The performance of a tissue is solely dependent on the health of that tissue. Bone is one of the most complex tissues in the body and is intimately affected by disease and lack of use or overuse. The maxilla and mandible are subjected to extremes of disease. Chronic inflammation of the gingiva, endodontic infections bore holes in the bone and exude infection and purulent exudate, periodontal disease that may persist for years harboring pathogens that destroy wide areas of alveolar bone, and the trauma of extraction that results in microfractures throughout the alveolus causing further alveolar resorption.
All this disease, trauma, disuse, and misuse commonly leads to bone of very poor health and vitality. With all the strain bone must endure, there is often no consideration of the health and ability of the tissue to support dental implants. This discussion will consider what can be done to regain the health of this tissue in order to support dental implants for a lifetime.
When a tooth is extracted without treating the surgical wound, it commonly results in poor mineralization and poor vitality. No other place in the body is a surgical wound left untreated. Even the slightest surgical intervention is closed and dressed in all of medicine – except for dental extractions, and the patient suffers both resorption and poor bone vitality. When a socket is not dressed and left to heal on its own, the health of the bone is compromised. The bone structure atrophies, loses its vitality, and becomes weak.
All implantologists have experienced poor bone during osteotomy preparation. You begin with your pilot drill and as you get further into the bone your drill falls into the mandible due to poor bone quality. Every implantologist has prepared maxillary posterior osteotomies with minimal drilling resistance. These sites have suffered from the disease and trauma that preceded implant placement and exhibit very poor vitality that will affect the degree of integration and the long-term success of the dental implant.
The following cases demonstrate how D4 bone can be treated and converted into D2 bone during implant integration.
Improving Bone Health
This molar was extracted years prior without complications and left to heal on its own without treatment. Notice the thick alveolar crest (white and black arrows). This thick bone is indicative that there is poorly mineralized cancellous bone below the crest. The alveolar crest is normally not composed of cortical bone. Cortical bone at the alveolar crest is a response to poorly mineralized cancellous bone below it as identified by the red arrows.
This is a low power of a trephine core sample of the underlying cancellous bone. This poorly mineralized bone will give very little drilling resistance.
A mid power view shows the tissue is not composed of cancellous bone but fat cells. Fat cells are never normally found in the maxilla or mandible and signify bone pathology.
A high-power view shows a cluster of inflammatory cells. Some dentists call this bony lesion a cavitation. Other dentists say cavitations do not exist. Irrespective of the terms applied to this lesion, it is obvious that this bone is not suited to support a dental implant.
With the advancements in bone graft technology available today, this bone can be regenerated while the implant is integrating. After the osteotomy is prepared, BioDensification™ is injected into the osteotomy. The implant is then placed into the osteotomy. During implant placement, the graft material is forced into the surrounding fat and bone formation is stimulated through the process of osteogenesis.
Three months after implant placement and treatment with BioDensification, the fat has been converted into healthy vital bone. Now that the cancellous bone has been regenerated with no more fat content, it can now fully support an implant. Notice the thick cortical bone that was found on the crest has been remodeled into normal healthy crestal bone.
How does SteinerBio’s technology improve bone vitality?
The first molar is scheduled for extraction. Note the position and shape of the interradicular bone.
Day of surgery. The socket is grafted with Socket Graft Plus.
4-months after grafting, a core sample is taken directly over the preexisting interradicular bone as outlined.
This is histology of the bone that grew over the top of the preexisting interradicular bone. The crest is on the right showing healthy vital bone with early trabeculae formation.
This is a low power view of the pre-existing interradicular bone. The right and left of the sample are preexisting lamellar bone and the mid-section is newly formed woven bone.
A high-power view clearly shows the pre-existing lamellar bone (LB) on the right and left with newly formed woven bone (WB) in the mid-section. This is the same process that occurs when placing BioDensification into poorly mineralized bone. The graft material stimulates osteogenesis and the stimulated osteoblasts fill the area with mineralized bone and then migrate into the surrounding bone to continue to improve mineralization, bone density, and integration into the surrounding tissues.
How else can we use this technology in our daily practice?
A common problem are “spinners”. When the bone lacks the structure to stabilize the implant, it will commonly spin in the socket. BioDensification is a calcium phosphate bio-cement that bonds to bone and implant surfaces. In combination with SL Factor, which stimulates the bone formation, BioDensification bridges the gap between the bone and implant surface and produces bone to implant integration when primary stability is not achieved. Let’s review the process with the following case.
This implant was in function for many years. However, shortly after removal of the second molar, the patient noticed the implant was mobile. It is assumed that the implant was used to elevate the second molar and the implant was separated from the bone during the extraction.
The implant was removed and the site was planned for an immediate implant. However, the defect was larger than the largest drill and the implant spun in the defect. The implant was then removed, BioDensification was injected into the osteotomy, and the implant was driven back into the grafted site.
Day of surgery. The implant is in place surrounded by BioDensification which will act as a bridge for the osteoblasts to migrate onto the implant surface and integrate to the implant.
Understanding bone vitality and using modern science-based bone grafting materials that simulate bone formation, bone health can be restored producing ideal bone for a lifetime of implant function. Whether it is poorly mineralized bone in the posterior maxilla, bone filled with fat in the mandible, or a “spinner”, the clinician now has the regenerative materials to return the bone back to vital healthy tissue.
MEMBER:
American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)