At age 2, the following patient suffered trauma to her lower jaw. At age 12, a significant lesion was found in her mandibular symphysis. The diagnosis was a traumatic bone cavity (previously called a traumatic bone cyst).
Severe Lesion, Delayed Growth
In 2016 at age 12, the lesion was operated by a skilled oral surgeon as follows:
The lower left image shows the lesion filled with mineralized freeze-dried bone allograft. The lower middle image shows the graft covered with a particulate allograft in a polymer designed to function as a barrier.
In 2020, the area was rescanned, and the radiologist noted that the lesion had increased in size.
Wanting a second opinion, the patient sought SteinerBio bone grafts and subsequently found Dr. Steiner. As a precaution, the patient was referred to an endodontist to evaluate the vitality of the anterior dentition. All teeth tested vital. While cadaver bone grafts require blood for mineralization, science based bone grafts require regenerative cells for mineralization. One complication of this lesion is the paucity of regenerative cells available for regeneration of the defect. The coronal portion of the lesion presented only root tips. The inferior border contained nerve innervation that is necessary for the regenerative process. The buccal and lingual walls consisted only of cortical bone with no regenerative cells. The only viable source of regenerative cells that could migrate into the lesion were located in the cancellous bone on the lateral walls of the lesion. The surgical plan was to clear out the lesion and perforate the lateral cortical bone for access to the regenerative cells that would then migrate into the graft material.
In August 2021, the lesion was re-operated.
After reflection of a full thickness flap, perforations on the thin buccal cortical bone were noted. The remaining buccal bone was removed for access to the lesion and access of the lateral walls to perforate the cortical bone. The purpose is not to induce bleeding but to provide a portal for migration of the regenerative cells located in the cancellous bone. The lesion was filled with thick dark brown fluid including clumped masses of necrotic tissue. The lesion was thoroughly rinsed with sterile saline as bleeding from the perforations slowed.
The lesion was grafted with Ridge Graft. Ridge Graft is a combination of pure phase beta tricalcium phosphate granules (OsseoConduct) and Socket Graft Injectable putty. These bone graft materials are mixed at chairside. The β-TCP particles supply volumetric support for the graft material and Socket Graft Injectable putty supplies the matrix needed for the migration of the surrounding osteoblasts and regenerative cells. Regenerative cells have pseudopods which allow them to migrate into and throughout the graft material. As the regenerative cells migrate, they absorb the osteogenic molecule that exists in Socket Graft Injectable, allowing them to carry the molecule throughout the lesion. Without this molecule, the osteoblasts are unable to mineralize such a large lesion.
For better understanding of this process, please watch this free video:
Ridge Graft is covered by a d-PTFE (Teflon) membrane and closed with primary closure.
The follow up radiographs were taken December 2023:
With complete resolution of the lesion, the patient underwent orthodontic therapy to correct her open bite. However the orthodontist was unable to correct her malocclusion.
The patient’s current orthodontist has referred the patient for orthognathic surgery due to the open bite. The family is seeking a second opinion. Cost and distance are not a concern. If you or any of your colleagues can provide an opinion regarding this patient’s options, it would be greatly appreciated. We will put them in contact with you or someone you feel may be a good fit for her therapy. The family has two specific questions.
- Do you know of anyone who may specialize in non-surgical treatments that can correct her malocclusion
- Are you are aware of any alternative materials that can be used in place of titanium plates for orthognathic surgery?
Any feedback is greatly appreciated. If you could use any further information, complete scans of the patient’s maxilla and mandible including the patient’s TMJ, they are available.
Please contact SteinerBio at (866) 317-1348 or contactus@steinerbio.com
MEMBER:
American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)
American Academy of Implant Dentistry (AAID)