Exposure of Bio-Oss Graft in Endodontically Treated Tooth: How to Approach?

Are we not supposed to check sockets for any remnants of: root pieces, granulomas,cysts or other pathology or foreign bodies like amalgam particles or gutta percha before closure,grafts or no grafts? The only option you have is to remove graft ,including those gutta peecha remanants at earliest.

That graft is lost, so cut your losses and remove it now, get the socket clean and re do the graft. (in grafts I usually place 1/2 a capsule of tetraciclyne for every 0,5 cc of material in the mix, it works great)

If your patient dosen't agree with additional surgery, put him on Chlorhexidine immeidately, plus systemic antibiotic.

Anon mentioned pieces of gutta percha ,overextensions, from an extracted endodonticallt treated tooth, were overlooked and left in the area where the graft was placed. He/she does not mention why the tooth had to be extracted. Gutta percha is in itself an inert material and well tolerated. If there is no granulomatous tissue, and protection is given to prevent infection both systemically and intraorally (i.e. Peridex); waiting would probably be a good option. The fact that the membrane became dislodged and the Bio Oss material became visable, but remained in place, is indication that an Osteoid has formed and is containing the particles..... time will tell.

I agree with Dr. Rudick in that the gutta percha is inert and would most likely cause no problem. What concerns me however, is the fetid odor at the site. Due to the etid odor I would remove the existing graft material, debride and irrigate the area, plae pt on antibiotics and regraft at a later time. Good Luck!

This described my case and afterward I was thinking that I should have made an extra x-ray. The tooth was extracted because of a fracture in the furcation. The endodontic treatment itself wasn't the poblem. I clean the sockets with a microscope and took bit of pieces of cementum in both sides and didn't see the rest untill I took the final x-ray to follow up the case and saw that I have missed somewhat I didn't see in the socket itself under the microscope. I removed the smelling and swelled tissue above til I had a good bleeding and have put a hemcon over it to stabilize the bloodclot and this went very well with tissue overgrowing the graft completely. Since this went well and the piece on the x-ray didn't show any inflammation we decided to watch the situation. The smell seems to come from the dislodged resorbable membrane. In a later stage the patient told me that he didn't have followed my instructions and probably caused some damage to the stitches and flap. The graft material it self didn't smell and was hard and I couldn't remove it. To satish Josh: you are right to check or all the foreign bodies, but in this case the patient wasn't a normal patient but with anxiety with a VAS scale of 16 and during the years I manage him to cope with dental situations, but in this case we maybe pushed too far and makig the surgery very dificult to do. In this case my attention was drawn away from the surgical procedure and left me with some unwanted complications. So one sequence of events let to more and in this way to complications. So if you see what really went wrong then it was the selction in the beginning and maybe we should have done it under general anesthesia, but with we didn't choose this because of the fact that other treatments before went really well. It was a good learning experience ( not the one I like) for future cases and the patient was well informed after the surgery about the complications and what could be done. This thing is not an excuse to leave remnants behind in the sockets, but it happened to me! Maybe some docters manage it always without complications like satish josh. i wish I was one of them!!

No CHX, it will slow the healing process. The graft is infected and shoud be treated with an Antibotic. The graft may have been packed too tight and therefore no blood supply. Remove the graft and treat the area as an infected tooth that must be removed. The gutta percha is not the real problem. Osteoid can not form in two weeks.

I agree with the doctor who stated the odor was probably from the dislodged membrane. I completely disagree with the need for removal of the graft. Just because the bone was exposed to the oral cavity does not mean it needs to be removed. I would have treated this case with CHX and systemic antibiotics. Was this patient a smoker or diabetic. Did you see any purulent drainage from the site? If not then I see no reason to just sit back and wait to see how things progress. Most often in my experience root canal teeth that need to be extracted have some PAP associated with the roots, therefore, a more thorough currettage would have been waranted.

Dear Dr. D. Please do not be offended by my comment. It is not supposed to be a criticism but a suggestion. Being a faculty in Implant Dept. it is a part of my job to check every possible detail for work being performed by my residents, whether it is a simple socket grafting or advanced surgical procedure. As far as complications are concerned, yes I have my share. Even biggest of big names do make blunders sometime. Main thing is we should try to learn from our mistakes and try to improve our selves. As far as Gutta percha is concerned I never intended to say it is the sole cause of your problem. Graft failure can have many reasons. I do agree Gutta percha is an inert material and that’s why we use it to obturate canals for decades. But inertness is related to sterility of Gutta percha. Do not expect an over extended part of Gutta percha swimming in a cesspool of purulent medium of peri apical pathology to be as inert, so it won’t cause any problem to graft or future implant. Please remove it (gutta percha). As Dr. Callan advised it is better to remove graft let soft tissues heal without using CHX in initial stages, with systemic antibiotics and re graft after few weeks. Good luck.

Unfortunately xenografts can become infected from a resiual or adjacent infection , removal as said is the best action to allow the body to heal. Do not be alarmed to see the extent of bone loss though which we seen in other cases. Some mix Tetracycline into the graft at placement , but caution using these materials when any infection is about is advised.

I still do not understand,why all graft materials should be removed?If only membrane was a problem,just remove membrane, otherwise there may be huge defect. I do not think leaving Gutta percha fragments will have any effects on the success of implant.

Initiate a chlorhexidine rinse if the patient hasn't already been using one. I would also have the patient on an antibiotic such as amoxicillin if appropriate. Don't remove the graft at this point unless the site is truly infected and not healing. The scenario you deccribe is not unusual and there is no need to panic. I would expect the site to heal uneventfully and will probably still be suitable for an implant.