Graft Vs. No Graft?

Dr. H. asks:
Please see the case photos below. I have a 31 year old male patient who presents with root tips in the #30 + 19 areas [mandibular right first molar and mandibular left first molar; 46, 36] and a sinus tract on the buccal of #18 [mandibular left second molar; 37]. My treatment plan is to extract these 3 teeth and to replace them with implants. My first treatment option is to extract the 3 teeth, lay full thickness flaps to expose the sites, do an aggressive and thorough curettage, harvest bone from the buccal of #18, 19 and to mix the autogenous bone with TCP [tricalcium phosphate, a synthetic ceramic graft material] and to graft the sites and cover with a resorbable membrane. Then place implants after 4-6 months of healing. My alternate treatment plan that I am considering is to extract the teeth and do an aggressive curettage then go back in for implant placement and bone grafting as needed at that time. I suggesting the second option because I am wary of causing an infection in the area. Which do you think would be the better option?

defect on 19

defect on 30

panoramic x-ray

47 thoughts on “Graft Vs. No Graft?

  1. I practice in a small town and my patients come from all over. Therefore I prefer to get things done. I would have a CT taken and evaluate bone damage and bone availablity . Yes open a flap clean out well, i dip my curreettes in poldine as added miracle dust. I try to place implants immediatly , if needed add bone augmentation membrane and then close. Many times if multiple implants are placeed with good torques i place the abutments and temporise and after healing 3-6 months i remove temps check abutment torques ,refine abutment preps ( recession) impress and yhen cement crowns . good luck

  2. Sounds like you are a relative beginner.
    Here are my thoughts:
    Implant osseo-integration is almost guaranteed in bacteria free sites with adequate bone. The case presents with infection and bone loss.
    If you extract / graft and wait 4 months for healing, you have erradicated the two biggest causes of implant failure. (infection – poor bone quality/quantity)
    Explain this to you patient. They won’t mind waiting. If you look at this patients mouth, these teeth have been rotting away for years. Why try to fix it all in one day??
    Keep it simple. Your implants and patients will thank you.

  3. I would agree with dr sb oms. I have done successful immediate implant placements into infected sites, but there is a number of issues you would need to understand before proceeding. The safest is to remove and graft. When you become more proficient then you can look at alternative treatment.
    Good luck

  4. I would extract, curettage thoroughly, and medicate with appropiate antibiotics for at least 7 days post operatively. After 2 or 3 months (I wait 8 weeks minimum), re enter for implant placement and graft if needed: advantageously you will be able to achieve primary closure if you wish to cover the implant and graft. If implant placement is suspected inconvenient, you can always graft and wait, and place implants 4 or 6 months later. Hope it helps

  5. Extract currette extensively , graft needed as the buccal wall will have defects and if left to heal there will be extensive re-modeling . Graft with Easygraft ( DS ) as you do not need soft tissue closure for up to 3 weeks as the particles are bound by the poly-lactide coating.The material is bacterio-static and initially bacterio-scidal so helpful in these situations and fully bio-absorbs in 9 to 12 months .Place implant at 3 to 4 months , done countless cases all recorded no issues.

  6. I would suggest going with the extractions, currettage and graft at that appointment this will help prevent further loss of the crestal bone without the socket graft expect alot of resorption in the site and more extensive grafting will be needed before an implant can be placed. I would go with allograft material such as Regeneform or Grafton as these will turn over much faster then TCP and allow you to renter at 3 months to place the implants. Also you will need to place a membrane to get site closure and my preference for this is Ossix as it is durable resorbable and will work even if primary closure is not acheived over the top. Mobilize the flap on buccal with elevation past the MGJ and score the periosteum and you should be able to stretch the tissue to get primary closure. Place the patient on antibiotics a week before surgery ad continue 10 days after. Also after curretting the site flush with saline mixed with Doxy (f the patient isnt allergic to that) making a paste then pack into apical of the socket let sit for 3 min rinse out repeat rinse out and pack your graft this will help reduce the bacterial load in the area

  7. REmove the roots adn currete and if you can take a large round diamond into the sockets. The place Southern Dental impalnts and Graft a little around the impant. The have 8 and 9 mm wide. i have been having great success with this impant in molar extraction sites. Talk to your Rep in your area about these unique niche implants. Ask for the Tri-Max. Amazing!

  8. I agree with sb. Why do you want to make life difficult?
    Remove the causes of the infection (absolutely NO indication for antibiotics at this stage, once the cause of the infection is removed), allow to heal for 4+ months, then place 3 uncomplicated implants which will have an excellent chance of success. Why do you want to complicate things by doing bone augmentation when there is probably no indication for it?

  9. Staging the case is great advice. Reflect a flap, extract the teeth and thoroughly curette the defects. Placing a graft is prudent to help provide a scaffold for bone formation. You can use several different materials to successfully graft this case. However, I would disagree with the recommendation for demineralized allograft materials (Grafton, Regenaform). The “alleged” benefit of these materials is that BMP is made available to the site by demineralization of the allograft. The amount of BMP is so miniscule that it is debatable these materials are even osteoinductive. The lack of a significant mineralized component results in a softer quality bone upon healing. You are much better off with minerialized bone allograft (Puros, MinerOss) or TCP (which has a fast turnover). You do not need a barrier membrane in a case like this unless the defect has multiple missing walls or is not “space making”. There should be enough bony walls in this case to contribute to the bony incorporation. In addition, mobilizing a flap for primary closure is not necessary and only causes more postoperative pain and swelling. Contrary to a previous posting, if a collagen membrane is not covered by soft tissue (becomes exposed) it will not serve as a barrier. The collagen has been found to prematurely break down when exposed and loses its barrier function. You can use a collagen product such as CollaPlug to cover the graft as it will stabilize the blood clot and resorb. Antibiotic coverage can begin one hour prior to surgery and continue for one week (17 days is much longer than needed – if you have ever had a patient develop a C. diff infection or antibiotic colitis from prolonged antibiotics it is debilitating). You can re-enter in as little as two months for implant placement but the graft will still be turning over. Waiting four months will result in a better quality bone that provides favorable implant stability.

  10. Clearly, even if the extraction totally collapsed, there should be at least 10 mm away from ID canal. Why do we bother to graft?? I can say, if the graft is infected, it would be even a bigger tragedy.

  11. [Amended] Clearly, even if the extraction sites totally collapsed, there should be at least 10 mm away from ID canal and 8 mm away from sinus. Why do we bother to graft?? I can say, if the graft is infected, it would be even a bigger tragedy.

  12. K.I.S.
    Extract. Do not over qurate. No antibiotic needed.
    Wait 6 weeks. The longer you wait the more bone you loose.
    Place implants at gum level. No flap,no grafting
    DO NOT PLACE PARTIAL DENTURE OVER THE IMPLANTS

  13. Take Dr M`s advice, which co-incides with mine.A two stage approach, each stage with 95+ success rate, delivers each time not more than a 5 % failure rate (fairly acceptable). One stage-probably will get you with 20% chance of peri implant bone loss, or infection, or both, meaning that you can`t control the process. Go slow-one step at a time, these are not cases for immediate placement. I would extract, curette thoroughfully, use a round bur (if curette can`t remove all soft granulated tissues), rinse with copious amounts of saline, probably with AB (metronidazole, or similar), graft the site with xenograft (biooss or B-TCP), whatever you like, place a colla-plug on top, taking care to have it richly soaked with patients own blood from the wound margins and suture around it (horizontal mattress to stabilise the coagulum)-preferably with PTFE sutures (monofilament). I take care to prevent saliva from contaminating the plug, before blood comes in first. Put the patient to per oral intake of Amoxicilline 1000/day (if not allergic). Prescribe copious home rinses with salty water every 1 hour for the first 2 days. NO SMOKING. If god willing, and if patient complies you should have a fast healing coagulum- the best barrier against epitelium ingrowth and bone loss.
    After 4 months when ou have enough mineralisation for primary stability, proceed to implantation and graft(if needed)
    Best of luck,
    Dr Dimitrov

  14. Love dentistry ,two threads on essentially socket grafting , multiple solutions and they are probably all “right” as they work for us.
    Thankfully we do not decide foreign policy !!

  15. A few comments.
    ALWAYS, when you take out teeth, do some sort of socket preservation or augmentation. Whatever soft and/or hard tissue volume you preserve is cheaper in terms of patient cost and site morbidity than if you have to perform a ridge augmentation at a later date.
    Like Dr. K, I use a lot of Regenaform. I don’t agree that it turns over any faster than TCP (depending on which TCP you use) in a site. Whatever material you use, be sure that you protect with a barrier and follow healing radiograhically to determine the best time for implant placement.
    Using some sort of growth enhancer, ideally BMP or PRF will help you as well.
    Dr. M – TCP is not a xenograft. There is NO literature advising or even studying the use of irrigation of sockets with antibiotics in terms of elimination of bacteria. There’s more literature on the use of lasers (see Dr. Robert Miller of Florida) in those instances. With large lesions missing buccal plates, 4 months is VERY EARLY for reentry into a TCP-grafted site. There will be minimal to no turnover of the graft in that time period. And yes, I’ve done extensive clinical and histologic research on TCP’s (2 papers published, 1 in Titanium, the other in Compendium).
    Good luck on the barrier that Dr. K suggests – Ossix is the best but has been off the market for years.
    Don’t forget – deal with the upper 3rd molars and give the patient some sort of occlusal stabilizing device to keep the other teeth from shifting and getting traumatized as the bite will tend to collapse.

  16. This chap’s upper third molars look very likely candidates for the rubbish bin, and he’s got large holes in both right second molars and his lower left third molar. He also appears to have an anterior open or incomplete overbite. So what’s the point in replacing just three teeth, two of which will be unopposed, with implants? I agree with Drs Berne and Ljungburg. Just keep it simple – remove the upper left and both lower first molars, the lower left second molar and possibly both upper third molars (although they are worth conserving if at all possible). No need to curette the sockets or poke any foreign materials down the holes and no indication for antibiotics. Then sort out the other teeth and get his oral hygiene into shape.

    Two to three months later place enough implants to give him a functioning dentition. Job done.

    Many of the contributors to this site seem to be obsessed with technology where it isn’t needed. Even this little thread has recommended: a CT scan, Poldine, Easygraft, Regenaform, Grafton, B-TCP, Ossix, Doxy, BMP, PRF, Puros, MinerOss, Collaplug, BioOss, metronidazole, amoxicillin and a laser. There must be a message in there somewhere.

  17. I agree with Dr. Horowitz, always do socket preservation when removing teeth when implants are are planned. There are several good bone grafting materials and a couple of membranes suitable for this type of grafting. My preference is BioMend or BioMend Extend.

    Remove the teeth and debride the socket, wait for healing and some condensation of the graft, then place the implant. The length of time to wait will be dependent on the size of the defect and the number of bony walls.

    Antibiotic coverage should be employed. Antibiotics should be started at least several hours PRIOR to the surgery so the blood levels are high and all tissues have been well perfused. Starting antibiotics after the graft has been placed means the antibiotic will not be IN the graft as well as if it had already been in the blood and mixed with the graft.

  18. As an admirer of Dr Horowitzs work and his knowledge of BTcP , he will know how much the material can be varied (porosity , paritcle size and shape and whether mixed with other materials such a Caso4 ) as well as the variation in Patient physiology can change the rate of bio-absorbtion . Whilst I have only worked with these materials for the last 8 years including some development work , I routinely place at 4 months and load in a further 3 months when socket grafting.
    When repairing large defects at the time of placement we load at 3 to 4 months in line with bone regeneration to utilize an earlier re-modelling.
    I have numerous photographs of sites showing this turnover again this is using a BTcp which is in a Caso4 matrix with an added negative Zeta Potential which may upregulate the bodies response.
    Peter

  19. Just to update my my entry of February 2nd 2011. I would like to add BioMend, BioMend Extend, and finally the big one – BTcP in a Caso4 matrix with an added negative Zeta Potential! – to the list of crap you can shove up a tooth socket.

  20. i am a periodontist from india doing substantial number of GBR cases usin PRF & tricalcium phosphate . i would be very greatful if dr horowitz or any of the senior clinicians would elaborate more on the ideal particle size of TCP to be used for optimal results since here in india wehave particle sizes varyin from 250-350microns which i have difficult to handle , 500micron & 500-1000 microns which take more than 8-12 months to resorb and get replaced with host bone

  21. It is not the particle size but rather the porosity and crystallinity of the bTCP that determines resorption time. Micron size is site optimized, with the smaller sizes used for periodontal defects and larger sizes for bone and sinus grafts. Longer resorbing TCP is primarily used in orthopedics while the faster resorbing is used for dental. Check the specifications of the material you are using for the most appropriate parameters.
    RJM

  22. Dr. Miller Knows that I am one of his biggest fans and a serious admirer of his deep knowledge but I would like to make sure what he meant by the previous comment.Is that what he says? “The larger non-porous particles of bTCP get resorbed sooner than the smaller porous particles”.Is that right or I am misunderstanding the whole issue? C’est vrai ?

  23. Any TCP graft material should have porosity, regardless of particle size. The greater the porosity, the more quickly the graft will resorb. In an extraction site or sinus graft, I prefer a higher porosity graft. In an onlay graft, I prefer less porosity to delay resorption and maintain volume more predictably. The choice of particle size is really related to the volume of the graft area. In a periodontal defect, you will have a difficult time placing 500-1000 micron graft particles. In a sinus graft, the larger particle size will create larger inter-particle spaces, enhancing early angiogenesis. Mehdi, a la conference dans septembre.
    RJM

  24. I would like to ask Dr.Miller what is the mechanism of Tcp resorption? is it dissolution or osteoclastic activity?

  25. Cell-mediated resorption is regulated by osteoclasts while solution-mediated resorption is regulated by tissue pH. There is no way to single out one mechanism or the other in graft turnover as both processes are ongoing at the same time. The predominance of one over the other is directly related to chemistry; porosity and crystallinity. The higher porosity and lower crystallinity grafts (i.e. aTCP and bTCP) favor cell-mediated resorption. The lower porosity and higher crystallinity grafts (i.e. HA) favor solution-mediated resorption. I prefer cell-mediated graft turnover as it keeps the pH closer to physiologic neutral. This favors osteoblast metabolism and faster production of provisional matrix.
    RJM

  26. It is not a prosthetically driven treatment plan, because any surgical suggestions are not consider a future occlusion factor from possible anthogonists.

  27. Regeniform is 95 percent mineralized allograft which is not resorbed by any process. Neither is any mineralized allograft. Check out figure 16 and 17 at http://cde.dentalaegis.com/courses/4498 and you will see no resorption or resorptive cells at 7 months in this recent publication. I don’t know of any granular HA graft material that is resorbed by any process either. I do not believe that solution-mediated resorption exists in normal or healing connective tissue with a granular graft material. I would like to know if any proof of solution-mediated resorption is in the literature other than Tulsa Dental advertisements. If you are interested in the resorptive process and rate of resorption of one bTCP product the histology is available at http://www.steinerlabs.com/osseoconduct-granules.shtml. If you look at the failures posted on Osseonews many of them are a result of placing immediate implants in sites like this case. I suggest you remove the teeth and graft the sites to maintain volume and bone vitality. Place your implants according to the resorption rate of the graft material. In my opinion the graft should be at least 50% resorbed before implant placement.
    Greg Steiner Steiner Laboratories

  28. If you look at an endodontically involved tooth that suddenly develops a fistula, the bone loss through facial plates and cortical bone is certainly solution mediated resorption. There is no way that osteoclasts can work that quickly to produce extensive bone resorption. Localized infection will produce a considerable drop in pH. And, the last time I checked, bone is HA.

  29. To Dr. Miller
    The mean pH of pus is 6.68 ± 0.324 with a range between 6.0 and 7.3. The pH in the resorption lacune of an osteoclast is between pH 5-6. It does not seem like a pH above 6 could cause rapid bone resorption but you could be correct. I don’t know if anyone fully understands the mechanism of rapid bone loss. However, when it comes to granular bone grafts I have never seen evidence of solution-mediated resorption. I apologize to Dr. H for getting so far off track and to the readers who are bored by our trivia but I hope some enjoy the discussion.

  30. Thanks for the responses Dr.M &Dr.S the discussion is not boring at all. but I have some comments. for DR.MIller Tcp resorped more faster than HA,this means that TCP resorped by dissolution & HA by cell mediated osteoclasts and this vice verse what you mention.
    also for Dr.Steiner there is evidence of bone graft material resorption by dissolution in vitro experiment.

  31. On the contrary: lowered pH helps to break down the high porosity, low crystallinity graft materials more quickly. This allows phagocytic activity on the part of the osteoclasts resulting in the quick graft turnover that you see. As a result, bTCP’s resorb at approximately the same rate as autogenous bone is forming. The opposite is true for xenografts. There is no porosity of the granules and the crystallinity is so high that the acidic pH the body is able to develop is insufficient to start the resorptive process. No initial breakdown by solution mediated resorption – no osteoclastic activity. Resorbable HA’s are in the middle range.
    RJM

  32. In the article published in the British journal of bone & joint surgery 2010, Vol 92-B, Issue SUPP_I, 92.
    it was concluded that the resorption mechanism of HA and β-TCP was different than each other in vitro study. The coated β-TCP was degraded mainly by dissolution , on the other hand, the HA was resorbed by osteoclastic activity

  33. Our histology shows osteoclastic resorption of TCP particles. Plenk, Lederer (2005) also show three-dimensionsal resorption via osteoclasts. But remember what I had posted earlier. BOTH pathways are occurring concurrently. If you have an implant impregnated with calcium phosphate, the primary mechanism will be solution-mediated resorption as there are no porosities for the osteoclasts to enter. If the TCP is primarily granular, osteoclasts can be seen lining up on the borders of the granules, internally and externally. The greater the crystallinity of HA’s, while you can see osteoclasts lining up at the borders, the longer it takes to resorb. I guess we can split hairs in a rhetorical discussion as to what constitutes solution vs cell-mediated resorption, under what conditions it takes place (infection vs normal bone remodeling), or the time frame during which it takes place. But it is clear that both pathways are responsible for bone (or graft) turnover.
    RJM

  34. To Drs Barghash and Miller thank you for your informed comments. I will keep an open mind about the subject of solution-mediated resorption. Can you please give me the title of the article from the Journal of Bone and Joint surgery so I can review it and get back to you. Thank you. Greg Steiner

  35. Beta tricalcium phosphates undergo reabsorption via dissolution and fragmentation over a 6–18-month period. Ceramic HA preparations are resistant to reabsorption in vivo, which occurs at a rate of 1–2% per year. However, non-ceramic HA is more easily reabsorbed in vivo and so, can be used as self-setting cement. A minimum pore size of 45–100 µm is needed for bone ingrowth into porous ceramics. Pores of size 100–150 µm provide a more rapid ingrowth of fibrovascular tissue, thus making the reorption-replacement faster and easier process.

  36. To Dr. Jafari
    Your comments are correct for older B tricalcium phosphate granules but not all. Our bTCP that was FDA approved in November has much smaller pore size than you have listed but is resorbed much faster. We wanted a granule with micropores to prevent bacterial invasion into the granule and subsequent graft failure but a rapid resorption rate. There is no solution-mediated resorption but only cellular-mediated resorption with our granules. Monocytes (phagocytes)line the granules early on and when bone arrives osteoclasts begin work. In three month our granules are approximately 50% resorbed and in 6 months completely resorbed. We have manipulated other factors to keep a small pore size but rapid resorption. The resorption histology is available on our OsseoConduct web site. Greg Steiner Steiner Laboratories

  37. the name of the article in the British journal of bone & joint surgery 2010 ( RESORPTION MECHANISM OF HYDROXYAPATITE AND SS-TRICALCIUM PHOSPHATE COATING ON TITANIUM SURFACE)
    if we claim that Tcp does not get the chance of osteoclast activity because it is not in the granular form rather coated on implant surface as in the experiment, How osteoclast was able to do this to the HA which was also coated to the implant surface?

  38. The HA’s that are used on implant surfaces today are approximately 97% crystalline, making them on par with xenografts. Hard to have osteoclastic resorption when they are this dense and hard. And, just because you see osteoclasts lining up on a surface, it does not mean there is an active resorptive process. There are over a dozen different types of calcium phosphate materials. While HA implant surfaces are closer to pure phase, most alloplasts are mixtures of different phases. This means that you can have solution-mediated resorption of one part and osteoclastic breakdown of the other. Hard to make a definitive statement on the mechanism of resorption under these circumstances. And, as Dr. Jafari mentioned, where is the peer reviewed literature on the studies mentioned. I place little credence on corporate driven studies.
    RJM

  39. For Dr.miller
    my comment on resorption mechanism Tcp was on response to your post march 22ed sate (The higher porosity and lower crystallinity grafts (i.e. aTCP and bTCP) favor cell-mediated resorption. The lower porosity and higher crystallinity grafts (i.e. HA) favor solution-mediated resorptionying( which is opposite to result stated to referring paper study.
    I do agree that there is no one way mechanism for resorption and it is multifactorial effect.

  40. Dear Gentlemen;
    Here’s just some helpful literature. I,Personally,have only read the abstracts.

    (1): The resorption of nanocrystalline calcium phosphates by osteoclast-like cells.
    Detsch R, Hagmeyer D, Neumann M, Schaefer S, Vortkamp A, Wuelling M, Ziegler G, Epple M.
    Acta Biomater. 2010 Aug;6(8):3223-33.
    (2): Proinflammatory and osteoclastogenic effects of beta-tricalciumphosphate and hydroxyapatite particles on human mononuclear cells in vitro.
    Lange T, Schilling AF, Peters F, Haag F, Morlock MM, Rueger JM, Amling M.
    Biomaterials. 2009 Oct;30(29):5312-8.
    (3): Osteoclastic resorption of calcium phosphate ceramics with different hydroxyapatite/beta-tricalcium phosphate ratios.
    Yamada S, Heymann D, Bouler JM, Daculsi G.
    Biomaterials. 1997 Aug;18(15):1037-41.

    Thanks.

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