bone graft options

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Lilith

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I am thinking about getting implants done on couple molars that were extracted many years ago. I had gone to two dentists for consultations. Both of them told me that I had need bone grafts. One suggested using autogenous bone graft first, then proceed to implants after letting the wounds heal for 6 months. The other one suggested using a bone mixture to repair bone loss (GBR?), and getting implants on the same day. Although I think it would be good to have bone graft and implant done on the same day to save time, I don't know if this is the best way to go. Any suggestions? Thank you.

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First, I would be wary of advice on bone grafting given from pre-doctoral students (like myself) because we have very little clinical experience with it. That being said, I would also be cautious about taking the quick route instead of focusing on what will give you the best prognosis. If I were you I would go with a tried and true method of bone augmentation rather than a quick fix. You are planning on having these the rest of your life, right?

Another option you did not mention was distraction osteogenesis. If you want the best result go to an oral surgeon who only does implants. They will have plenty of experience with what works and what doesn't regarding bone grafting. If you have a difficult time finding someone like that, call up the oral surgery department at the dental school nearest you and ask for a referral.
 
That is a problem for many dental patients. Dentists can agree on the problem (sometimes :D ) but there are as many different ways to go about fixing a problem as their are dentists. More often than not, it isn't that one technique is superior to another, but rather what a dentist has found to be consistent and reliable in his hands.

You could take a hundred dentists and let them fight all day long about autogenous grafts vs. "bone in a bottle" vs. immediate loading vs. two stage placement etc... and still never reach a conclusion. In the end, what really matters is that you are comfortable with your dentist; he would not attempt this procedure if he was not confident that his technique will work. Implants are a very successful and long-term treatment; it will be money well spent.
 
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lots of bone to chosse from
 
Demineralized Freeze-Dried Bone allograft (DFDBA)
It is just freeze dried demineralized human cadaver bone. DFDBA only mimics organic component of autogenous bone (Type-1 collagen)

PepGen P-15
PepGen P-15TM is the first and only bone graft material to mimic autogenous bone (your own bone). Autogenous bone is made up of two basic components, the organic and the inorganic. The following information will provide you with a better understanding of PepGen P-15TM and how it mimics autogenous bone.
The Inorganic Component:
The inorganic component of bone is calcium phosphate. This component is identical in humans and animals. In developing a bone substitute material to mimic autogenous bone, DentsplyFC took advantage of this fact and used the calcium phosphate from a bovine (cow) source. By utilizing this inorganic component, PepGen P-15TM provides the necessary calcium phosphate structure needed for bone formation.
The Organic Component:
The organic component of autogenous bone is collagen, which is a fibrous tissue that runs throughout bone. One of the main purposes of collagen is cell binding and proliferation, which starts the repair process of replacing missing bone. After years of research, it was discovered that only a small section of collagen, designated P-15, is involved in this process. To mimic the organic component of autogenous bone, scientists synthetically replicated the section of collagen, called P-15, and irreversibly attached it to the calcium phosphate structure (inorganic component), creating PepGen P-15TM.

PepGen P15 has also showed the highest rate of osteoblast proliferation.

Source: Growth and Proliferation of Human Osteoblasts on Different Bone Graft Substitutes An In Vitro Study. Implant Dentistry. 13(2):171-179, June 2004

Source: http://www.ceramed.com/Flow/FAQ.htm



Calcium Hydroxyapatite Ceramic (CHA)
It was not until 1920 that the first successful use of a calcium phosphate compound for bone repair was reported and more than fifty years later that the first dental application of a calcium phosphate (erroneously described as `tricalcium phosphate') in surgically created periodontal defects and the use of dense hydroxyapatite (HA) cylinders for immediate tooth root replacement were reported. Commercialization of synthetic calcium hydroxyapatite (HA) dental and medical applications occurred in the 1980's

Source: Calcium Phosphate Bioceramics: Past, Present and Future. Key Engineering Materials Vols. 240-242 (2003)pp3-10

Algipore phytogene hydroxyapatite
Hydroxylapatite graft material for repair of bony periodontal pockets. It has been shown to be very sutiable for grafting of the maxillary sinus is an established treatment modality to provide sufficient bone for the fixation of dental implants.

Source : The fluorohydroxyapatite (FHA) FRIOS Algipore is a suitable biomaterial for the reconstruction of severely atrophic human maxillae. Clin Oral Implants Res. 2003 Dec;14(6):743-9.

Tricalcium phosphate (Bio-Base)
The bone replacement material Biobase® is a pure alpha-tricalcium phosphate which was initially distributed for more than 10 years in former East Germany. Over 10.000 patients have been treated with Biobase® without any complications or side-effects. Biobase®, is an approved drug and received CE approval in 1996.

Further research and tests on this originally compact grain led to the development of a porous grain. This porous grain extended the field of application, particularly in the branch of orthopaedic surgery. Essential advantage of this porous grain are improved growth in to the bone and reduced volume of waste material. CE approval in 1997

Source: http://www.biovision-biomaterial.de/english/products.htm

Bovine hydroxyapatite
Bio-Oss® has a natural mineral structure which is very similar to the structure of human bone, with the following positive effects: High degree of physical and chemical similarity to human bone:
– Rapid revitalization
– High degree of osteoconductivity
– Excellent osseointegration
– Integration into the natural remodelling processes of the bone
After sinus augmentation with a mixture of Bio-Oss® and autogenous bone in an animal study, bone volume proportion remained constant throughout the entire test period. The height of a purely autogenous bone transplant however clearly diminished.

Controlled manufacturing process:
The mineral structure found in Bio-Oss® is manufactured through a combination of chemical processes and heat treatment. The manufacturing process involves several steps, which effectively kill prions should they be present 65. The bone material undergoes amongst other processes, a high temperature treatment for more than 15 hours and a strong alkaline treatment that lasts several hours. This results in the highly-purified mineral bone structure of BioOss

Source: Clinical and historical findings in sinus augmentations using autogenous and xenogenous materials Z Zahnärztl Implantol 2001; Supplement Int. Congress on Reconstructive Surgery:14

Source: http://www.geistlich.com/biomaterials/en/dental/index.html

HTR synthetic bone grafting
Hard tissue replacement (HTR) polymer (U.S. Surgical Corp., Norwalk, CT) was introduced in dentistry in 1968 in its porous molded form,and in the mid-70s as a particulate porous material. The earliest clinical trials were performed by clinicians in their own practices, and according to the first statistical analysis report by periodontists, oral surgeons and general dentists, use of HTR polymer demonstrated a 97.9% success rate.HTR polymer is a microporous synthetic bone grafting material that combines a polymethylmethacrylate core with a polyhydroxyethyl methacrylate surface, resulting in a biocompatible composite resin.3 This compound interfaces with bone at its outermost calcium graft layers.

Source: The Clinical Applications of Synthetic Bone Alloplast. J Can Dent Assoc 1999; 65:559-62

Hydroxylapatite of Algal origin
Articles discuss this type of material, but I cannot find the companies that produce it.

Demineralized Bone Matrix
The use of allografts for bone repair often requires the sterilization and deactivation of proteins normally found in healthy bone. Contained in the extracellular matrix of bone tissue are the full cocktail of bone growth factors, proteins, and other bioactive materials necessary for osteoinduction and, ultimately, successful bone healing. To capitalize on this cocktail of proteins, the desired factors and proteins are removed from the mineralized tissue by using a demineralizing agent such as hydrochloric acid. The mineral content of the bone is degraded away, and the osteoinductive agents remain in a demineralized bone matrix (DBM).
DBM has been incorporated into several products currently on the market. AlloGro is a DBM product (Wright Medical Technologies and Allosource). AlloMatrix is AlloGro combined with calcium sulfate. This paste can be formed into an onlay or injected directly into a defect site. DynaGraft (GenSci Regeneration Technologies) is DBM mixed with a temperature-sensitive polymer. It forms a solid, putty, or injectable paste, depending on the composition. Orthoblast (GenSci Regeneration Technologies) is DBM mixed with the same polymer and cancellous bone chips. It is available as a putty or a paste.
Source: http://www.emedicine.com/orthoped/topic611.htm#section~polymer-based_bone_graft_substitutes

Emdogain
Emdogain consists of resorbable enamel matrix proteins of porcine origin. It is applied to the root surface of teeth and claims to form root cementum while preventing the downgrowth of a long junctional epithelium. Emdogain provides only an organic component despite the fact that autogenous bone is composed of both organic and inorganic components. Emdogain claims 36% defect fill in 36 months

Source: http://www.dentsplyfc.com/PEPGEN/Part_FAQ.shtml

Irradiated Cancellous Bone
This is an allograft bone usually from cadavers that has been irradiated. This type of bone is used very successfully in maxillary sinus lifts where additional bone is needed for implants.

Source: Porous-surfaced dental implants placed in grafted sinuses with irradiated cancellous bone and platelet rich plasma. Journal Dentaire Du Quebec Vol. XXXVIII Dec.

Source: http://www.bcm.edu/oto/grand/81392.html

Decalcified cortical bone
Case reports and controlled clinical trials have shown the potential of both mineralized and decalcified cortical freeze-dried bone allograft to reconstruct the bone defects caused by periodontitis. Histomorphometric analysis of human biopsies following grafts of decalcified freeze-dried bone allograft have shown the ability of decalcified freeze-dried bone allograft to promote regeneration of new bone, cementum, and periodontal ligament on a tooth root surface previously exposed to bacterial plaque. The addition of mineralized freeze-dried bone allograft and decalcified freeze-dried bone allograft to the guided tissue and guided bone regeneration procedures have significantly enhanced results, especially in large osseous lesions.

Source: Bone Allografts in Periodontal Therapy. Clinical Orthopaedics & Related Research. (324):116-125, March 1996
 
Lilith said:
I am thinking about getting implants done on couple molars that were extracted many years ago. I had gone to two dentists for consultations. Both of them told me that I had need bone grafts. One suggested using autogenous bone graft first, then proceed to implants after letting the wounds heal for 6 months. The other one suggested using a bone mixture to repair bone loss (GBR?), and getting implants on the same day. Although I think it would be good to have bone graft and implant done on the same day to save time, I don't know if this is the best way to go. Any suggestions? Thank you.

It hard to give advice without seeing the site, however, bone in a bottle (FDBA, DFDBA, and Bio-Oss) works great if you are filling in a defect. If you are talking about block grafting an autogenous block graft works great but there is always the poss. of some morbidity at the harvest site. A realtively new option for block grafting is a tissue-bank derived block allograft. Again the research shows these work. It is up to your comfortablity with surgeon doing the procedure. Just as an aside- Distraction osteogenesis is an excellent idea, however, it is extremely technique sensitive and in many surgeon's hands does not provide predictable results.
 
Periogod said:
Just as an aside- Distraction osteogenesis is an excellent idea, however, it is extremely technique sensitive and in many surgeon's hands does not provide predictable results.
Especially if you're a periodontist. SLAM!
 
Thank you all for your inputs. :)
 
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