Exposed bone graft, what is the infection probability?
 

Three weeks ago I had bone graft on "tooth" 11. I had this tooth removed 4 months ago due to fracture and an autologous bone graft (from my chin) was placed for a future implant.

The bone graft got a little exposed on the palate site, I think this is because of exagerated vertical augmentation and poor blood irrigation.

This little piece of exposed bone is dead and I'm afraid of getting an infection, specially because I know ostemyelitis is a severe problem.

I'm washing my mouth and brushin the exposed bone with Chlorhexidine after each meal. I took antibiotics for the first 19 days (amoxicillin 14 and levofloxacin 5). Now im on day 23

How dangerous is my situation? What cares should I take?

Thanks

capsula4,

If I am understanding you correctly, a portion of the grafted bone on the palate side is not covered by palatal tissue. Was it covered initially? Have you been back to the oral surgeon since the grafting was done?

Bryanna

The situation is as you described Bryan, there is a small portion of the bone graft not being covered with soft tissue on the palate.

I cant really tell if it was initially covered since I realised of.it after the 4th day.

The surgeon saw me several times. The first time at the 4th day and he saw there was a fibrin clot right were I have the exposed bone (i dont have fibrin.any longer).

He just told me to have great higiene over that area and now he is on vacations, he doesnt seem to worry much about the exposure. In one month he will make a flap and take out the dead bone, tho Im worried if it gets infected.

Hi capsula,

Chances are the tissue coverage on that portion of the bone graft was inadequate at the onset. It is wise to keep it clean of food debris and plaque, but be careful not to be too aggressive as that could introduce bacteria in to the surrounding tissue. Keep in mind that you do not want to disturb the rest of the graft.

Gentle brushing with a soft bristle toothbrush and salt water rinsing should be adequate at keeping it clean.

Please keep us informed on how things go..

Bryanna

first of all, thanks Bryanna for taking the time not just for reading my post, but also for replying!

I have been using clorhexidine for almost a month but I think using water with sodium bicarbonate may be a better option for not getting my teeth colour affected by CHX.not sure if there is any other effect of abusing of CHX.

As soon as I meet de surgeon I will tell how everything keeps on going!

Here is a picture of the exposed bone graft, next to a crown post. I know is not pretty clear but it may help you.

Btw, I wouldnt like to think the surgeon didnt cover the whole graft with soft tissue, isnt kind of obvius that it will kept exposed? Im thinking he may haven't had enough soft tissue to cover it.

Capsula,

That is a large piece of exposed bone. Either he didn't have an adequate amount of soft tissue to cover the entire graft or he did cover it but the tissue died and sloughed off early on. The tissue margins around the graft are dark and irritated. Did he tell you to actually brush this piece of bone? Or was that something you decided to do on your own?

I could understand lightly brushing it... as I said with a very soft bristle toothbrush... but definitely gently if at all. Sometimes chlorhexidine can be irritating to the gum tissue when over used... and yes, it definitely will temporarily stain your teeth. If you switch to salt water... do not make the water very salty. Just a pinch of salt in about 2 ounces of warm water is adequate. There is no need to use more than that. As a matter of fact, overuse of salt will also cause irritation and soreness to the oral tissue.

Can I ask ... are you in the medical field? You sound quite knowledgeable :)

Bryanna

Yes, my surgeon definetely told me to brush it gently with CHX. When I asked him how much should I keep brushing it with CHX he told me I should decide my own. This answer was not clear at all to me.

He said it was a small piece of bone, I think he said that way for not making me worry.about it. Still I think the graft is large. If you see it from the front side, the gum tissue is larger than the gum on the surrounding teeth.

Im not into the medical field, im computimg engineer but I love reading and reseaeching. Before posting here I read everything I found on the subject.

Here is a better front view picture of the graft (right next to the crown post).

Another last question. My crown on 11 has attached a false teeth to it to fill the grafted side. Wearing it should be a matter of risk for the graft? I dont use them for eating though.

ps: English is my second language so excuse me if I dont use the exact words or if I have too many grammar mistakes.

capsula,

Yes, the grafted tissue is quite large on the front (facial) side. I have to admit, I have never seen this done this way. May I ask.... What country are you in?

Also, this appears to be your right front tooth which is actually tooth #8, not #11. Correct? You have a temporary 2 unit bridge that you take in and out that fills the space and fits onto the other front tooth #9... is that correct? I know #9 has been shaved down for a crown but has that tooth also been root canaled? I ask because it gives the dark appearance of a non vital tooth.

Ideally nothing should be worn against the bone graft site, especially if tissue was grafted, until it has healed for several weeks or so. Does your temporary bridge rub against the palate side of the graft? Could that be why the bone is exposed?

Could you post a picture with the temporary in place? By the way, these pictures help a lot with your description.

Bryanna

I'm from Argentina, and as regards to the numbering, I was using the FDI Dental Federation notation (I would link an image but I cant due to my number of posts). My bad I didnt clarified it.

I'm not sure, but I got the sensation that my surgeon didn't have that much experience on bone grafting, though he is known as one of the most experienced and best surgeons on my area, if not the best. Still this doesnt make him good at bone grafting. Btw he gave me ketorolac ome hour before the surgery and I was bleeding a lot during the op.

Both 8 and 9 were root canale due to an accident I had 9 years ago, thankfully only one of them got inffected and had to be removed (had a cyst). I first tried an apicoectomy with the same surgeon but it failed (1 year ago).

As regards to the bridge, I didn't wear it for the first 4 days, and the exposure was there on day 4 (probably even before, but never looked to it).

I'm on day 25 since the surgery and I tend to avoid wearing the bridge, just when I go out. I don't feel the temporary bridge rubs the exposure site (plus since there is no gum tissue, it feels like there is gap between the bone graft and the crown).

capsula,

Thanks again for the pictures. They are a little blurry, but I know what I'm looking at so they are okay :)

Just wanted to clarify the tooth number, thanks for helping me with that.

It concerns me that your surgeon may have been inexperienced with doing the bone graft. To be honest, that is what I thought when I first saw it. I honestly don't see how this site can be prepared properly for a dental implant. Is there anyone else (who is competent) that would give you a second opinion?

Yes, Ketorolac is an NSAID and one of the side effects of that type of drug is bleeding. In the US, we don't use that drug prior to oral surgery if we can avoid it.

To properly inform you... all root canaled teeth are chronically infected because it is not possible to remove all of the infected nerve material from the microscopic canals inside of the tooth. Because of the chronic infection and inflammation, the jaw bone surrounding the root canaled tooth is never healthy. So there are additional risks associated with any surgery that is done next to a root canaled tooth.

I am sorry to say that I would be concerned about both areas, # 8 and 9, as neither one looks healthy from your photos. If you can, please seek a second opinion before you allow this dentist to do any further work on you.

Please keep us informed along the way....thanks!

Bryanna

Sorry for the blur in the pictures, I took several and couldn't make it better. It's hard taking pictures by myself.

I'm not sure about someone else who might be competent thought I'll try to locate some other surgeon and ask for another opinion. I'm pretty aware "my" surgeon is a good implantologist, not sure about bone grafting.. I'm defintely not happy with the results, plus it's autologous bone graft and that costed me a lot from myself.

I have read some posts (here) about the root canals and came to know that nice things! I have that root canal on #9 and two more in lower molars, and thats not a good prognosis. Better late than never! I won't go for extraction but I will watch them out.

I have a screw on the bone graft, so I'm pretty sure I will go with another surgery with the same surgeon. I'd like to think he can't actually do anything wrong in removing dead bone and the screw!

After 5 weeks of the procedure, I went back to my surgeon for a revision.

He told me the exposed bone remains the same, it doesn't have supuration nor a rare color, so he thinks it's alright.

He knows I will lose the exposed part, but in one month more (2months +1week from surgery) he will mill the bone until he finds bleeding bone and will take out the screw. He is pretty positive that the bone will be okay for a dental implant.

I guess that on the next surgery he will have a great outlook on the bone graft, and if its really prepared for an implant. I'll let you know.

Hi capsula,

What does he plan on using to cover up the exposed bony area once that bone is lost?

Seriously, I urge you to get a second surgical opinion before proceeding with this dentist. What could it hurt??

Bryanna

He said that once he find bleeding bone, that will cover up the exposed bone. Plus I think that if the bone is milled, there will be less bone to cover up and probably the soft tissue is enough to cover all or pretty much of the bone. What do you think about this?

Anyway I'm making an appointment with another surgeon, just wanted to know what you thought about the last opinion from my surgeon.

capsula,

I'm finding this hard to believe! That exposed bone is large and if there wasn't enough tissue originally to cover it up... how will there be enough once that is removed and more bone is exposed? He talks about drilling into bone until it bleeds simply because the blood indicates live bone. That's all well and good, but it doesn't reduce or eliminate the problems with this exposed area of bone.

Glad to hear you are consulting with someone new.... hopefully he will be more knowledgeable and forthright with you.

Keep us posted..
Bryanna

I guess he will just remove some bone, not the soft tissue, through a flap. Then if the bone is shorter (smaller vertically), probably the tissue may cover it up.

Who do you think it may be better to consult, another oral surgeon or a periodontist?

See an oral surgeon.

Bryanna

Just in case you wonder, here are some actual pics where you can see the situation hasn't changed much.

I just noticed today the gum tissue is a lil bit more reddish near the exposed bone (bottom.jpg). The surgeon told me yesterday that it seemed that the bone graft had started to get vascularized, not sure if that redness has something to do with the vasculization process.

PS: I already made an appointment to consult another surgeon, I'll keep you informed.

I finally visited another oral surgeon, who seemed to be more experienced with these kind of issues.

I told him my case and about my failed apicoectomy he said I should have had performed a re-root canal treatment along with the apicoectomy, which I think it's a better approach than the apicoectomy alone (point in favor).

I asked him about the exposure and he said that the bone graft should have been placed higher, that probably the surgeon didn't have enough periosteum to cover the graft and then the exposure took place (second point in favor).

He now asked me for a digital Rx to see how much bone looks vital and see if there would be enough soft tissue to cover it. Here are the Rx's thought I haven't showed them yet (next appointment its in one week).

I finally got the second opinion.

This new oral surgeon saw the Rx and told me that he says everything is alright in spite of the exposure.

He told me that he thinks there is enough vital bone for the implant and that he would add any more bone. Also he told me I should have that exposed bone removed as fast as possible so I don't lose more bone.

I'm pretty positive and happy as well that the bone graft has worked pretty much.