Alternative to Bone Grafts for Implants?

A, a dental implant patient, asks:
For personal religious reasons I do not want animal or human bone graft material to be placed in my body. I have an implant in position #8 [maxillary right central incisor] with dimensions 4mm x 18mm. It has to be removed because it has failed and my dentist says I will need a bone graft. At this time, he cannot offer me a bone graft that does not include animal or human graft products. So I’m wondering what my alternatives are? I’ve read on this site about surgical grade calcium or calcium sulfate graft material as an option to fill a large void in my bone? Is this my best choice? Any other ideas? Thanks.

45 thoughts on “Alternative to Bone Grafts for Implants?

  1. We have used only synthetic Beta tri-Ca products stabilized ( to set hard) by Ca Sulphate or a polylactide for the last 5 years wihtout using a membrane. With hundreds of documented cases, these materials and their future derivatives offer the way forward.No Animal ,No human products needed , and no membrane for improved graft site healing ( improved blood supply)

  2. TO Peter Fairbairn: I agree, the synthetic particulate materials work very well given time for the sigma protection of the graft material and preperation of the recipient site etc. I have been using “Osteogen” from Impladent Ltd. since 1991 without any issues. Richard Hughes, DDS, FAAID, FAAIP,Dipl.ABOI/ID

  3. Best option would be rBMP2

    Infuse is the name. Recombinant technology and turns your cells on to make bone. Does require collagen plug which most likely is bovine. Good luck!

  4. If the implant has failed the the bone defect will likely be considerable size. Bone substitute that are chemically synthesized may not have enough regenerative potential to repair the bone defect. Seek out a surgeon that uses your own bone to repair the defect. A small amount of your own bone can be harvested from another area (such as your lower jaw where the wisdom teeth used to be). The bone graft is placed into the upper jaw to repair the defect. This technique worked extremely well and is more predictable than trying to use synthetic bone materials. Although there are some surgeons using Infuse (rhBMP-2) this approach has less research. In addition, as pointed out previously the carrier for the liquid bone protein is cow tendon (collagen).
    Dr. C

  5. The Infuse route is all animal, the carrier is bovine and I think the BMP itself is from Hamsters. The newer synthetics can regenerate larger graft sites in fact I have seen early studies ( with histo) where the posterior mandible has been regenerated vertically by 4mm by tunnel grafting.We have cases of defects 5mm by 10mm both Palatally and buccally fully regerated ( with no membrane) and loaded at 3 years.There are further new materials soon to be released which will hopefully lead to even better results.
    We have not used autogenous for 4 years for 3 main reasons, donor site morbidity ( Wipperman etal), osteoclastic activity and most importantly when we talk about synthetic use if autogenous is used the audience will assume that this led to the bone regeneration.
    Essentially bone regeneration is an stabalized blood clot in the correct enviroment (bone) where we prevent the ingrowth of soft tissue. The issue is to be able to stabalize and bulk the graft site and this is where the polylactides and Ca Sulphates play a part.
    We await the next generation of synthetics

  6. There is a combination approach that could be used. Bone marrow asperation allows you to use your own bone and bone progenitor cells mixed with a synthetic (non animal) material such as osteogen covered with calcium sulfate hemihydrate. Or it could be covered with a gortex membrane which would be removed at the time of implant healing.

    Bone marrow aperation is done with a biopsy needle used in iliac crest of the hip. It is less painful post operatively than any bone aquisition technique I have used intra-orally.

    Good luck to you.

  7. I must agree with Dr. Craig Misch, autogenous bone is gold, bone from your chin, ramus, or maxillary tuberosity are all ideal. If the bone is available there is no need for allograft(cadaver bone) or xenograft(bovine), or alloplast(synthetic). Autogenous bone has many atvantages including biocompatabilities as well as growth factors that allow for osteogenesis, as well as osteoconduction and osteoinduction.
    Thus for your situation, only a small volume of bone is required which is easily and best harvested from yourself(ramus, chin, tuberosity).
    Please refer to Contemporary Implant Dentistry (Carl E. Misch) the authoratative text regarding Dental Implants.
    Regards,
    Karethdentistry.com

  8. I agree autogenous bone is best. However, we practice in the real world and sometimes patients just flatout will not consider additional surgery and want us to get in and get out. There ia also a considerable cost increase. I strongly suggest that any serious implantologist learn other modalities such as: BLADES, SUBPERIOSTEALS, RAMUS FRAMES, DISC & ENDO STABALISERS, NERVE REPO. Also giving time, materials like “Osteogen” work very well in the proper situation.

  9. Dr Hughes,

    Did you drive or take a horse and buggy to work? Get with the times. Those treatment plans are barbaric! Implantologist, what ever that means, with lack of educatuion and understanding are destroying this industry. I cant blame the dentist, I blame the patients for not asking the right questions!

  10. Dear Dr John Peter,
    are you speaking from experience or just an emotional outburst? I have not had experience with Ramus frames and subperiosteals etc. but I wouldn’t call any thing other than a screwed in implant barbaric. And if you insist then isn’t it “barbaric” to screw in a screw implant itself?

    I think one needs to punch words with a thesaurus in hand because a lot of non-medicos read the stuff and we inadvertantly put in ideas that are not always completely scientific.

    For the benefit of mankind nothing really gets outdated completely. Every type of implant has it’s right full place. it’s probably case selection that’s the key here.

    Sorry to speak out of turn and without experience. But I thought that I had to uphold what is right.

  11. L’alpha-tri-calcium-phosphate est un substitut osseux de fabrication synthétique pouvant être résorbé et totalement assimilé par l’os du patient dans un délai prévisible. Ce matériau se présente uniquement sous forme de granules, il est composé principalement de phosphate alpha tricalcique synthétisé exempt de phases d’hydrox apatite. Pour sa fabrication, on utilise des substances d’une grande pureté chimique, ce qui diminue les risques d’infection et toute réaction immunologique. La composition chimique comporte exclusivement de l’oxyde de calcium CaO (52–54,2 %) et du pentoxyde de phosphore P2O5 (45,8 à 48 %), le rapport atomique du calcium au phosphore est de 1,5 se rapprochant le plus possible du rapport atomique calcium/phosphore de la phase minérale de l’os (environ 1,6). Le procédé de fabrication permet d’obtenir une structure poreuse assurant l’interconnexion osseuse avec chaque particule de phosphate tricalcique. Grâce à cette porosité, le temps de résorption variable de six mois à deux ans se trouve réduit par rapport à un substitut osseux plus compact. Le traitement ciblé à haute température consolide la structure interne, si bien que la dissolution physicochimique après implantation se fait au niveau moléculaire et non au niveau particulaire.

  12. Dear patient, your concerns are real and I receive this request often. I would suggest you have a conversation with your dentist about B-TCP unless you are willing to have bone surgically removed from another area of your mouth. I would suggest you have a discussion with your dentists about Cerasorb and do some research yourself. There are several different synthetics on the market but in your case, implant placement with a synthetic will be most successful with B-TCP.

  13. i agree with dr misch , autogenous bone graft is the gold standard, dr jafari please write your openion in english it benifits many of us

  14. Did anyone hear about titanium grains from TIGRAN. It is a bone graft substitute where each grain is made of 20% titanium and 80% air. The blood fulfils the 80% empty space and the 20% titanium brings the stability needed. Sounds like a solution when animal source is a problem.

  15. Interesting material used in Sweden but not sure about aesthetic zone , as to autogenous , results are very dependant on operator skill and donor site morbidity is a big issue leading to a significant reduction of the number of block grafts done ( judging by the reduced number of screws sold by dealers here in UK).
    I would not have a block graft done on myself , through fear

  16. Monsieur Le Docteur Mehdi Jafri, je ne parle pas français.

    Sil vous plait charbonner en anglais?

    Merci’beaucoup!

    My French needed to be polished, Thank you once more!

    Back to TCP hmmmm…. what were we talking about?

  17. A,

    Please seek a second opinion from a Oral and Maxillofacial surgeon.

    If you current Dentist is unable or unwilling to help you explore the myriad of synthetic and harvested possibilities that exist….

    Perhaps a more experienced surgeon would be appropriate.

    To R. Hughs;

    Your post caused me to spit my coffee onto my computer.

    I don’t know where to begin, I believe in an open mind and I love old school techniques….

    But did you seriously just suggest a subperiosteal implant in the anterior maxilla #8 with a defect!

    Blade implant….. I though I had taken the last one of those out years ago….and in a #8 defect…ahhhh!

  18. No big deal, I had just suggested that Alpha Tricalcium phosphate would be a better choice than punishing the patient by creating a new surgical(donor) site.Another colleague had suggested the Beta one.The clinical difference between these two is the estimated time of resoption.The Beta-Tricalcium phosphate is resorbed much sooner than its Alpha twin.The problem is that those biomaterials that resorb very quickly, cannot be used at those areas that one needs to have a very strong and dense substituting bone formed, to whithstand the future loading forces especially when the vector of these forces are a bit off-axial.

  19. To: Empirical Medicine: No, DO NOT SUGGEST A SUB FOR # 8. AS FAR AS THE REMOVAL OF A BLADE. I HAVE REMOVED ROOT FORMS, BLADES AND SUBS. THESE ALL WORK, BUT FOR THE RIGHT SITUATION. FOR YOUR INTEREST, INTERDENTAL SUBS WERE MADE IN THE PAST AND WORKED, AND CAN STILL BE A VIABLE OPTION IN THE RIGHT SITUATION. I SAY KEEP ALL THE OPTIONS ON THE TABLE AND DO WHAT’S BEST FOR THE PATIENT. IN THE MEAN TIME BE CAREFUL WITH YOUR COFFEE! How long was the blade in function, THAT YOU REMOVED?

  20. To R. Hughes;

    I thought we had taken all of the blades out that were ever put in! Except the one that is still in function in my father… yes another coffee spitting situation when I discovered in residency that my own father had a blade done years before.

    I AGREE IN KEEPING AN OPEN MIND, However, these forums are read by lay people and lay dentists who really don’t understand the complexities of what you suggested with your post.

    In general, as I am sure you know, subs and blades are not done any more. Why??? because of the high failure rate and resulting disaster when forced to remove them. They perform poorly because they are based on flawed science. That doesn’t mean they can’t work, ie my father, it just means they are a bad idea…..

    ESPECIALLY IN THE ABOVE CASE OF A DEFECTED #8!

    Just because they have worked in the past, doesn’t mean they meet modern standards.

    I really can’t believe I am actually still fighting this topic!

  21. To Empiricial Medicine; Blades, subs, and ramus frames are still great modailties. Hoewever they require more skill and the principles are a little different. The science is not flawed-they are undermarketed. A trained monkey can place a root form. I still place blades, ramus frames and subs with good success. I also place root forms. Look at your father’s case. Is it successful or not? Like I stated earlier, not every Doc has the skill to perform these procedures, but they can learn, if they are motivated. Not all patients can afford grafting nor do they wart to take the time and not all Docs are proficient with grafting, nor does every patient have the regenerative capabalities. So, I say we can agree to disagree. This is an ever evolving dicipline.

  22. I have to place an addendum to my prior comment. Yes placing a root form is alot easier then the other modalities. However, placing in the proper position for optimal aesthetics is an art form. I believe there is alot more to this field that meets the eye. One that is serious has to be a dedicated and continous student to this evolving field. It has been my experience that the surgery unless extensive grafting is involved is not usually as demanding as the prosthetics. The patients aesthetic demands are driving this field into a good direction. We have to thank the authors such as Drs. Misch, Babbush, Linkow, Weiss et. al. for putting into our hands a sound body of knowledge based on experience, clinical and basic science. For the good of the patients we should be versed in multimodal techniques, so “no jaw will be left behind”. Richard Hughes, D.D.S., FAAID, FAAIP, Dipl. ABOI

  23. To the patient that lost the implant at the site of # 8 and cannot have human or animal bone I ask can you have your own bone? As Dr. Misch pointed out this is most likely is a large defect. There are some options that may work such as ridge expansion, grafting with osteogen (over contoured) etc. but protect the graft, a Maryland Bridge, a convential bridge One has to be examined and bone soundings made.

  24. I HAVE FOUND THAT SMALL DIAMETER IMPLANTS CAN REALLY SAVE PATIENTS THE NEED FOR UNNECESSARY SURGERIES AND COSTS. I THINK ALL DDS’S THAT DO IMPLANTS SHOULD HAVE THIS MODALITY IN THEIR ARSENAL OF TRICKS.
    PEOPLE SHOULD BE MADE AWARE OF ALL OPTIONS AVAILABLE.

  25. I need options. 8 yrs. of implant sx. upper jaw, no bone left, after many failed implants, fears of increse infection with hip bone graft…also working,with little time off What other lesser invasive options I have to have teeth???? running out of funds after 8 yrs…. Where can I go for information? Thankyou so much

  26. Mini’s by IMtec.Place four in max anterior and a complete max cd can be placed.After a short wait,month or two,cut out palate of max cd and cut back flange area.The patient will love this and the fee is quite reasonable.Imtec has much info on doing this .

  27. Possably a maxillary subperiosteal implant. The Doc that is currently the most experienced with this modality is William Nordquist, D.D.S. in San Diego Ca.

  28. Enough about blades, subs, rootform…you’re not putting anything in there without bone. Of course none of us knows exactly what the defect will look like but I believe Peter F. and Dr. Misch are on the right path. You could do tibia, mix with some PRP…very good osteogenic potential, good predictable results. Also over the course of the last 2 years I’ve been using a pure-phase beta-TCP, Cerasorb, with outstanding results. Purely synthetic, predictable, no soft mushiness or particles on reentry. No membrane except sometimes a collatape or collaplug. Use the larger particle size for more bulk and slower resorption. There are other brands which mix in HA, I like the pure TCP, fully resorbable and replaced by the patient’s own bone. I’ve been placing implants 4 months post-graft. I’ve even had to use a bone tap once or twice. The science behind it is great. In February at the AO in San Diego, Dr. Buser from Bern summarized some very nicely done studies done over the last decade on these new, synthetic, resorbable materials.

  29. Cerasorb, the Beta-TCP product has been proven highly effective in all indications! They do not spend their money on marketing like the huge companies do (passing those costs onto you), they spend it on clinical studies and the results have been amazing. This is not like the old TCP products of the past. It is a pure phase TCP that gives very predictable results and is not only a good alternative to allograft or xenograft, but a good replacement,…period!

  30. I have been placing bone grafts of different types for over thirty years. I totally agree with Dr.Craig Misch. A small simple autogenous bone graft from symphysis/ramus would be the best for this patient. Anything else would be sketchy. Why take a chance with artificial grafts in a previous failed area that appears to be large

    Large size defects heal faster with natural bone.There would be more reliabilty and retain the future implant much better than alloplasts

  31. hi every body;
    i think this case is ideal for non grafting techniques as bone expansion technique which avoid any bone grafting

  32. hi everybody :bone expansion allows increasing bone width either in maxilla or mandible but if the defect in height we consider distraction techniques

  33. This is a nice case of osseonews making up a scenario to get everyone hyped up, (too much detail to be a real patient). Which is good, look at the conversation it have created. Of course you are going to use autogenous, and will need to have the surgical knowledge and experience to know how to manage the case, a difficult one indeed because your are trying to re-establish the esthetics, not compromise the soft tissue or bone on the adjacent teeth or grow bone around the roots of the adjacent teeth. No one knows the real situation, if you are placing implants, and feel you have put a lot of I like to call heart tissue into your discipline, learn how if you dont already know, to do autogenous harvest and grafts so that you can treat these types of cases. Even today there is no magic powder to fill all defects, there are some great barriers, but no magic. We at Loma Linda University have done much research, check medline, and we can not put all cases into a box and say that all defects can be grafted with puros, synthetic etc, but I can say that all defects can be restored with autogenous done properly. Good luck, be smart and keep your liability down, I am greatful implants are growing at such a rate, which means we need to band together.

  34. Dear patient A,
    There has a been a lot of hullabaloo created (in the 5-6 months since your post appeared)over what seems rather well-established in not just Implant science but in Bone Biology in general.
    Universal, the tenets of bone grafting are said to follow a simple rule… ” Replace what is missing”!
    If you were to apply the same quarter here, the removal of the Central Incisor Implant would leave behind a defect in the anterior Maxillary ridge. This defect would be part Cortical and majorly Cancellous.
    This therefore dictates that a Cortico-cancellous component of bone graft / substitute needs to go in there or at least needs to be regenerated there.
    The issues here would be clearly identifiable as –
    1) Osseointegratability of the Implant (if one were to be placed again in the region after Explantation and grafting)
    2) The ability of the Bone to take on load after the Implant is rehabilitated with a Crown
    3) The soft-tissue issues (aesthetics , cretal bone, Contact points, papilla etc)

    We have come along way from the times in the last century when , just the secure engagement of the Implant within the bone (Osseointgeration) was the definition of success. we would look at criteria, that would establish predictability in function and aesthetics as criteria for success in the long term.

    Having the bone produce cells in the immediate vicinity of the Implant , for the healing process to be initiated would require that the Implant be placed within “live” bone and not within graft. hence the need to have a material go in to the defect that would generate “new, live” bone before the Implant could be placed.
    Having the load (Chewing forces) be directed towards the Cancellous component ( around the areas adjacent to the middle portion and the deepest aspect (tip) of the Implant) would be a priority>
    Having the peripheral bone immediately subjacent to the Implant’s neck at the crest of the ridge be spared of the insult of load would be optimizing chewing (occlusal) load.
    Having the quality and quantity of gingiva (gum tissue) that would enable long -term maintenance of the level of the Implant as well as the bone around it, would be a pre-requisite, not just for response of Bone to load after osseointegration but also for maintenance of cosmesis.
    There is therefore no reason to believe that anything but an Osteogenic regenerative mixture(Autogenous bone) would do the needful; either in the form of a Trephine core or as Block.

  35. These are challenging cases. First find out why the initial implant failed, you’d like to find a reason. This can be difficult as the initial provider may feel threatened. I suggest right from the beginning, let the provider know that you are trying to decide if you are a good candidate for addititonal surgery, not trying to expose any fault. Make sure you are indeed a good candidate for surgery, and ask for your case to be mounted to study any occlusal interferences. If surgery is reasonable I would go with an autogenous block, and ground autogenous mixed with synthetic for undercuts and around block. I would not attempt this large graft with all Calcium Sulfate, and I would suggest grafting first (no implant at the appointment) then come back to place the implant later. As patients we all have to do our homework, today maybe more than ever before. Good job for doing yours.

  36. Dr. Miller’s input is correct. In addition the original site could of been one that was occupied by a tooth with prior endo and amalgam retro fill, or a large periapical lesion. These sites are tricky. Said and done. Perhaps a bone expansion with graft and membrane would work very well.

  37. I may be chiming in a bit late, but I have to agree with Dr. R. Hughes re. other implant modalities. I started performing implant placements in 1987 and have placed blades, subs, and root forms (including minis). I have removed very few failures of any of the modalities. Subs and blades do work in the situations, and if anyone tells me that he/she has 100% success with root form implants ( if they’ve placed more than a few) is lying through their teeth. I would still place a sub, in the mandible especially. If any one would care to see it, I will post a full mandibular sub case I did 23 years ago. The patient was just in on recall 2 weeks ago and I took photos. By the way, she was the first sub case I did.

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