DFDBA Demineralized Freeze Dried Bone Allograft Merit Dental

DFDBA Demineralized Freeze Dried Bone Allograft : Merit Dental Clinic Hur, Yin –Shik DMD, MSD, Ph. D

Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation A retrospective study on 123 implants with 1 -5 year follow-up Massimo Simion, Sascha A. Jovanovic, Carlo Tinti, Stefano Parma Benfenati, Clinical Oral Implants Research, 2001

Multicenter study of GBR: 123 implants with 1 -5 year follow-up Group A GTAM+blood cot Group B GTAM+DFDBA M. Simion, S. A. Jovanovic, C. Tinti, S. P. Benfenati, COIR, 2001 Group C GTAM+autograft

Amount of vertical bone formation by GBR method GTAM+blood cot Up to 4 mm GTAM+DFDBA Up to 4 mm M. Simion, S. A. Jovanovic, C. Tinti, S. P. Benfenati, COIR, 2001 GTAM+autograft Up to 8 mm

Mean crestal bone loss at the first year examination GTAM+blood cot 1. 35 mm GTAM+DFDBA 1. 87 mm M. Simion, S. A. Jovanovic, C. Tinti, S. P. Benfenati, COIR, 2001 GTAM+autograft 1. 71 mm

Conclusion We can confirm and conclude that the regenerated bone with GBR technique reacts to the implant placement in a manner that is clinically similar to native, non-regenerated bone. M. Simion, S. A. Jovanovic, C. Tinti, S. P. Benfenati, COIR, 2001

What is the best choice ? Demineralized Freeze-Dried Bone Allografts ?

Classification of Bone Graft Materials 1. Autogenous bone graft : gold standard 2. Bovine xenograft : Bio. Oss 3. Human allograft : DFDBA 4. Alloplast

Following Events after Bone Grafting 1. Osteogenesis 2. Osteoinduction 3. Osteoconduction 4. Transduction

Osteoinduction ? A healing process in which local stimulating factors cause mesenchymal cells to disaggregate, migrate, reaggregate, proliferate, and differentiate into chondroblasts or osteoblasts.

Why DFDBA ? Osteoinductive role of BMP in DFDBA

1992 J. Periodontol. 1994 J. Periodontol. 1995 J. Periodontol. 1996 J. Periodontol. DFDBA Becker’ reviews Anti-Becker’s reviews 1994 Simion et al. IJPRD 1994 Landsberg et al. IJOMI 1996 Doblin et al. IJPRD 1996 Simion et al. IJPRD 1997 Artzi et al. IJPRD

Becker’s Opinion about DFDBA 1. 2. Does not osteoinductive due to little BMP in DFDBA Different results among products (aging effect, donor effect…)

GBR with an e-PTFE membrane associated with DFDBA : Histologic and histochemical analysis in a human implant retrieved after 4 years of loading Massimo Simion, Paolo Trisi, Adriano Piattelli Int. J. Oral Maxillofac. Implants 1998

Simion et al. 1996, IJPRD

Simion et al. 1996, IJPRD Considering that during the surgery the original bone defect measured 7 mm in depth and 8 mm in width and was completely filled with DFDBA particles, the authors argue that only a few remnants were still detectable 4 years later.

The presence of some particles of DFDBA completely embeded and isolated in the supracrestal connective tissue and not involved in the bone regeneration seems to exclude the osteoinductive potential of those particles. DFDBA Simion et al. 1996, IJPRD

Conclusion 1. DFDBA particles are able to be resorbed and substituted by vital newly formed bone, but that the rate of resorption is very slow and complete after 4 years. 2. Load-bearing capacity and the functional activity of the bone regenerated with the membrane technique associated with DFDBA seems to be clinically similar to that of normal bone. Simion et al. 1996, IJPRD

Conclusion 3. It is more likely that bone grew from the deeper portion of the defect around the DFDBA particles that acted as a scaffold for bone formation. Simion et al. 1996, IJPRD

Explanations of the effectiveness of DFDBA Experimental approach by Becker et al. Not osteoinductive, not effective Clinical & histological approach by Simion et al. Not osteoinductive, but resorbable And substitutable by new bone Clinically not useful Clinically useful

Selection Criteria of Bone Graft Materials 1. Original bone quality as a osteogenic source. 2. Resorbable and substitutable by new bone 3. Clinically, not technique-sensitive 4. Osteoconductivity

Why not DFDBA ? 1. Hard to handle 2. Quality of DFDBA is not standardized 3. DFDBA is not osteoinductive, but osteoconductive

Maxillary sinus floor elevation for implant placement with Demineralized Freeze-Dried Bone and Bovine bone (Bio-Oss ) : A clinical study of 20 patients Pascal Valentini and David Abensur Int. J. Periodontics Restorative Dent. 1997; 17: 233 - 241

Group 2 : 1 -stage approach 1. 10 patients (6 : Kennedy class 1, 4 : Kennedy class 2 edentulism) 2. Subsinus bone height of less than 5 mm 3. Stage 1 : elevation of sinus floor and placement of the grafts 4. Stage 2 : placement of the implants (IMZ) after 6 months healing (loading took place 6 months later, or 12 months after the placement of the graft) Valentini et al. IJPRD 1997 17 : 233 -241

Group 2 : simultaneous approach 1. 10 patients (2 : Kennedy class 1, 8 : Kennedy class 2 edentulism) 2. Subsinus bone height over 5 mm 3. 12 sinus grafting and 28 IMZ implants placement, simultaneously 4. Reentry and loading took place after a healing period of 9 months. 5. Inferior border of window situated at a level corresponding to the residual bone height. Valentini et al. IJPRD 1997 17 : 233 -241

Material and Method 1. Elliptical or rectangular-shaped window (3. 0× 1. 5 cm) 2. 1: 1 mixture of DFDBA (Pacific Coast Tissue Bank) and Bio. Oss : 1 gram of Bio. Oss corresponded to 3 ml of DFDBA 3. Grafting sequence : posterior part anterior part central part 4. Graft material always situated short of the middle meatus ostium to avoid interference with the draining of the sinus. Valentini et al. IJPRD 1997 17 : 233 -241

Results : success rate 1. Group 1 : 96. 8% (1 lost / 32 implants) prior to loading, 100% after loading. 2. Group 2: 92. 8% (2 lost / 28 implants) prior to loading, 89. 3% (96. 1% of the implants loaded), mean loading period of 25 months. Valentini et al. IJPRD 1997 17 : 233 -241

Histological evaluation 1. 6 months : new woven bone in contact with Bio. Oss and the absence of mineralized new bone in contact with DFDBA. 2. 9 months : lamellar bone with osteons were present, as were islands of woven bone 3. 12 months : new bone was totally remodeled into lamellar bone except in the nonresorbed DFDBA area, in which there was no new bone or mineralization. At 9 and 12 months there were no areas of Bio. Oss resorption Valentini et al. IJPRD 1997 17 : 233 -241

Valentini et al. IJPRD 1997 17 : 233 -241 At 6 months (Patient 2, Group 1), newly formed woven bone (wb) surrounds the granules of Bio. Oss (bo) and has formed bridges between the grafting material. 25×orinal magnification.

Valentini et al. IJPRD 1997 17 : 233 -241 At 6 months it appears the DFDBA particles (df) undergo a partial recalcification but that no new bone is formed on the surface. 10×orinal magnification.

Valentini et al. IJPRD 1997 17 : 233 -241 At 9 months (Patient 1 Group 2), some areas still show a woven bone (wb) structure, While other areas contain a lamellar structure (Im) with osteons (os). Original magnification × 40

Valentini et al. IJPRD 1997 17 : 233 -241 At 12 months (Patient 2 Group 1), Bio. Oss (bo) is completely embedded in a new lamellar bone (Im). Partially mineralized DFDBA granules (df) are still visible in the center. 10×orinal magnification.

Histologic findings of DFDBA 1. Osseoinductive effect of DFDBA is insufficient and that promotion of new bone is a result of the osseoconductive properties of the bovine bone mineral matrix (Bio. Oss) 2. The use of DFDBA (previously accepted to have osseoinductive qualities by the authors and others) seems questionable. Valentini et al. IJPRD 1997 17 : 233 -241

Quality of osseointegration 1. Failures in Group 2, like that of Group 1, can be interpreted as a consequence of the insufficient osseointegration of screw implants with a machined surface in grafts of this type. 2. The bone obtained by means of these composite graft is of type 4, or at best of type 3, and the prognosis for screw implants in this type of bone is well below that of TPS cylinder implants with this bone quality (4 lost / 8 machined implants) Valentini et al. IJPRD 1997 17 : 233 -241

Conclusion 1. Composite grafts represent an important alternative to autografts in sinus floor lift procedures, especially when cylindrical implants are used. 2. Bio. Oss showed excellent osseoconductive properties and could be indicated alone in case of sufficient remaining bone around the sinus. Valentini et al. IJPRD 1997 17 : 233 -241