Doug Kase
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YOU MAY REMEMBER (or not), I reviewed the Orthogen Corporation’s product
BoneGen™ in an earlier “Tales” article
(JanuaryMarch 2006), and it’s now time for a followup! First, let
me remind you what the product is. BoneGen is an FDA-approved medical-grade
calcium sulfate hemihydrate for bone regeneration in dentistry. It
inhibits nonosteogenic cells, stimulates blood vessel growth in filled
defects, and is totally resorbable, safe, and osteoconductive. The
material allows secondary intention healing and can be mixed with other
bone graft materials, although I have used it only as a stand-alone product.
It is additionally a great hemostatic agent in bony procedures. It
is easy to mix and use, and it is relatively inexpensive.
Orthogen has just introduced a new timed-release
version of BoneGen called, appropriately, BoneGen-TR. The conventional
products of calcium sulfate hemihydrate tend to resorb over a four-week
period, thus limiting their effects. In short, the product may be
totally resorbed before total or more complete bony regeneration can occur.
BoneGen-TR resorbs over an 18-week period, allowing more complete bone
regeneration while the product is in place. Additionally, due to
its slower resorption time it can be used to fill bigger defects when combined
with traditional BoneGen or as a standalone material. Also, there
have been concerns over other bone graft materials. Those concerns
include biological contamination in human source material (i.e. cadaver
bone) or other disease issues and the fact that some materials do not completely
resorb. Freedom from these concerns makes BoneGen, with its total
resorption while inducing regeneration, a great alternative.
With this re-review in mind I will present
a case that clearly illustrates the potential for this product in the endodontic
arena.
A patient presented to my office with pain
related to a non-vital maxillary right lateral incisor. There was
some swelling at the apical area as well. Radiographs confirmed a
large periapical radiolucency and the need for endodontics (Figure 1).
The treatment was done using the SafeSiders® and EZ-Fill® technique
(Figure 2), and the patient was placed on a regimen of clindamycin for
seven days.
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| FIGURE 1: Radiograph confirming
a large periapical radiolucency. |
FIGURE 2: Following treatment. |
Upon his return for a one-week followup, he was totally asymptomatic
(and quite happy to boot), reporting no postoperative discomfort following
the treatment. He was dismissed, to be recalled for a six-month followup.
Due to the size of the original pathology, I was hoping for healing, but
also informed the patient that surgical intervention, apicoectomy, might
ultimately be necessary. The patient unfortunately ignored his six-month
reminder and returned at ten months instead due to a relapse of symptoms,
mucobuccal swelling. Radiographs confirmed the lack of healing and
continued degeneration, now possibly involving tooth # 8 (Figure 3).
It was time to do an apico! The patient was placed on a regimen of
Augmentun 875 mg bid for ten days and returned when the acute symptoms
subsided. He now presented with chronic sulcular drainage upon palpating
the apex, and I was able to pass a periodontal probe down the buccal root
surface to the apex as well. The situation looked entirely hopeless,
and I suggested that he consider extraction and an eventual implant and
that the apicoectomy would be purely heroic. After a long discussion
and a couple of “Hail Mary’s,” we decided to give it the old college try!
Tooth # 8 tested vital, but I informed the patient that eventual endodontics
might be necessary. After adequate anesthesia, a sulcular incision
was made from the mesial of # 5 to the distal of # 9, with a vertical release
incision for greater access. The tissue was reflected to reveal the
mother of all defects. Tooth # 7 had virtually no buccal bone to
speak of, and my heart sank with my expectations. On we went!
The area was completely curetted and a biopsy was taken of the tissue.
I tried to avoid the apex of # 8 as best as possible. The root was
beveled back and prepared for retrograde with an ultrasonic hand piece.
A layer of BoneGen was pushed against the bony crypt for hemostasis, and
then MTA was used as a retrograde filling material. The remainder
of the crypt was filled with two additional packets of BoneGen (Figure
4).
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| FIGURE 3: Radiograph confirming
the lack of healing and continued degeneration. |
FIGURE 4: Showing the remainder
of the crypt filled with two additional packets of BoneGen . |
I also packed a layer of the material over the buccal surface of the
root to fill the defect. The incision was sutured tightly, and the
patient was ultimately released. I contacted the patient that evening
and again during the following few days, and I was as happy as he was that
there was no postoperative pain, only a little soreness.
Let’s jump to one week later. I removed
the sutures, and everything seemed “hunky dory,” other than some oozing
from the sulcus, minor tissue puffiness and the slightest facial swelling
under the nose. There was some expected gingival recession on tooth
# 7, and tooth # 8 tested non-vital. The biopsy came back, and the
diagnosis was an apical granuloma. I followed him up on a weekly
basis over the next month, and to our surprise the gingival tissue became
very pink, firm, and normal-looking. At the three-week and four-week
intervals, I was not able to probe any significant pocket depth, but tooth
# 8 was still non-vital. At the two-month followup, endodontic treatment
was performed on # 8, due to the continued lack of a vital response.
The final radiograph (Figure 5) clearly shows the resorption of the BoneGen
from the defect as well as the apparent granulation of bone into the area;
a happy ending that I will continue to monitor.
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| FIGURE 5: A happy ending,
showing the resorption of the BoneGen from the defect as well as the apparent
granulation of bone into the area. |
I look forward to reviewing BoneGen-TR for my loyal readers in a future
“Tales From the Chamber.”
January - March 2007
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