talking about osteoinduction , that implanted allograft did not change muscle or nerve tissue into bone,
induction process is to turn the UMC not differentiated cells.and the motivation come from the protein and you have to expose it to the playing ground by demineralization. and the point to test it out side the bone to prove that the osteoblastic activity come from differentiation of UMC and not osteogensis of an already existing osteoblast.. .
second you mention that your graft is labeled nonpyogenic,this term does not exclude that it is non inflammatory, it means it is not causing supurative inflammation..plus inflammation is a physiological process bringing more blood and cells to the area helping repair,defending the area against infection ,but with variable degree up to pathological effect.
finally can we do grafting without inflammation assuming that the graft material is not causing body reaction , yes in case you do not do surgery.
greg steiner
3/18/2013
Hassam I agree. The classic definition of pyogenic is suppurative inflammation however the FDA uses the term pyogenic to include inflammation based on laboratory tests of inflammation and not exclusively related to purulent exudate. We provided histology that showed no inflammation during bone formation in the grafted site but we also needed to quantify the degree of inflammation produced by our graft using a laboratory model and our graft material produced no discernible inflammatory reaction and therefore we can either state that our grafts are noninflammatory or we can say they are nonpyogenic. Greg Steiner Steiner Laboratories
