Bone Grafting Materials and Techniques Update

1 Dental Management Coalition Annual Conference July 21, 2008 Port St. Lucie, Florida bone Grafting and Implant Dentistry Update Jeffrey L. Turchi, DDS. Director of Educational and Clinical Affairs Senior Product Manager J. Morita USA. Irvine, CA. Objectives Understand the evolution of bone Grafting Techniques and Materials Identify the different types of bone grafts, their characteristics, and the benefits/risks of each Overview of the latest trends in implant hardware and the technology for diagnosis and planning My Background History- UCLA. Teaching Credential Program- CSU Dominguez Hills University of the Pacific, AAD SOD.

2 18 years private practice 3 years with J. Morita USA. Member ADA, CDA, OCDS, AO, IADMFR. Family of dentists Motivation . What is a bone Graft? Historically, bone Grafting has consisted of: A surgical procedure to harvest the patients own bone from a secondary site Utilization of an organic or artificial material to replace missing bone bone Grafting - A Brief History 1668- Dutch Surgeon, Job Janszoon van Meekeren: Described the use of canine bone to repair a cranial wound Who did it? Did it work? Russian church The amazing Dr. Van Meekeren??? Thanks, destructive nature of warfare in the 20th century bone Grafting Today Surpassed only by blood transfusions as the most transplanted human tissue 7-10 days of antibiotic coverage is routine with all bone Grafting Techniques bone Grafting has become a very hot dental topic bone Grafting applications Socket preservation Periodontal defects Third molar extraction sites to support 2nd molars Ridge augmentation Defects following cyst removal / apicoectomies Sinus lifts Distraction osteogenesis Nerve repositioning IMPLANT DENTISTRY!

3 !! Why Preserve the Alveolar Ridge? bone loss is continuous and inevitable Chewing pressure from roots or implants stimulate bone cells Alveolar bone in edentulous areas resorbs to 1 mm per year Why Preserve the Alveolar Ridge? Dr. Jon Suzuki, Director Post-Graduate Periodontics at Temple University: placing some type of graft material in the socket following every extraction is rapidly approaching standard of care status.. Characteristics of Graft Materials Most bone graft Materials fall into two main categories: Osteoconductive: A framework for new bone to grow into at its normal healing rate.

4 Osteoinductive: Stimulate bone to grow at an advanced rate. Most have added ingredients, (Growth Factors or bone Morphogenetic Proteins). Types of bone Grafts Autografts Allografts Xenografts Synthetics Autografts Also referred to as autogenous or autologous . grafts. Source: patient's own bone , usually harvested from their palate, hip, chin, or pelvic crest. Gold Standard . Autografts Pros: contain living elements for bone growth, no risk of rejection Cons: requires a second surgery, not recommended for patients with low bone density Allografts Human bone , usually harvested from cadavers.

5 Risk of morbidity and mortality due to poorly screened sources April, 2008: California DPH required a separate license if a dental office stores an allograft for more than 24 hours. Commercially available allografts: - DFDB by Biomet - Puros by Zimmer Dental Allograft examples DFDB crystals (Biomet) Puros block (Zimmer). PBS- Masterpiece Theater Alistair Cooke (1908-2004). PBS- Monsterpiece Theater Cookie Monster (1969-????). Alistair Cooke body snatch leader pleads guilty (March 19, 2008 London Telegraph). The leader of a body-snatching network which stole the bones of the broadcaster Alistair Cooke and illegally plundered more than 1,400 other corpses between 2001-2005 has pleaded guilty.

6 Dr. Michael Mastromarino, the head of Biomedical Tissue Services, made more than $ million by selling the body parts to about 20,000. transplant recipients throughout the US, Canada and Europe. Funeral home owners in New York, Pennsylvania and New Jersey were paid $1,000 for each corpse to harvest bones, skin, arterial valves, ligaments and tendons - some of them diseased. Mastromarino, a 44-year-old former oral surgeon, (whose license was suspended prior to running BTS), was convicted and will spend 18-54. years in prison. More than 900 civil law suits have been filed against him.

7 Faux bone ???? Xenografts bone or other tissue from animals, usually bovine or porcine Must be manufactured in a specific manner to ensure sterility and biocompatibility Most Materials act as a scaffold for new bone to grow into at its normal rate. Some examples include: BioOss by Osteohealth PepGen15 by Dentsply Xenograft examples Powder (minerals of bovine bone ) and sterile saline Bio Oss (Geistlich). Xenograft examples PepGen P15 (Dentsply). Powder (Collagen, Bovine minerals &. synthetic analog of a peptide chain) Liquid (Sterile saline). Synthetic (Alloplast) Materials Alternative Materials to avoid the drawbacks of autografts or allografts Examples include coral and TCP.

8 Very little risk of morbidity or mortality Some are non-resorbable and act as replacement bone Others are resorbable frameworks or scaffolds for bone to grow into at it's normal rate Some commercially available products are: Bioplant by Kerr Dental Gem 21S by Osteohealth. Examples of Alloplasts B-TCP. granules Polymethyl MA + Polyhydroxyethyl MA rh-PDGF solution (Platelet Derived Growth Factor). Bioplant (Kerr) Gem 21S (Osteohealth). BMP's and Growth Factors bone Morphogenetic Proteins: Discovered 1965 Dr. Marshall Urist UCLA. Found in human blood and bones that stimulate osteoinduction 20 have been identified, 2 have FDA approval for use in bone Grafting (2 & 7).

9 Extracted from human tissue or fabricated in the lab Interact with receptors on surface of bone cells Expensive, but stimulate bone to grow faster Suspicion of carcinogenicity? (June 2008 Journal of American Academy of Orthopaedic Surgeons). BMP's and Growth Factors Products containing BMPs: Infuse: (Medtronics Corporation). OP-1: (Stryker Biotech). Accel Connexus: (IsoTis Orthobiologics). Accel DBM 100: (IsoTis Orthobiologics). Grafton DBM: (BioHorizons). Regenafil: (Exactech). BMP's and Growth Factors Platelet-derived growth factor (PDGF): One of numerous proteins regulating cell growth and division Role in embryonic development, cell proliferation, cell migration Stimulates bone to grow faster PRP.

10 Platelet Rich Plasma Centrifuge technique Platelet functions: Hemostasis Scaffold for tissue regeneration PPP. Increase level of GF's PRP. Attract stem cells Barrier Membranes Are there other Grafting options? YES!!! Collagen-based products are also now available. FOUNDATIONTM. Collagen-Based bone Filling Augmentation material for Use in the Filling of Extraction Sockets What is Collagen? Insoluble, extra-cellular protein found in all animals Most abundant protein in the human body Essential component of all connective tissues such as cartilage, bone , tendons, ligaments, and skin The History of Foundation Terudermis Teruplug (approved in Japan 1993-skin Grafting ) (approved in Japan 1997- dental).