Bone graft failure: any ideas?

tissue appeared healthy for the most part at the 3 month appt. slightly inflamed around 22 and 27 due to what I assumed was some light plaque build up.

patient had a flipper. was instructed not to wear it and she stated she did not

Im afraid/embarrassed to say I panicked. I curetted the sites, added the same graft material and membrane and closed. same med regiment. Its been about one month since the second procedure. Nervous as heck about seeing the same result. thank you everyone for the responses!!

You may want to revisit the site and degranulate and decorticitate. I use a thin laboratory acrylic bur. it is about the width of a .22 cal bullet. I use this to remove all soft tissue inside the socket, next detoxify with tetracycline for 3 minutes by the clock, irrigate with saline, now decorticitate with a 557 surgical bur on the lingual aspect of the socket. In Europe they recommended to chop up most of the lamina dura. I like to at least preserve the mesial and distal portions of the lamina dura. This way you can check on the radiographs when the lamina dura has disappeared. This denotes about the same time when the graft has turned over. Yes use a resorbable membrane. If the patient has some sort of sucking habit, they could of sucked out the graft material and then you will get fibrous tissue ingrowth. Don't feel bad, we all have had a learning curve. I like to use OsteoGen for the particulate graft material. I would change the antibiotic. Think about Ceftin 250 mg 1 tab BID

thank you for responding. will look into your suggestions further.

dynacore allograft 70:30 Cort/Can and dynamatrix.

thank you. what is your materials of choice for these instances?

Any human cortical/cancellous two brands I like are Maxxeus and Allosorb, the price points are good.

Great post, I like the humor. I would just be careful with the comparison to orthopedic healing of long bones which are different in regards to osteointegration in the oral cavity. I feel dental implants need to be fixed during osteointegration but that is my take.

thank you for your response. what is your materials of choice for these instances?

so in other words, extraction, bone grafting and primary closure only? ive used oraplugs where i cant obtain primary closure-thoughts? could you relay your materials of choice in this situation?

HI CRS , agree morphologically more like a pelvis ...... But Histologically and physiologically bone is bone unless there is a non resorbable remnant material , then it becomes ''bone like " . There is a lot of research done with Osstell showing some very interesting things about how fast integration ( merely healing of the bone close to an Implant ) can be . As to even primary Stability actually not necessary again only if certain graft materials are used which fully turn over . Have 50 or 60 cases all well recorded with Osstell , just need time to write it all up as starting another animal study next week . Regards Peter

thank you for your contribution

Hey Robert, quick question I use decadron routinely it wears off in about three days. Can that effect bone resorption over the course of several weeks? I give it for soft tissue swelling after surgery and patient comfort. I like your post, but I don't use antibiotics with my graft either. As always could you post some resources? I like the thought process in your post and and open to learn more. Thanks

THANK YOU FOR TAKING THE TIME! Curious as to why you would extract three teeth with “no periodontal issues or bone defects”? But assuming there was a valid rationale, let’s pose the following questions:ANSWERED BELOW 1. Following extraction, was there bleeding from the osteotomies? GOOD BLEEDING DURING. PRIMARY CLOSURE, NO BLEEDING UPON RELEASING PT. PT DID NOT NEED THE GUAZE. 2. If the bleeding index was poor, did you decorticate the walls of the osteotomy prior to placing the graft? I DID, BUT PERHAPS NOT VIGOROUSLY ENOUGH? I REMEMBER THINKING I SHOULDVE BEEN MORE AGGRESSIVE BUT I HAD SUFFICIENT BLOOD, IN FACT I USED IT TO MIX THE GRAFT INSTEAD OF SALINE. 3. What type of graft did you use and was it of high or low crystallinity? What is the recommended resorption time? DYNACORE ALLOGRAFT 70:30 Cort/Can and DYNAMATRIX MEMBRANE... CRYSTALLINITY? 4. Was there any tissue movement or microtrauma to the flap during healing? NO 5. Why did you use a corticosteriod immediately post-operatively, what was the dosage and for how long was the patient using it? If you want to interfere with the early inflammatory phase and resorption of the graft, then you chose the right drug. (2) 4 MG TABS. 1 THE DAY OF, 1 THE NEXT DAY 6. Why did use mix clindamycin with the graft rather than metronidazole and what was the dosage? CLINDAMYCIN 300MG X30 WERE GIVEN FOR PT TO TAKE ORALLY. I DIDNT MIX WITH THE GRAFT. I know I have been critical of these types of cases on this site in the past, and have received my share of “hate” mail after my posts, but this is just basic biology guys. Without a respect for basic pathways of healing, you can expect to see these results routinely. But these “empirical” cocktails have no longer have a place in implantology. Take a good bone augmentation course and get caught up with current protocols. NO HATE MAIL HEAR, I ASSURE YOU. JUST APPRECIATION

robert...define good bone grafting course...I feel there are so many it is hard to know which ones are good and which are not.

thank you for the link!

Thanks so much!

why would you assume that? I didnt think itd be relevant, perhaps I was wrong in not painting a clearer picture. my apologies. the patient was very crowded, with #24 being approximately 80% lingually displaced. #s23 and 25 had deep carious lesions extending subcrestally. extractions and a bridge between 22-27 was discussed but the pt was adamant that she did not want another bridge. ortho, endo, crown lengthening, cast post/cores, and crowns were given as a treatment alternative. Looking back, I was probably guilty of favoring (and relaying that opinion) extractions/implants as the treatment of choice, but the pt WAS given the aforementioned options.

Ok, thanks for the clarification. I'm not throwing stones. I was curious. I tend to favor the six unit bridge in these cases.

Unless theres an undisclosed medical issue, Im leaning towards this. I recall thinking I shouldve been a bit more aggressive.

thank you for your reply. ive debated on taking a phlebotomy course in the past. i may have to revisit this.