The swelling appears to be dose related. The XXS kit has the lowest amount of rhBMP-2. The swelling is localized with only a few cases of moderate facial swelling. The swelling is greater with sinus bone grafting and ridge augmentation as more BMP is used.
This particular technique is only applicable to socket graft cases. As I previously mentioned the concept of using rhBMP-2 is different than traditional GBR procedures. Barrier membranes are not typically used with rhBMP-2. In fact some research suggests they may actually have a negative influence on the outcomes. If you use rhBMP-2 for ridge augmentation then titanium mesh is used to support the graft site as the collagen sponge has poor scaffold qualities. The soft tissue flap will compress the graft. The mesh is not a barrier membrane - it only supports the flap and protects the graft ("protected bone regeneration"). I have a publication on this coming out soon in the Int J Periodontics and Restorative Dentistry.

Craig;
How exactly do you mix the Mineross with the BMP-2 and ACS?
Some clinicians cut the sponge into pieces and mix it all together collectively while others sprinkle the bone on the outside of the sponge, while others use the bone and wrap it up inside the ACS sponge like a burrito.
What is your style?
thanks
Maurice

No membrane is used with rhBMP-2. It is unnecessary and some research has shown it may even have a negative influence on the result. Just placing the collagen sponge saturated with rhBMP-2 + 20% by volume mineralized bone allograft. I am reserving this technique to significant facial plate defects (> 50%).
If the socket is intact I usually use a mineralized bone allograft for socket grafting (if I am not immeidatley placing an implant). I personally have found MinerOss to have favorable characteristics (combined cortical/cancellous, nice particle size 0.6 - 1.25 mm, cost competative and a reliable source - OsteoTech)

Interesting discussion! The use of rhBMP-2 is definitely FDA approved for the repair of alveolar defects associated with tooth extraction. Keep in mind my article on rhBMP-2 was on type 3 sockets (> 50% of facial plate missing). These cases are typically treated with GBR (membrane + graft) or bone blocks. Furthermore, the repair of these more significant defects is usually delayed in the esthetic zone as you need primary closure (otherwise advancing a flap with alter the normal gingival architecture). The use of rhBMP-2 was simultaneous with the extraction. No flap reflection was needed (as would be required with GBR or blocks). Therefore less tissue manipulation was needed – less morbidity and less surgical time. I must take issue with those that claim that simply placing a bone substitute into the defective socket (> 50% missing facial plate) will provide equal results (please show me a published reference with more than one case where it “worked”). Maybe you can get “lucky” one in a while but I am search for consistency. The rhBMP-2 technique (with a small amount of allograft) worked well in all 10 cases. Also note I did not obtain primary closure over the rhBMP-2 in this study. The growth factor stimulates angioneogenesis and soft tissue healing. Implants were inserted and all integrated for restoration with crowns. The cost is a factor but the simplicity overrides this concern (15 minutes for a socket graft). Patients are more than willing to pay for a procedure that has less morbidity and can be done the same day the tooth is removed. The swelling seems to be dose dependent – socket repair has much less swelling than sinus grafting. This approach has become routine in my practice for this particular application.

If you are using infuse for extractions and GBR isnt it off label. Isnt this material only approved for sinus applications?

I was during some research and noticed that in orthopedics there has been some deaths associated with bmp2 and spine surgery. Does this translate to dental? Is there a risk here?

http://journals.lww.com/spinejournal/Abstract/2010/04201/Complications_R...

My oral surgeon uses this all the time for ridge augmentation. He achieves excellent vertical augmentation as well as great bone.

What are the limits of the material?

I dont see the value in spending 900 dollars to place this in the socket when a 30 dollar bottle of bone works fine. Otherwise the other comments on this thread are spot on for infuses use.

In general I would not use this in a routine socket. Not worth the price. But I would use it in a socket where I knew that because of teh amount of infection and bone loss I would probably need to do additional surgical procedures to get an implant in there.

Infuse my save you a surgery or 2.

This seems pricey to me placing this in a socket. Is it worth it?

I am a restorative dentist and my surgeon uses infuse. The patients come in with alot of swelling and I am frequently tap dancing to give them answers. How do I reduce the patients fear after they have this product used on them?

Those of you that have used it in the socket what is your justification? What was your results? Was it better then just sticking graft in the socket?

I would agree with what with has been said.

I use it for GBR and sinus grafts. GBR, Ti-mesh is a must. I mix the infuse collagen with FDBA.

For sockets I dont see the value as I can get great results with Nu-oss, Bio-oss or FDBA in a socket without BMP. Infuse adds to much expense.

Swelling can be a killer in this case. The flaps must be released or the flap will open from the swelling.

I saw a lecture by Craig Misch at the IJPRD using infuse in a socket that has tremendous loss of bone due to infection. He placed the infuse in the socket with some allograft and 5 months later he had great bone.

I think infuse in sockets like this may enhance healing and avoid doing major grafting after the extraction.

Opinions?

This to me is a promising material. While expensive it give us the opportunity to provide patients and option when no other option is out there.

I have use BMP-2 on 20 cases. I have two failures. The bone has been type 4 in most cases with some type 3. My type 3 cases I have mixed the infuse with particulate and I think that makes the difference.

I have several success cases utilizing ti-mesh and an inion membrane.

I have used it in sockets that have been extremely destroyed by infection and doing nothing would have resulted in a defect that would have required multiple surgeries to correct.

I would love to hear of other experience

Sergio

First off great discussion.

Just met with my local Medtronic rep about Infuse BMP-2. The cost for the Infuse XX small is $876.00. The is the smallest amount of BMP they sell and is enough for a single area/one socket site for grafting.

How much do you charge to take out a tooth and socket graft with this?

Does this become cost prohibitive?

While it may be a good product, it is hard from a private practice prospective to charge for this especially in this economy.

Opinions on how your handle this in your practice

BMP-2 has shown alot of promise but I dont think its there yet.

While I have not used the product I think there are better forms of growth factors (Like PRGF and PRF) which has less complications and less expense.

I also am concerned about how complicated your surgery has to be to build the ridge. I am concerned with a product that needs ti-mesh, membranes, thick soft tissue in order to have any hope of working.

Opinions?

Brooke

I am not an experienced surgeon but I do take out teeth and graft with NuOss cow bone.

Is BMP-2 a better way to graft the socket? Is the bone better?

I think case selection is key. I have only done two cases in the sinus and the results were great. Type 3 bone.

To avoid the slumping issue I add bone as decribed in this Tarnow article.

Int J Periodontics Restorative Dent. 2010 Apr;30(2):139-49.

Maxillary sinus augmentation using recombinant bone morphogenetic protein-2/acellular collagen sponge in combination with a mineralized bone replacement graft: a report of three cases.
Tarnow DP, Wallace SS, Testori T, Froum SJ, Motroni A, Prasad HS.

sswdds.sinus@sbcglobal.net

Abstract
The objective of the following case reports was to assess whether mineralized bone replacement grafts (eg, xenografts and allografts) could be added to recombinant human bone morphogenetic protein-2/acellular collagen sponge (rhBMP-2/ACS) in an effective manner that would: (1) reduce the graft shrinkage observed when using rhBMP-2/ACS alone, (2) reduce the volume and dose of rhBMP-2 required, and (3) preserve the osteoinductivity that rhBMP-2/ACS has shown when used alone. The primary outcome measures were histomorphometric analysis of vital bone production and analysis of serial computed tomographic scans to determine changes in bone graft density and stability. Over the 6-month course of this investigation, bone graft densities tended to increase (moreso with the xenograft than the allograft). The increased density in allograft cases was likely the result of both compression of the mineralized bone replacement graft and vital bone formation, seen histologically. Loss of volume was greater with the four-sponge dose than the two-sponge dose because of compression and resorption of the sponges. Vital bone formation in the allograft cases ranged from 36% to 53% but, because of the small sample size, it was not possible to determine any significant difference between the 5.6 mL (four-sponge) dose and the 2.8 mL (two-sponge) dose. Histology revealed robust new woven bone formation with only minimal traces of residual allograft, which appeared to have undergone accelerated remodeling or rhBMP-2-mediated resorption.

I have not used this product and I like reading about others clinical experience and I am hoping to gain some more insight from others opinions here.

Infuse comes with a hefty price tag. Base on what I am reading is it worth the price?

Thank you

Musin

I would concur with all that has been said but I would add the following:

1) For GBR you have to use ti-mesh. I tried several cases without the mesh using bio-oss and the infuse and it was a disaster.

2) For sockets it is very nice, I add a small amount of FDBA or Puros to the matrix and I can go back into a socket 8 weeks later and place the implant in solid bone.

3) you need to inform the patients about the swelling. Patient management can be an issue when you have to explain a month after the surgery why they are swollen.

Tim