Craig Misch - (2/25/2013 11:05 PM)

Robert, I discussed the case with Dr. Salama. Maurice took out the teeth adjacent to the defect and did a connective tissue graft. After 2 months healing the bone repair was performed. I treat complication/retreat cases more conservatively and tend to use "tried and true" techniques. The patient felt the same way. Maybe we can post the case and see what others think. The patient needed significant vertical and horizontal augmentation. I felt most confident to use a corticocancellous block from the iliac crest. I could have used cancellous bone from the tibia with timesh but the hip offers predictable quantity/quality bone with good three-dimensional reconstruction. I placed a bupivicaine pain pump in the hip and she was very comfortable after surgery. The block graft completely restored the defect and she healed without any complication. I would be cautious using BMP on a complication/retreat case as there is minimal documentation in the literature(for BMP ridge augmentation). I have had good experience to date but not the experience of 1000's of cases I have done with autograft.

Robert Kuepper - (2/25/2013 3:04 PM)

Dr. Misch: Did you harvest iliac marrow/ cancellouos bone or a corticocancellous block for my patient, Nancy Betchart? Did you use a membrane and if so, which material? Why did you choose this bone graft rather than BMP-2 w/ MinerOss or a proximal lateral tibial marrow harvest and titnium mesh? Thank you. Robert Kuepper

Bassam Algheryafi - (11/10/2012 8:20 PM)

Lots of materials, products, and critical sequencing that must be followed, and just enough to make confusion to what recipe should or must one make. Dr.Misch, Apart from the worry whether or not the mesh would get exposed, shouldn't we always place the barrier underneath or on top of the mesh to prevent the epithelium ingrowth into the graft? Also, ridge augmentation utilizing bone grafts treated with PRGF only seems to have similar results from using rh-BMP-2 but without the subsequent swelling or edema. Any comments please? Thanks.

Craig Misch - (8/27/2012 6:01 PM)

I would consider any bone augmentation procedure in a healthy patient that is taking oral bisphosphonate therapy. However, if there were other risk factors for BRONJ (steroid therapy, over 70 yrs old, bisphosphonate therapy > 3 yrs, diabetes) then I would be more cautious. Although a drug holiday has not been proven to avoid developing BRONJ I would recommend stopping bisphosphonate therapy for at least 3 months. Informed consent regarding the risk of BRONJ is also needed. To date I have not seen any complications with bone grafting in this patient population.

Sormani Queiroz - (8/26/2012 2:22 PM)

Great presentation Dr. Misch. Would you indicate rhBMP-2 +Ti Mesh to the reconstruction in the posterior mandible in a patient taking oral alendronate for 6 years to prevent osteopenia?

alper gultekin - (7/11/2012 4:49 PM)

Nice presentation and promising results with BMP. Thanks

Craig Misch - (7/1/2012 9:13 AM)

Excellent discussion Maurice. The concentration of rhBMP-2 (1.5mg/ml) is predetermined by lypholized powder/liquid ratio set by the manufactures instructions for each kit (ie. XXS, XS, S…). I would not alter the ratio to try and make a more concentrated mixture. Some animal studies have actually shown increased osteoclastic activity with higher BMP concentrations. It appears that a 1.05 mg dose is appropriate for each 2 tooth span you are trying to graft. This would correspond to an XS kit for a 2 tooth span. Although I never used rhBMP-2/ACS alone (without added particulate bone graft) for ridge augmentation or extensive socket defects I have heard from others that the bone formation and quality was less predictable especially with larger defects. The ratio I currently use is about 50% mineralized bone allograft and 50% rhBMP-2/ACS. One would expect a more favorable defect morphology (great # bony walls) would provide better results just as in guided bone regeneration cases. The type 3 socket cases (complete absence of buccal plate) have all healed extremely well. I have had very good results in both the maxilla and mandible. However, there was one case in the posterior mandible (vertical deficiency) that healed uneventfully but formed no bone. It may have been due to a lack of adequate stem cells in the area (dense cortical bone/minimal cancellous). My experience with severe atrophy (ie. flat maxilla) is limited as I still prefer to use iliac bone grafts in these cases. Some additional key points are 1) provide space maintenance with the mesh, 2) achieve TENSION-FREE PRIMARY CLOSURE, 3) avoid loading of the graft site and 4) allow adequate healing time. I hope this information helps.

Maurice Salama - (6/30/2012 11:44 PM)

Craig; I couldn't agree more with your assessment. Have you found that patient response to the BMP-2 has been varied depending upon concentration, size of defect, surrounding bone walls, maxilla or mandible, incorporation of bone graft particles etc. etc. I am trying to focus on variables that you may have seen during your experience that can highlight a trend. Thanks again Maurice

Craig Misch - (6/30/2012 6:09 PM)

Nicolas, I prefer not to do a free soft tissue graft at the time of mesh placement. There is always the risk of graft necrosis causing complications with the bone augmentation. I would prefer to do the soft tissue augmentation either two months prior to the mesh placement or at the mesh removal/implant placement surgery. I discuss exposure of the rhBMP-2/ACS collagen sponge in my extraction socket article (JOMI, 2010). The soft tissue healing over the socket appeared to be enhanced by the growth factor. However, I would not want exposure of the sponge under a mesh augmentation case. This would risk graft infection and early mesh exposures are poorly tolerated.