Bone Morphogenic Protein

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Dr. H. asks:

I have just read about using Bone Morphogenic Protein (rhBMP-2) to grow new bone around dental implant fixtures where bone has been lost after initial placement (Implant Dentistry 2006;15:361). I have not been able to find any long-term studies for this method. Have any of you used this technique to grow new bone to cover the exposed dental implant fixture? What has been your experience? What are some other options for treating some of the complications I see?

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16 Responses to “ Bone Morphogenic Protein ”

• anon January 16th, 2007

  
  

  Wait until you see what is costs and it isn’t always very predictable

• MDC January 16th, 2007

  
  

  To my knowledge BMP-2 is not yet approved for dental bone grafting, although the FDA advisory panel has recommended that the FDA do so. As such I do not think you will have much luck finding long term studies.

  Alternative treatments would include using a bone graft substitute to re-cover the exposed implant, in combination with a membrane. I prefer NuOss (anorganic bovine bone) from Ace, which is comparable to Bio-Oss only less expensive. However an allograft or an autograft would also suffice.

• piezo1 January 17th, 2007

  
  

  About rhBMP-2, i’ ve been using Regenaform and Regenafil (Regeberation Technologies inc., Alachua, CA).
  I’ m not a researcher, but results seem pretty good.
  Cons: it’ s very expensive.

  hope this helps

• HT January 17th, 2007

  
  

  It won’t matter what you put in, if the bone resorption is due to a “biologic width” phenomenon then the bone graft won’t be successful.

• kerem January 18th, 2007

  
  

  rh BMP is the ultimate bone regenerating material (otogen grefts aside of corse) in both dental and orthopaedic procedures. it is hard to find pure bmp grafting material but you may prefer by checking various graft materials’ bmp percentage on the market. ı am an oral surgeon and my clinical study was on evaluating the effectiveness of various bone substitutes such as beta tri calcium phosphate, bmp and dbm. bmp’s are osteoinductive materials at the operation site therefore they are much more effective than conventional graft materials. besides, there has been numerous studies concerning the topic and a vast majority of these studies suggest that if used in proper concentration with the proper carrier bmp’ s act as a perfect bone regenerating materials.
  you may check the literature especially in pubmed.
  kerem dedeoglu istanbul, turkey

• Chris Kruszka April 3rd, 2007

  
  

  The concentration of BMP’s in demineralized bone matrix or paste (such as Regenafil) is in the picogram/cc or nanogram/cc range - very low. The concentration of comercially available BMP (Infuse from Medtronic) is 1.5mg/cc, one million times greater than DBM. There are hundreds of long term studies for non oral applications, and numerous (not sure how many) for cleft palate, ridge augmentation, sinus lift, mandibular reconstruction (bone transport) etc. Plus tons of animal studies. The costs are relatively high if you use the largest sizes that are available for sale. Use the smaller sizes, and keep in mind that the costs of autograft harvest include: surgical time and donor site morbidity. I’m not sure how long it takes you to perform a typical autograft harvest, but it can be anywhere from 45min to 2 hours - that time seems to be worth something to me. If I can do several extra proceedures/day due to not having to harvest = more patients per day.

• Dr. Mehdi Jafari November 1st, 2007

  
  

  Bone morphogenetic protein (BMP), is a growth factor belonging to the growth factor-B superfamily (TGF-B). Multiple BMPs have been identified. Those of interest to oral and maxillofacial surgeons include BMP-2, −4, and −7. These have the ability to induce mesenchymal cells triggering their differentiation into osteoblasts. Recombinant technology has now made purified BMP readily available as commercial products. BMP-2 induces bone repair when used with or even without an autogenous bone carrier graft. While autogenous grafting for implant bed reconstruction remains the “gold standard,” rhBMP-2 usage offers significant advantages to the patient. These advantages may include shorter time for surgery, avoidance of sensory disturbances as well as decreased sites for scar formation, wound dehiscence and the possible infection. Type I bovine collagen sponges are usually chosen for the carrier because of their favorable biodegradable properties and their ability to create and maintain space within the soft tissue flaps and/or unwanted dilution causing a reduction in effective concentration. These collagen sponges have not shown any cross reactivity with rhBMP-2. No difference has ever seen clinically with the patients’ healing process except that the rhBMP-2-repaired bone defects tend to have slightly more postoperative swelling. This increase in swelling can be attributed to the properties of rhBMP-2 being an inflammatory cytokine which induces mesenchymal stem cells to differentiate into osteoblasts. The patients receiving BMPs have not reported any increased pain at the surgical site.

• Peggy November 1st, 2007

  
  

  This is an interesting discussion. I wanted to comment from a personal point of view - not a scientific one. In August my 22 year old son had an Infuse Bone Graft to reconstruct his upper right maxilla which had been removed four years ago for treatment of an ameloblastoma tumor.

  We do not know yet if the rhBMP-2 graft will work but the ease of the procedure compared to the failed non-vascularized bone graft utilizing his rib which he had in May of 2006, made it seem like a miracle to us. The failed rib-bone graft surgery required two days hospitalization and months of recovery time. My son had to be on a liquid diet for almost two months. At one week post surgery, soft tissue covering the graft became necrotic and sloughed off leaving bone exposed. After one month, he suffered a jaw infection. Bits of bone came out of his jaw for months and finally, 8 months after surgery, we found that the procedure had failed completely. The surgery and subsequent treatment cost over $65,000 compared to $8,200 for the Infuse bone graft which was done in the surgeon’s office on an out-patient basis ($5,200 was the cost of the Infuse rhBMP-2). So yes, the rhBMP-2 material is expensive but actually nothing compared to the cost and trauma of the other options available to remedy the missing maxilla.

  We consulted a vascular surgeon early last summer to explore the possibility of a vascularized bone graft utilizing his fibula. Due to the need for 3 to 4 surgical sites, intensive care for 3 to 4 days followed by months of recovery, a cost of upwards of $100,000….with no guarantee of success we decided not to do any thing further. Then a few weeks after that we learned about the Infuse rhBMP-2 procedure and decided to pursue that option. One of the deciding factors in choosing this was the fact that my son will be no worse off than he was if the procedure fails again. The same could not be said for the vascularized bone graft option.

  My son had the Infuse reBMP-2 bone graft surgery, and an uneventful recovery - he left for graduate school in Europe 10 days after receiving the graft. In a few months he will hopefully return home for a CT scan to see how the graft is doing and if all is well, they will begin the planning for implants to restore teeth to his upper right jaw. It has been a long, grueling and heartbreaking journey from the ameloblastoma diagnosis requiring the radical surgery (which removed 1/3rd of my son’s upper jaw, 4 teeth, 1/4rd of the roof of his mouth, sinus bone, cheek tissue, etc)….but we are very hopeful that full function will be restored to his mouth within the next year or two.

• Ahmed Noaman December 10th, 2007

  
  

  may I ask if there is any recent research in relation to BMP and tretment of bone loss in dental implant or eve peri-implantitis?.

• Ronda May 31st, 2008

  
  

  My story is a lot like Peggys above. My daughter was 15 when she had her 1st surgery to remove 1/3 of her upper left jaw and teeth. She had a bone graft from her hip to rebuild it 2 years later. Now after a year we have found out it didn’t take and she needs another. We went to a specialist and he recommended BMP. Is there any update on how her son has done? Anyone else have any personal results?

• NELSON GUERRA June 8th, 2008

  
  

  Agradesco la oportunidad que nos dan de comunicarnos con ustedes . Necesito saber que grado de éxito tiene la rh BMP-2 (en esponja de colágeno o cualquier otro transporte) aplicada en la región anterior del maxilar superior desdentado severamente atrofiado ,si se pretende aumentar la altura como el espesor en ancho ,de esa zona anterior del maxilar superior.Lo mismo les pregunto sobre la performance de dicho material en la reconstruccion de las mandibulas severamente atrofiadas. Les agradezco la comunicación.

• Nelson June 8th, 2008

  
  

  Agradesco that give us the opportunity to communicate with you. I need to know that success is rh BMP-2 (a collagen sponge or other transportation) applied in the region anterior maxilla desdentado severely stunted, if it is to increase the height and width in the thick of that area earlier Maxillary superior.Lo same ask about the performance of such material in rebuilding the jaws severely stunted. Thank you for your communication

• Gabriela June 16th, 2008

  
  

  I NEED HELP PLEASE!!! I have a first molar and second molar on my lower left side missing and my bone is very little left (I still have my third molar). I lost my bone when I removed my second molar which had the nerve removed and I felt no pain even though it had an infection that went into my bone. So, when I had it removed a lot of my bone was infected so I lost it. I watched TV not long ago on Discovery I think and there was a case where this doctor used the rh BMP-2 on this young patient that had a part of his jaw missing and he used the rh BMP-2 on him and it worked. The patient’s jaw grew bone and it looked wonderful, I think the case might have been the case above that I just read. I went to few doctors and they tell me that I need to have bone grafted from my hip and replaced to my missing bone in my mouth. I would love to have the rh BMP-2 done rather than be put to sleep and have my hip bone removed. Can anyone help me understand more about the rh BMP-2?? The doctors that I went to had no ideea and they never heard of rh BMP-2. Does anyone know a doctor in the Seattle area that uses rh BMP-2?? I hear so many good things about it, so yeah, I would rather go with rh BMP-2 than hip bone repalcement. Please anyone help!!!!!!!

• Pedro Cuartas June 24th, 2008

  
  

  Gabriela, I don’t know of anyone in your area, but i know a docotor in miami who may. His name is Arun Garg. You can look him up online. I think you may benefit from the bmp and even something called platelet rich plasma (prp). Good luck

• Peggy June 25th, 2008

  
  

  Rhonda - I happened to see your post about your daughter and your question about my son’s status today.

  I am sorry to hear your daughter’s bone graft with bone taken from her hip failed. I remember very well the devastation we felt when it was confirmed that my son’s rib graft was a complete failure. It is hard to watch your child suffer and then to find out it was in vain is almost too much to bear.

  My son is coming home from Belgium tomorrow (6/26/08) for a month and on Monday, June 30th we will find out if the rhBMP-2 bond graft done last August was a success. You can be sure I will post the results. I am hopeful and optimistic - I hope I have good news to relay to you next week.

• Peggy July 3rd, 2008

  
  

  Update - The Infuse rhBMP-2 bone graft was not a complete success BUT there is enough bone at either end of the missing maxilla to have two implant posts placed that will be sufficient to secure a fixed bridge holding the three or four teeth he needs to have replaced. There is some bone in the middle of the length of jaw but it is too thin to allow implant posts. So, while we had hoped for individual implant posts and subsequently individual teeth (crowns) just like a normal mouth, we are not upset that that won’t happen. We are all really happy that the graft succeeded sufficiently to allow us to proceed with getting teeth on that side of his upper jaw and restoring function to that half of his mouth.

  The surgeon does not know why the graft didn’t do as well as hoped other than the possibility it was because of the abundant scar tissue from the several prior surgeries. The only other option (besides two implants & the bridge) would be to try another grafting procedure, wait 6 months more and see if it grew thick enough bone, etc….. But my son felt he’d rather move ahead and get the two implants to allow the bridge to be placed any time after 6 months, than wait hoping for another bone graft to succeed or fail. The surgeon really felt this was best too. So my son is scheduled for the implant surgery on July 7th.

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