Infected Bone Graft: What is the Best Treatment?

Dr. S. asks:
I did a bone graft and the area has now become infected. I want to get some advice on this and similar cases, as my experience in this treatment is limited. If I place a bone graft into an edentulous site, like an extraction socket and the graft becomes infected, what is the best treatment? If I place a bone graft around an implant and the bone graft becomes infected, what is the best treatment? I am more interested in long-term success that is most predictable. But if conservative treatment options are available, I would like to try them first.

18 thoughts on “Infected Bone Graft: What is the Best Treatment?

  1. Did u prescribe prophylactic antibiotics? Whenever I graft I give the patient 2 gm of amoxicillin one hour preop and 500 mg tid for one week postoperative. I rarely get infections with this protocol. Try placing your patient on antibiotics and a chlorhexidine rinse at this point and monitor for supporation. If it persists you will have to remove the graft and re-attempt, preferably at a later date.

  2. New bone grafts have no blood supply. If there is no blood supply, antibiotics and topical rinses are useless. Infected bone grafts, especially particulate, need removal ASAP. The antibiotic will simply not get to the bacteria, and therefore be useless.
    This site should be conservatively opened, curretted, and irrigated. The site should be monitored closely. If purulence persists, the entire graft needs removal and you need to start again.
    The antibiotics here are of questionable value. There is simply no bio-availability where you need them.

  3. Aggresive curretage prior to grafting is necessary and then then use of a bacterio-static graft material will help but once infected remove the graft ASAP as is well stated by Sb oms. Further bone loss unfortunately can be the result so time is of the esssence.
    Peter

  4. dr. fairbaum-
    what’s your bacterio-static graft material of choice?
    do you consider a mineralized allograft hydrated in an antibiotic solution (liquid clindamycin) bacteriostatic?

  5. I personally don’t use it, but I’m familiar with some clinicians adding tetracycline (to create an acidic environment), some swear by it, not sure if it helps.

  6. BTcP and CaSo4 , product called Vital in Europe or Genex in US ( Spinal and Orthopeadic product ). Or Easygraft a BTcP product coated with a polylactide which has shown bacterio-static properties to Staf. Both are routinely used without the need for a collagen type membrane .
    Using Tetracycline may pollute the implant surface , infection is always an issue and can lead to nasty suprises so I assess each case prior to any decision on immediate placement.
    Regards
    Peter

  7. Please tell us the type of graft material used so we can consider how the infection occured and how to best resolve the problem.

  8. I use both the Clindmycin to hydrate the bone and systemic antibiotics. I also agressively clean the site before placing the graft ( currtte then a #8 round burr). As a result I very rarely have PO infection around these sites. The systemic antibiotics help kill the residual bacteria in the bone. Tx should be to eliminate all infected graft material at this point.

  9. when ever you have an infected bone graft, you should remove the graft up on my experience when the graft site infected it will not cure again & any delay in the removal of the infected graft my cause bone resorption , once i saw a patient with infected maxillary graft, which not removed the floor of the sinus has a complete resorption 7 the patient develop more complication & it was so har to graft abone later, so you should remove the infected graft& give bactericidal Antibiotic with monitoring the infected site.

  10. remove and replace with another bone graft. If it was a socket, probably left infected tissue and didn’t irrigate enough. If you used a non-resorbable membrane, stuff must have gone inside and caused the infection.

  11. I had that same problem before. Now I’m using non-resorble membrane on top of ext pocket with 3mm tugging on buccal and ligual with vicryl suture. So far so good. I believe ‘primary closure’ is the key.

  12. Sir,
    Instead of curettage or removal of the grafting material, I suggest that you begin to irrigate and disinfect the grafting site by 20 CCs of normal saline, three times a day for one week.I have been witnessing this strategy to be very effective.

  13. The problem with this question is the lack of qualification of the original presentation of the site. Is there suppuration or just pronounced edema/bleeding? Is the problem in the apical area of the osteotomy or at the tissue margins? Was there incomplete debridement of the extraction site pre-grafting or is the problem subperiosteal? Was the infection noted within days of graft placement or several weeks later? Each of these differences belies a different etiology and thus treatment of the problem. If the infection is subperiosteal, careful debridement and saline rinses, as Dr. Jafari has suggested, may be sufficient. If the infection is in the apical part of the graft area, nothing short of removal, definitive debridement, and regrafting will be adequate.
    RJM

  14. did you tri laser for steriling the area before your grafting>>
    see i will till you>> my first failure implant case was with bone grafting>> i remove the implant + grafted bone(there was unexpected bone resorbtion arround the grafted bone>>>
    then i currate the area +laser application+new implant+new grafted bone>>>>>> its work nicly>>

  15. I february there was bone graft placed in the lower jaw, the infuse bone graf thBMP-2, also dentist have placed I believe a membrane barrier, it has been 3 months since, and all the gums got opened and show some kind of material, since I am not a dentist i dont know what is it, but looks like that membrane, it is pushing my other teeth, to the point that all gums are flying around them. can anybody tell me if I can get an infection if my gums are so opened?

  16. Dear Dr
    I feel a good curettage and decortication of the defect site (it is important to induce entry of bone progenitor cells in defect area and literature supports available). You can go for autografts mixed with DFDBA in the defect site. Make sure the flap is properly approximated with the graft material not exposed to the oral environment, collagen membrane use wud b better. suture with monofilament material. Post op prescription of Chlorhexidine mouthwash.I agree with ‘Sb oms’ regarding antibiotics.Doxycycline can be prescribed for maintenance, however prophylactic antibiotic therapy is not an indication for bone grafts(atleast in the dose of 2gm,not encountered in literature)No question of graft mixed with antibiotics if defect site properly curetted.antibiotics mixed with graft may interfere with bone formation. U need to take care of infection seeping from the oral environment.
    Experts plz comment. Thanks

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