Infected Site and Bone Graft

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Dr. Y., from California, asks:

My patient presented with buccal abscesses at both maxillary central incisors for 1 year (root canal treatment were done 8 yrs ago). I am planning to replace the two upper central incisors with dental implants. Upon examination, buccal bone was resorbed and bone graft is a must in order to proceed with dental implant placement.

Which grafting technique and time frame should I use? Should I graft immediately at the time of extraction or should I graft 2 months after extraction? Should I do a buccal onlay bone graft fixed with screws, bone particulate fixed with membrane (which type of membrane? collagen, titanium, Goretex…), or even no membrane? Any suggestions?

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7 Responses to “ Infected Site and Bone Graft ”

• GC March 13th, 2007

  
  

  dear colleague, in such a situation i would recommend that you wait at least 6weeks before reevaluation of the site because the history of past infections on both roots suggest a poor potential for healing.
  as bone turn over takes about 6 weeks, you may expect healthy bone but probably not healed and previous alveoli filled with some woven bone.
  site evaluation could then be made using both clinical and radiographic exams so your bone grafting approach can be complete.
  most frequently , we find soft tissue deficiencies as well that need some treatment and according to the findings, you may choose to first soft tissue graft to get more tissues in order to provide in fine ample blood supply for the following bone graft.Use the techniques that give the best results in YOUR hands ( I think of avoiding techniques like GBR so sensitive even in expert hands…)

• Dr. Gerald Rudick, Montreal March 14th, 2007

  
  

  As commented above, it is best to wait 6 weeks before considering bone grafting following the presence of an infection, or after a currettage and citric acid wash to rid the area of granulomatous tissue. Allow the underlying area to clean itself out and start the healing process. Soft tissue approximation is very important in doing lamination or onlay grafting.

  In my experience,I find the best result for buccal grafting in the incisor region is with autogenous bone blocks harvested from wherever you can retrieve them. It is important that the grafted sections of bone are firmly screwed to the recipient site, and that a particulate graft mixed with PRP is incorporated to fill the spaces, much the same as mortar is used in brick laying.

  The frustrating thing about the process, is that more often than not, regardless of the suturing technique used, the approximated soft tissues over the grafted site will open, thus causing an intraoral exposure.

  I have used various membranes, titanium mesh ( with and without a covering membrane) and found that very shortly after suture removal, the gingival tissues will pull apart, exposing what you hope is the newly formed osteoid tissue, and not a sandy loosely mixed graft that will disintegrate.

  In our office, after the tissues pull apart,and after healing about 6 weeks, we may see a chunk of the block section exposed. 4-6 months later, the site is flapped open, and we see that the block graft is growing, and what was exposed, is like loooking at an iceberg, with 90% of the block firmly attached and vascularized, and the 10% exposed section just resting there ready to cut off.

  Titanium mesh is wonderful to “tent-up” the gingival tissue over the graft, but it does become exposed. Patients are instructed to keep the exposed mesh clean by gently scrubbing it with a Q-tip soaked in Peridex. The underlying Osteoid seems to grow uneventfully under the mesh and vigorous oral hygiene will keep infection at bay.

  Regardless of the membrane used, in my opinion, exposure almost always occurs,and that grafts attract bacterial plaque….. remembering that some growth is always better than no growth. It is not unusual to have to go back a second or more times to enhance and bulk up with followup grafts to attempt to achieve the desired result.

  Gerald Rudick dds, Montreal, Canada

• MHA March 14th, 2007

  
  

  Dear Y,
  The aesthetic zone is difficult area to treat .From your discription this case is more challenging than average. I am uncertain about the level of your experience . But from the way the question is posed ; my humble advice is to go on a lengthy course on bone grafting where all such problems and their management are discussed. Otherwise you may end up with an unhappy patient.

• ramesh March 14th, 2007

  
  

  dear y,
  i agree with the above sugestion that you go for extraction and debridement of the socket for any granulation tissue and then place the graft and close and and leave it for 3 months and then you can go for the placement of the implants. meanwhile as the extractions are done in the esthetic region(anterior )you can give a bride with wings on the lateral(maryland)

• RK March 18th, 2007

  
  

  An understand of wound healing and surgical technique are the only two prerequisites to helping you solving this situation. The infected site is acutely inflamed and therefore the healing process is amped up to happen once the source of infection is removed. The concept of intermarrow penetration is to accelerate the healing process that you have here occurring “naturally.” I almost always do the bone grafting at the time of tooth removal.

  Next comment is about the biomaterials. I have had very good results using particulate materail(Bio-Oss mixed with calcium sulfate. This is covered with a resorbable membrane(Ossix plus). The flap must be agressively released so as to have primary closure without tension, not some tension. Then suture with something like Gore Tex or some long lasting resorbable material(Vicryl). Leave the sutures in as long as they are helping to keep the wound closed. If there is any exposure, a resobable membrane is very forgiving.

  If the bone healing is insufficient for the needs which is almost never the case, additional grafting can be done either as a stand alone procedure or with the placement of the implant fixtures.

• site » Comment on Infected Site and Bone Graft by Dr. Gerald Rudick, Montreal April 1st, 2007

  
  

  […] Original post by unknown […]

• Dr SDJ May 12th, 2008

  
  

  I was planning to go ahead with some bone grafting/Tissue grafting courses. But nothing seems very encouraging here! My first attempt to graft autologous + TCP on a dehiscence came to a naught after the Ti mesh exposed on the 10 th post operative day, and my instructor advised me to remove the graft and implant both!

  I am curious to know what percent of patients really benefit from bone grafts (apart from Sinus graft which is a closed space).

  If the grafts don’t work out often then they are in an experimental stage in dentistry and most of us are just shooting in the dark!

  God save us!

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