31 - Bone Grafts 1 - Hunter - DONE Flashcards
Should I do intramarrow penetration when I am doing grafting?
Yes you should.
Crea found OFD alone vs OFD + intramarrow penetration had 2x the radiographic bone fill in the mandible compared to OFD alone.
According to faculty as long the defect is bleeding on its own thats adequate. Faculty said it is difficult to do the amount and extent of intramarrow penetrations that they did here
What is osseous coagulum? What was the idea of using coagulum?
Robinson. Intraoral cortical bone dust that collects in the oral site while you are working. It mixes with the patients blood. Idea that autogenous bone is a readily available source if doing osseous surgery.
What is bone blending?
Diem.
When you put collected autogenous bone in an amalgam capsule and triturate it to decrease the particle size. Reported particle size is 0.2 mm.
Froum showed that this is better than OFD alone
What is the difference between defect resolution and % bone fill?
Defect resolution - takes into account crestal resorption as well as regeneration of bone
% bone fill - does not take crestal resorption into acount
Can you use intraoral cancellous bone as a graft for intrabony defects?
Hiatt showed the the maxillary tuberosity, healing extraction sites, and edentulous areas are viable sites of cancellous bone to use as graft material.
This bone did not do as well as iliac grafts in furcation defects only. Same result in vertical defects.
Talk about using a healed extraction site for a source of bone grafting in vertical defects.
Soehren gave recommendations in a review paper. Stated that the optimal time to enter the donor site is 6 to14 weeks post-extraction (depending upon any healing complications, where later is better). Gingiva over the site needs to be free of inflammation
First 6 weeks allow for clot retraction, clot reorganization and primary ossification. Based on clinical experience, the authors recommend 8 weeks for the maxilla and 12 weeks for the mandible due to the difference in blood supply. Harvest of the graft is accomplished by curettage of the socket contents with a Kirkland 13 and 14.
Evian (THIS WAS ASKED IN CASE PRES) looked at the histology of healing extraction sites to determine the optimal times to use it in autogenous grafting.
BL: 2 distinct phases of bone healing.
From 4-8 weeks, a very active osteogenic phase with many osteogenic cells and immature bone formation. After 8 weeks, osteogenesis slows down as the bone volume has increased and the bone starts maturing. By 12-16 weeks, the trabeculae are mature with little osteiod and few bone cells.
It is not known if it’s the osteogenic property or the “scaffolding” property is more advantageous for new bone formation. However, bone from the 8-12 week period contains elements of both.
Talk about using autogenous iliac bone grafts in vertical bone defects
Dragoo studied iliac bone grafts. He found that they do achieve regeneration. They are an osteogenic material because they have live cells in them. However, Dragoo detect root resorption at a 2.8% incidence. He said that it was associated with gingival inflammation and patients with meticulous home care would not have root resorption.
What diseases are human cellular and tissue donors screened for?
Tissues are screened for various bacteria and fungi, antibodies to HIV-1, HIV-2, HTLV-1, HTLV-2, HBcAb, HCVAb, and syphilis antibody.
In addition, testing is conducted for the HIV and hepatitis C virus as well as HBsAg (hepatitis B surface antigen.)
What type of processing does bone donor material go through? Does it take care of certain diseases?
DFDBA generally includes: soft tissue stripping, initial size reduction, initial cleansing and decontamination, microbiological treatment, freezing, dehydration, secondary size reduction, demineralization, buffering, final rinse, packaging, and terminal sterilization.
The process for FDBA is a little shorter as it does not include demineralization, buffering, or a final rinse.
These processing steps for DFDBA have been demonstrated to inactivate HIV, HBV, HCV, CMV and poliovirus.
What citation would you use to defend antibiotic use after bone grafting?
Sanders was looking at the results of FDBA in periodontal defects. T
Complete or >50% osseous regeneration was seen in 85% of grafted sites following the use of post-operative antibiotics (vs. only 38% of sites when antibiotics were not prescribed). For both groups, a significant difference in osseous regeneration was noted with antibiotics, intramarrow penetration and endodontically untreated teeth.
There was an apparent enhancement of the FDBA’s clinical success through the addition of autogenous bone for the treatment of 1,2 or wide 3 wall defects and furcation defects.
Can you use FDBA instead of DFDBA to treat periodontal defects?
Tsao says yes
Partial bone fill was obtained using mineralized bone allograft with and without GTR. Vertical bone fill was improved to a greater extent than horizontal bone fill.
Can you use mineralized cancellous bone allograft for periodontal regeneration?
Yes, Koylass found that that periodontal regeneration is possible using MCBA (mineralized cancellous bone allograft, PUROS) is possible.
Can I use cortical DFDBA to treat an osseous defect?
Mellonig
Cortical DFDBA shows bone fill in periodontal defects
Rosenberg came up with the threshold for success if greater than 50% bone fill
Do patients that have donor bone in them create HLA antibodies against the HLA-incompatible donor bone?
Quattlebaum
No, FDBA lacks clinically significant antigenicity
Can we achieve periodontal regeneration without using grafting material?
MEALEY said that the Bowers studies are very important
Yes, BOWERS found significantly greater regeneration of new attachment apparatus and individual tissues in a submerged environment compared to a nonsubmerged environment after scaling and root planing. WITH NO GRAFT MATERIAL
THIS IS A HENNAH STUDY
Will DFDBA enhance the amount of formation of a new attachment apparatus and component tissues?
IMPT - BOWERS HENNAH STUDY
There was a significant difference in the amount of new bone formed in DFDBA grafted defects vs no graft at all in submerged environment. In addition, more cementum formation occurred in grafted sites than in nongrafted, but the difference was not significant. Fibers of the PDL were more often oriented parallel to the root surface in grafted sites vs. both perpendicular and parallel in nongrafted sites.
Will DFDBA enhance the frequency of formation of a new attachment apparatus and component tissues?
IMPT - BOWERS HENNAH STUDY
There was a greater chance for regeneration of a new attachment apparatus in submerged, grafted defects vs. non-grafted defects. In grafted sites, new bone formation was observed coronal to the calculus reference notch in all sites. Nongrafted sites had more CT regeneration compared to the grafted sites.
Are root resorption, ankylosis, or pulp death common sequelae of grafting with DFDBA?
No - There was no evidence of extensive root resorption, ankylosis or pulp death in either type of specimen.
So if you have an intrabony defect how would you decide to treat it?
Bowers found that:
OVERALL, There is significantly more new attachment apparatus, including cementum and new bone, and a greater chance for regeneration of a new attachment apparatus in submerged intrabony defects grafted with DFDBA vs. nongrafted sites.
Do we have histologic evidence that DFDBA encourages reattachment?
Yes. Bowers found in studies that DFDBA had new attachment above the calculus reference notch either CT or JE. IN their studies *no new attachment was observed in any of the non-grafted sites
In grafting intrabony defects is it helpful to close the site with a soft tissue autograft to prevent apical migration of the epithelium?
Bowers found that No, free gingival grafts did not retard epithelial apical migration and did not enhance regeneration
Does smoking influence the long term outcome of intrabony defects treated with regenerative therapy?
Rosen found that Smoking was significant associated with a decrease in CAL gain and a decrease in PD reduction compared to nonsmokers
What happens to the DFDBA after healing in intrabony defects?
Reynolds and Bowers: In histologic studies 72% of the grafted sites still had DFDBA particles 6 months afterwards which were “amalgamated” within new viable bone.
Sites that had residual graft particles had significantly greater amounts of new attachment apparatuses than sites w/o residual graft
Is it helpful to add tetracycline to intrabony sites treated with DFDBA?
Masters found that there was no benefit gained by adding tetracycline to DFDBA when grafting osseous defects
Is using calcium sulfate as a barrier as beneficial as using an ePTFE membrane in treating intrabony defects?
Aichelmann-Reidy found that significant gains in attachment level and reduction in probing depth can be achieved using either calcium sulfate as a graft binder and barrier in combination with DFDBA or ePTFE as a barrier in combination with DFDBA. More recession occurred with the ePTFE.
How is DFDBA processed? Does it get rid of HIV? Has HIV ever been transmitted in bone grafting?
Mellonig study: 2 case of bone allograft and transmission of HIV in transplantation of unprocessed, fresh-frozen bone allografts.
The processing protocol by which demineralized freeze-dried bone allograft is made renders donor bone safe for human use by elimination of HIV.
Comments: General information to know for oral examinations (processing of DFDBA and particle size). According to this paper: bone is cleaned, ground to a course particulate, washed, and defatted with 70% ethanol. The particulate bone is then freeze-dried in a vacuum, and afterward are dried and further ground to yield a particle size of 90-500 micrometers.
Can DFDBA induce new bone formation?
Schwartz - Yes, it can induce new bone formation (osteoinductive) but it can vary greatly between donors
Other things to note: this study found that DFDBA particles were acidic (neutralization was incomplete) and that particle surface area varied widely by bank
What aspects fo the donor affect the osteoinductivity of a graft?
Schwartz found that the ability of DFDBA to induce bone was age dependent. At age 50+ there was a significant decrease in induction. Sex did not affect ostoinductivity
In patients with a history of bisphosphonate use (alendronate) who then become donors is residual bisphosphonate present in the donor tissue?
No, Hunter found that in DFDBA procured from people with hx of alendronate use did not show residual alendronate in the graft
However, only alendronate was studied. Did not look at other bisphosphonates
Is tricalcium phosphate effective?
• In intrabony lesions, CAL gain 2.6mm and PD 3-5mm
• Histologically, graft particles walled off by collagen, surrounded in a CT capsule with no osteogenesis . It is a non-irritating filler
Stahl, Froum 1986
Is porous HA effective?
• In intrabony lesions, CAL gain 2-4mm, PD 3-5mm
• Long JE, CT between graft. Some osteogenesis but not histologic evidence of new attachment
• Stahl, Froum 1987
• In a split mouth design of OFD vs OFD/HA (Periograf), HA lesions were stable at 5 years and resulted in a higher degree of clinical improvement in PD reduction and CAL gain
Yukna 1989
Compared FDBA vs porous HA
• In a split-mouth study w/ re-entry at 6-11 months, FDBA had greater osseous fill, CAL gain, PD decrease, and more recession
• HA is a filler with little evidence of osteogenesis
Barnett, Mellonig 1989
What does bioactive glass do and is it effective?
• It releases soluble silicon calcium, phosphorous, and sodium ions that leads to cellular responses at the interface of the glass and bone. When glass comes into contact with tissue fluids, a chemical reaction occurs on the glass to stimulate osteoblasts
• In a SR MA, bioactive glass has slightly better PD reduction (0.72mm) and CAL gain (1.18mm) and no difference compared to EMD/GTR
• Sohrabi 2012
• In furcations vs OFD, Perioglass BG had significantly greater PD reduction vs OFD alone
Anderegg 1999
Compare BG vs DFDBA
• In patient’s w/ paired osseous defects and re-entry, BG and DFDBA have comparable 6 month results for moderate to deep intrabony periodontal defects
Lovelace 1998
What is hard tissue replacement and is it effective?
• Polymethylmethacrylate (PMMA), polyhydroxymethacrylate (PHEMA), and calcium hydroxide. It is a non-resorbable, microporous, synthetic bone graft material
• In 1-2 wall defects, CAL gain 1.8mm.
• Particles surrounded by dense collagen and encapsulated. Mainly forms long JE without new attachment.
• Stahl 1990
• In mandibular class 2 furcations compared to osseous coagulum, HTR had better horizontal furcation fill and % furcation fill.
Yukna 1994
What is ABMP/P-15 and is it effective?
• Anorganic bovine-derived HA matrix + cell binding peptide 15
○ P-15 is a 15 AA residue w/ the exact homology to the AA sequence of the a1 chain of type 1 collagen. It is thought to bind fibroblasts and osteoblasts
○ ABM is produced by high heat, and doesn’t preserve the microstructure like Bio-Oss does
• When compared to DFDBA and OFD for 1/2/3 wall defects, ABM/P-15 had better clinical results for defect fill (72% vs 51% vs 40%)
• Yukna 1998
• When compared to ABM alone, ABM-P15 had greater defect fill (73% vs 50%) compared to ABM alone
Yukna 2000
Are bovine xenografts safe?
• Yes, according to German Federal Ministry there is effective processing and screening
• Sogal 1999
• Bovine spongiform encephalopathy cause Creutzfeldt-Jakob disease in humans, which is a fatal prior illness (proteinase-K resistance AA)
• Risk of transmission not quantifiable
Kim 2011
Compare BioOss and DFDBA
- No difference for intra-bony defects at 6 months
* Richardson 1999
Is Bio-Oss osteoinductive?
• Deproteinized cancellous bovine bone is decalcified and placed into mice for osteoinductivity testing
• Some osteoinductive potential and growth factors
Schwartz 2000
Is Bio-Oss effective for GTR?
• When paired w/ Bio-Gide for intrabony defects, Bio-Oss performed better than OFD alone
• 2mm facial PD reduction, 1mm lingual PD reduction, 1.5mm greater CAL gain, 2.5mm greater bone fill
• Similar results as allograft/ePTFE w/o need for membrane removal
• Camargo 2000
• In mandibular class 2 furcations, Bio-Oss better than OFD for PD reduction (1.7mm), CAL gain (1.2mm), and defect resolution (83% vs 43%)
Houser 2001
Who provided histologic evidence for Bio-Oss?
• 3/4 with regeneration coronal to apical calculus notch in intrabony defects
• Radiographic bone fill present
• PDL parallel more often when the volume of new bone was diminished
Mellonig 2000
Is BioOss Collagen effective for GTR?
• In intrabony defects, regeneration in 2/8 with long JE in 5/8.
• Regeneration is possible, no difference with or without a collagen barrier
• Hartman 2004
• In intrabony defects, complete new attachment apparatus with Bio-Gide limited to contained portions of the defects
• + BioGide, better with membrane
• Regeneration possible in 4/4 subjects
Nevins 2003
