INFUSE® Bone Graft & Platelet Rich Plasma
Why is bone important for dental restoration?
Teeth are anchored into the jaw in an area of bone called the alveolar ridge. The alveolar ridge bone surrounds tooth roots to secure teeth, and allows for normal tooth use such as chewing.
Without enough alveolar ridge bone, the jaw cannot support either natural teeth or dental implants. There are many reasons why you may have lost bone in your jaw. For example, you may have had either a tooth knocked out and bone was lost with the tooth, or you may have periodontal (gum) disease. For whatever the reason, you may not have enough bone in your jaws to anchor your natural teeth or to support the successful placement of dental implants.
If you have lost alveolar ridge bone, and need to re-grow the bone to place dental implants, your surgeon may recommend that you have a bone graft surgery. INFUSE® Bone Graft may be an option.
What is INFUSE® Bone Graft?
INFUSE® Bone Graft consists of two parts: a protein that is found in everyone’s body, plus a natural carrier for delivery. The protein ingredient in INFUSE® Bone Graft is rhBMP-2 (recombinant (engineered) human bone morphogenetic protein-2), a synthetic version of a protein everyone’s body produces naturally in small amounts to regulate bone growth and healing. The natural carrier is made of a material found in tendons. It releases the protein over time where it is placed, provides a scaffold (framework) for new bone to grow into, and is absorbed and replaced by bone. Using INFUSE® Bone Graft eliminates the need for a second surgery to “harvest,” or remove surgically, bone from your body (“autogenous” bone) for placement at the oral surgery site. Autogenous bone harvest has the risk of pain, complications, longer surgical time and more anesthesia. Choosing INFUSE® Bone Graft eliminates the need for the harvest surgery avoiding the pain and bodily harm associated with the bone harvest procedure. For procedures where autogenous bone is not typically used, INFUSE® Bone Graft can also be used.
How does INFUSE® Bone Graft work?
INFUSE® Bone Graft is surgically placed where new bone growth is needed. It attracts your body’s own bone building cells to the site and over time, new bone is formed. Bone grows where the INFUSE® Bone Graft is placed, for predictable bone growth results.
Who is INFUSE® Bone Graft for and how will it fit into my doctor’s prescribed course of treatment?
INFUSE® Bone Graft is now approved for two oral procedures: in sinus augmentation, and for localized alveolar ridge augmentation following tooth extraction. INFUSE® Bone Graft gives you and your surgeon a choice for growing bone where it is needed for the support of dental implants or other dental restoration. You and your doctor should discuss the benefits and risks of INFUSE® Bone Graft versus autogenous bone or other treatments.
A sinus augmentation, or “sinus lift,” is a surgical bone grafting procedure that is performed in the maxillary (upper jaw) sinus cavity (above the area that anchors your teeth) to prepare the patient for dental restoration. Some patients have such small amounts of existing bone in these areas that dental restoration simply cannot occur without sufficient formation of new bone. Your surgeon may feel that autogenous bone or INFUSE® Bone Graft is needed to form the necessary bone in this area for reliable and functional dental restoration. In this case INFUSE® Bone Graft or autogenous bone harvested from another site in your body may be placed into your upper jaw to promote bone growth in the floor of the sinus cavity to anchor the dental implants to allow for dental restoration.
A localized alveolar ridge augmentation after tooth extraction, or “ridge augmentation,” involves placing INFUSE® Bone Graft directly into the empty socket where a tooth’s roots used to be, to help create the natural shape of the gums and jaw that may have been lost following tooth extraction. Patients usually need a ridge augmentation procedure after losing one or more teeth, to prepare for a future dental restoration.
Who should not receive it?
INFUSE® Bone Graft should not be used if:
- you are pregnant, or suspect that you might be pregnant
- you are hypersensitive (highly sensitive) to bovine (cow) Type I collagen or recombinant human Bone Morphogenetic Protein-2
- you have an infection near the area of the surgical incision
- you had a tumor removed from the area of the implantation site
- you are being treated for cancer.
What are some warnings for using INFUSE® Bone Graft?
This product has not been tested in pregnant women to determine if it could harm a developing fetus. This product has also not been studied in nursing mothers.
It is not known if a woman who gets pregnant after receiving the product could have a second immune reaction to the BMP-2. BMP-2 is normally found in a developing fetus and an immune reaction to it may result in harm to the mother and/or the fetus. In a rabbit pregnancy study, no increase in the immune reaction to BMP-2 was observed.
Women of childbearing age should not become pregnant for one year following treatment with 7 the product. Women of childbearing age should be warned of potential risks to a fetus and should discuss other possible dental treatments with their doctor.
If I become pregnant after having treatment with INFUSE® Bone Graft, could there be problems for the fetus?
This issue was not studied in humans. However, in a rabbit pregnancy study, an immune reaction to INFUSE® Bone Graft developed by the mother crossed into the fetus; the effect of this immune reaction on the fetus is unknown. In addition, the rabbit study showed some bone formation abnormalities in a small number of rabbit fetuses tested; it is not known if these changes would disappear as the rabbit fetus continued to develop or at some time after birth.
What are some precautions for using INFUSE® Bone Graft?
This product has not been tested:
- in the lower jaw (mandible) or in extracted molar tooth sites
- in patients under 18 years of age whose facial bones are growing
- to see if there are side effects by using it more than once in the same person
- in people with liver or kidney problems
- in people with bone-weakening diseases 8
- in people with autoimmune (self immunity) or immunosuppressive (decreased immunity) disease, such as lupus or HIV/AIDS
- in people with immune deficiency (lacking immunity) due to other treatments, such as radiation therapy, chemotherapy or steroid therapy.
Although not seen in the studies performed by the sponsor, there is a possibility that too much bone may form at the implantation site (exuberant bone formation) or bone may form at a location away from the implantation site (ectopic bone formation).
What are the potential complications of INFUSE® Bone Graft?
As with any surgery, surgical treatment to promote bone growth in the jaw is not without risk. A variety of complications related to surgery or the use of INFUSE® Bone Graft can occur. These may occur individually or in combination. Some of these may be severe, affecting your outcome. You may also need to have additional surgery to correct these complications. Some of the possible complications include:
- allergic reaction to the implant materials
- bleeding, which may require a blood transfusion
- bone formation that is not normal, in excess or in an unintended location
- damage to nearby tissues or nerves
- fetal development complications 9
- pain or discomfort
- respiratory (breathing) problems
- scar formation or other problems with the surgical incision
- (short-term) mild to severe swelling
- side effects from anesthesia or the surgical approach
- skin swelling or irritation.
What can I expect after surgery?
Your doctor will have a specific recovery plan for you to follow after your procedure. It is important that you follow your doctor’s instructions carefully, so you can recover as quickly as possible and increase your chances of a successful outcome. Contact your doctor immediately if:
- you get a fever
- you do not feel well after your surgery
- you experience pain
- you experience tenderness or swelling of the skin or surgery site
- you experience itching, redness at surgery site
- you experience nausea and vomiting
- you experience anything else that is making you feel unwell even if it is not on this list.
Are there clinical data for INFUSE® Bone Graft?
Multiple studies were conducted on approximately 312 patients who did not have enough bone in their upper jaw to place implants. These patients received either INFUSE® Bone Graft or autogenous bone graft. INFUSE® Bone Graft grew bone without the need of a bone harvest procedure that is necessary for autogenous bone grafting. Both the INFUSE® Bone Graft and autogenous bone graft formed new bone that allowed for the placement of dental implants into patients who otherwise would not have been able to have implants placed. These implants were retained by the majority of patients for two years.
In the sinus lift clinical studies, most patients grew enough bone to place a dental implant regardless of whether they had autogenous bone or INFUSE® Bone Graft. However, the patients who received autogenous bone graft had a higher success rate of dental implant placement without additional augmentation and a higher rate of significant adverse events, such as limping, pain, and infection.
Complications were reported for both INFUSE® Bone Graft and autogenous bone graft patients. Patients who received INFUSE® Bone Graft had less complications than those patients who had autogenous bone graft. However, one adverse event, face swelling, was reported more often in the INFUSE® Bone Graft group. Refer to What are the potential complications of INFUSE® Bone Graft? and What can I expect after surgery? sections above to see the types of complications that can occur.
Please speak with your doctor concerning potential complications associated with your procedure, as well as for more information on these clinical studies.
What are my bone grafting alternatives?
Grafting options are different for different procedures. Before INFUSE® Bone Graft, surgeons relied on autogenous bone harvesting from the patient’s own body for reliable and safe sinus lift procedures.
In the sinus lift clinical studies comparing the safety and effectiveness of INFUSE® Bone Graft to autogenous bone, most patients grew enough bone to place a dental implant regardless of whether they had autogenous bone or INFUSE® Bone Graft. However, the patients who received autogenous bone graft had a higher success rate of dental implant placement without additional augmentation and a higher rate of significant adverse events, such as limping, pain, and infection.
Other grafting options are available. However, these options may not have been studied in the highest level of clinical trials as INFUSE® Bone Graft has. These options include allograft (bone from a human donor), xenograft (bone from another animal species, usually a cow), and synthetic or man-made grafting materials, all of which have their own considerations.
Questions To Ask Your Doctor
- Why do I need a bone graft (or bone augmentation)?
- Please describe the procedure to me.
- What medications will be prescribed?
- How long will my entire course of treatment take?
- Whom may I contact in your office if I have more questions, and how can I reach them?
Platelet Rich Plasma
Platelet Rich Plasma (PRP) is exactly what its name suggests. The substance is a by-product of blood (plasma) that is rich in platelets. Until now, its use has been confined to the hospital setting. This was due mainly to the cost of separating the platelets from the blood (thousands) and the large amount of blood needed (one unit) to produce a suitable quantity of platelets. New technology permits the doctor to harvest and produce a sufficient quantity of platelets from only 20 – 55 cc of blood drawn from the patient while they are having outpatient surgery.
Why all the excitement about PRP
PRP permits the body to take advantage of the normal healing pathways at a greatly accelerated rate. During the healing process, the body rushes many cells and cell-types to the wound in order to initiate the healing process. One of those cell types is platelets. Platelets perform many functions, including formation of a blood clot and release of growth factors (GF) into the wound. These GF (platelet derived growth factors PGDF, transforming growth factor beta TGF, and insulin-like growth factor ILGF) function to assist the body in repairing itself by stimulating stem cells to regenerate new tissue. The more growth factors released sequestered into the wound, the more stem cells stimulated to produce new host tissue. Thus, one can easily see that PRP permits the body to heal faster and more efficiently.
A subfamily of TGF, is bone morphogenic protein (BMP). BMP has been shown to induce the formation of new bone in research studies in animals and humans. This is of great significance to the surgeon who places dental implants. By adding PRP, and thus BMP, to the implant site with bone substitute particles, the implant surgeon can now grow bone more predictably and faster than ever before.
PRP has many clinical applications
- Bone grafting for dental implants. This includes onlay and inlay grafts, sinus lift procedures, ridge augmentation procedures, and closure of cleft, lip and palate defects.
- Repair of bone defects creating by removal of teeth or small cysts.
- Repair of fistulas between the sinus cavity and mouth.
PRP also has many advantages
Safety: PRP is a by-product of the patient’s own blood, therefore, disease transmission is not an issue.
Convenience: PRP can be generated in the doctor’s office while the patient is undergoing an outpatient surgical procedure, such as placement of dental implants.
Faster healing: The supersaturation of the wound with PRP, and thus growth factors, produces an increase of tissue synthesis and thus faster tissue regeneration.
Cost effectiveness: Since PRP harvesting is done with only 55 cc of blood in the doctor’s office, the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank.
Ease of use: PRP is easy to handle and actually improves the ease of application of bone substitute materials and bone grafting products by making them more gel-like.
Frequently asked questions about PRP
Is PRP safe?
Yes. During the outpatient surgical procedure a small amount of your own blood is drawn out via the IV. This blood is then placed in the PRP centrifuge machine and spun down. In less than fifteen minutes, the PRP is formed and ready to use.
Should PRP be used in all bone-grafting cases?
Not always. In some cases, there is no need for PRP. However, in the majority of cases, application of PRP to the graft will increase the final amount of bone present in addition to making the wound heal faster and more efficiently.
Will my insurance cover the costs?
Unfortunately not. The cost of the PRP application (approximately $400) is paid by the patient.
Can PRP be used alone to stimulate bone formation?
No. PRP must be mixed with either the patient’s own bone, a bone substitute material such as demineralized freeze-dried bone, or a synthetic bone product, such as BIO-OSS.
Are there any contraindications to PRP?
Very few. Obviously, patients with bleeding disorders or hematologic diseases do not qualify for this in-office procedure. Check with your surgeon and/or primary care physician to determine if PRP is right for you.