- Email: [email protected]
Nerve Damage From Bone Allografts and Xenografts—A Case Series
Accepted Manuscript Nerve Damage from Bone Allografts and Xenografts – A Case Series M. Anthony Pogrel, D.D.S., M.D., F.R.C.S., F.A.C.S. PII:
S0278-2391(17)30225-2
DOI:
10.1016/j.joms.2017.02.016
Reference:
YJOMS 57673
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 14 December 2016 Revised Date:
19 January 2017
Accepted Date: 17 February 2017
Please cite this article as: Pogrel MA, Nerve Damage from Bone Allografts and Xenografts – A Case Series, Journal of Oral and Maxillofacial Surgery (2017), doi: 10.1016/j.joms.2017.02.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Nerve Damage from Bone Allografts and Xenografts – A Case Series
AC C
EP
TE D
M AN U
SC
RI PT
M. Anthony Pogrel, D.D.S., M.D., F.R.C.S., F.A.C.S.*
* Professor, Department of Oral and Maxillofacial Surgery University of California San Francisco 533 Parnassus Avenue, Room UB10 Box 0440 San Francisco, CA 94143-0440 Telephone: 415-476-8225 Fax: 415-476-6305 Email: [email protected] 1
ACCEPTED MANUSCRIPT
Abstract. The concept of socket preservation, by placing a particulate bone allograft or xenograft into a tooth socket or on the alveolar ridge following tooth removal remains a somewhat
RI PT
controversial topic. The concept is that it will preserve the ridge from resorption and make subsequent implant insertion easier, with fewer complications. However, one
particular issue is that these materials, though not directly neurotoxic, appear to be irritant
SC
to nerves if they come in contact with them. We present a case series demonstrating this
AC C
EP
TE D
M AN U
complication.
2
ACCEPTED MANUSCRIPT
The concept of socket preservation, by placing a particulate bone allograft or xenograft into a tooth socket or on the alveolar ridge following tooth removal remains a somewhat controversial topic1-3. The concept is that it will preserve the ridge from resorption and
RI PT
make subsequent implant insertion easier, with fewer complications. However, one
particular issue is that these materials, though not directly neurotoxic, appear to be irritant to nerves if they come in contact with them. We present a case series demonstrating this
M AN U
Materials and Methods
SC
previously unreported complication.
In the past 18 months we have encountered eight patients where alloplast or xenograft bone substitutes came in contact with either the inferior alveolar or mental nerves and caused dysesthesia warranting surgical removal of the material in three cases. They are
TE D
presented in chronological order.
Case #1: A female age 53 underwent socket preservation with a human allograft
EP
following extraction of the lower left first molar. Panorex radiograph showed the socket apices in close contact with the inferior alveolar canal. She suffers moderate dysesthesia,
AC C
controlled with medications. She can detect von Frey hairs down to the 2.36 hair which is within normal limits so has no objective loss of sensation.
Case #2: A female age 38 had socket preservation and buccal plate augmentation with human allograft following removal of the lower right second premolar. This caused severe dysesthesia and also some loss of sensation. With von Frey hairs she could not
3
ACCEPTED MANUSCRIPT
feel below the 4.31 hair representing about a 50% loss of sensation. A panorex type radiograph was essentially normal, but a cone-beam CT (CBCT) scan showed the material both in the socket and on the buccal plate (Figure 1). She underwent surgery 17
RI PT
days later with decortication of the mandible, removal of the allograft which was in
contact with the inferior alveolar nerve via the socket and the mental nerve via the buccal augmentation. It was noted that the epineurium was very friable and almost gelatinous in
SC
nature and very inflamed. Following the surgery, the dysesthesia resolved immediately and findings with von Frey hairs have improved to 3.61 indicating about a 30% loss of
M AN U
sensation.
Case #3: A female age 61 had socket preservation with a human allograft following extraction of the lower right first premolar, which was in close contact with the inferior
TE D
alveolar canal. She suffered mild to moderate dysesthesia, controlled by medications and can feel von Frey hairs down to the 2.36 hair denoting no objective loss of sensation. She
EP
has deferred implant placement.
Case #4: A female age 47 years had a failed implant with peri-implantitis in the lower
AC C
left second premolar site, but no pain. The implant was removed and a bovine xenograft placed in the socket. She suffered from dysesthesia, and following a CBCT scan showing the relationship of the material to the inferior alveolar canal, the alloplast was removed via the socket. This caused partial resolution of the dysesthesia. She could feel von Frey hairs down to the 1.65 hair, which is the very finest hair, denoting normal sensation.
4
ACCEPTED MANUSCRIPT
Case #5: A female age 57 years had a human alloplast placed following extraction of the lower left second molar. She suffered severe dysesthesia following the procedure and radiographs showed the presence of the material in the inferior alveolar canal. The
RI PT
alloplast was removed via a buccal decortication procedure some 12 days later. The
findings on von Frey hairs improved from 3.61 (about a 30% loss of sensation) before the decompression procedure improving to 2.36 following the decompression. At
SC
decompression the epineurium was again shown to be severely inflamed and almost
M AN U
gelatinous in nature.
Case #6: A female age 53 underwent socket preservation with a human alloplast following extraction of the lower left first molar. She suffered severe dysesthesia following the procedure, and examination of a CBCT scan revealed the distal root socket
TE D
of the extracted tooth to be in contact with the inferior alveolar canal and the alloplastic material was seen in the canal (Figure 2). In contrast, a panorex type radiograph was essentially within normal limits (Figure 3). The alloplastic material was removed via
EP
decortication some 13 weeks following its insertion, and the severe dysesthesia resolved immediately (Figure 4). However, she does have tingling in the distribution of the
AC C
inferior alveolar nerve which finds troublesome. Von Frey hairs have remained at 2.36 before and after the decompression.
Case #7: A female age 63 who had socket preservation following removal of the lower right first molar. Radiographs showed a close relationship between the roots of the tooth and the inferior alveolar canal, and she suffers mild to moderate dysesthesia following the
5
ACCEPTED MANUSCRIPT
procedure. She is maintained on medication, and von Frey hairs are at 1.65 denoting normal sensation. She has deferred implant placement.
RI PT
Case #8: A female age 52 had an apicoectomy carried out on the lower left first molar followed by insertion of a human allograft into the apicoectomy cavity. CBCT scans
showed the apicoectomy cavity to be confluent with the inferior alveolar canal and the
SC
alloplastic material to be in contact with the inferior alveolar canal (Figure 5). She has moderate to severe dysesthesia which at present is controlled with medications. The
M AN U
tooth itself was subsequently extracted and attempts made to curette the material via the socket but without any real improvement. Findings on von Frey hairs have remained at 3.22 (about a 25-30% reduction in sensation) both before and after tooth removal. In this case, it is not known whether the nerve symptoms were caused by the apicoectomy
Discussion:
TE D
procedure itself or the alloplast since she has not undergone exploratory surgery.
This issue of nerve involvement from the use of allografts and xenografts
EP
appears to be a recent phenomenon related to the concept of socket preservation, when there is an intimate relationship between the apex of the socket and the inferior alveolar
AC C
or mental nerves. The scope of the problem is unknown so there is no denominator to attempt to get some idea of the incidence of the condition. However, there is virtually no published material on this topic4, though discussion with colleagues has led some to state that they are aware of this complication. In subsequent follow up it appears that in no case was any additional substance, such as bone morphogenic protein or other bone growth factors added or mixed with the allograft or xenograft. It is known that some of
6
ACCEPTED MANUSCRIPT
these materials can cause inflammatory changes5,6. In all cases, local anesthesia had also been given via an inferior alveolar nerve block so it is possible that the nerve involvement could have been related to the inferior alveolar nerve block, although the
RI PT
incidence of this is extremely low7,8. In the cases that we have seen, both allografts and xenografts were involved and we are not aware of any differences in the ability of the
different materials to cause this problem. Of interest is the fact that these materials have
SC
virtually the same radiodensity as bone and rarely show on a panorex radiograph unless the focal beam goes directly through the area. It does appear that CBCT scans may be
AC C
EP
TE D
M AN U
the only way to identify the problem accurately.
7
ACCEPTED MANUSCRIPT
References 1. Walker CJ, Prihoda TJ, Mealey BL, Lasho DJ, Noujeim M, Huynh-Ba G.
RI PT
Evaluation of healing at molar extraction sites with and without ridge
preservation: A randomized controlled clinical trial. J Periodontal Oct 27th 1-14, 2016. Epub ahead of print.
SC
2. Scheyer ET, Heard R, Janakievski J, Mandelaris G, Nevins ML, Pickering SR, Richardson CR, Pope B, Toback G, Velasquez D Nagursky. A randomized
M AN U
controlled, multicenter clinical trial of post-extraction alveolar ridge preservation. J Clin Periodontal 43:1188-1199, 2016.
3. Jambhekar S, Kernen F, Bidra AS. Clinical and histological outcomes of socket grafting after flapless tooth extraction: a systematic review of randomized
TE D
controlled clinical trials. J Prosthet Dent 113:371-382, 2015 4. Meyer RA, Bagheri SC. Etiology and Prevention of Nerve Injuries. InTrigeminal Nerve Injuries Ed. Miloro M, Springer, New York, 2013 Page 50
EP
5. Krafft TC, Hinkel R. Clinical investigation into the incidence of direct damage to the lingual nerve caused by local anesthetic. J Craniomaxillofac Surg. 22:294-
AC C
296, 1994
6. Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc. 131:901-907, 2000.
7. Shen J, James AW, Zara JN, Asatrian G, Khadarian K, Zhang, Ho S, Kim HJ, Ting K, Soo C. BMP2 induced inflammation can be suppressed by the osteoinductive growth factor NELL-1. Tissue Eng Part A. 19:2390-2401, 2013.
8
ACCEPTED MANUSCRIPT
8. Shah MM, Smyth MD, Woo AS. Adverse facial edema associated with off label use of recombinant human bone morphogenetic protein-2 in cranial reconstruction
AC C
EP
TE D
M AN U
SC
RI PT
for craniosynostosis. Case report. J Neurosurg Pediatr. 1:255-257, 2008.
9
ACCEPTED MANUSCRIPT
Legend to Figures Legend to Figure 1. Allograft placed not only in the socket beyond the apex of the extracted lower
RI PT
right second premolar (arrowed) (a) but also on the lateral aspect of the mandible, to give lateral augmentation (arrowed) (b). The material is in contact with the inferior alveolar nerve in the canal and also the mental nerve as it exited the
SC
mental foremen. A panorex type radiograph generated from the cone Beam CT scan shows increased density over the upper border of the mandible in the second
M AN U
premolar area (c), but the panorex radiograph is within normal limits (d). Legend to Figure 2
Allograft (arrowed) shown beyond the apex of the socket of the lower left first molar, and entering the inferior alveolar canal, as seen on coronal Cone Beam CT
Legend to Figure 3.
TE D
scan.
The density of the allograft is similar to the surrounding bone and so does not
EP
show on a panorex type radiograph, which only shows the distal root socket close to the inferior alveolar canal.
AC C
Legend to Figure 4.
Exposure of the allograft and inferior alveolar nerve via a lateral corticotomy (a), removal of the allograft (b), decompression of the nerve and replacement of the
lateral cortex of the mandible and stabilization with one screw (c) Allograft is arrowed.
Legend to Figure 5
10
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Post apicoectomy on the lower left first molar showing the alloplastic material
AC C
EP
TE D
M AN U
SC
RI PT
(arrowed) in contact with the inferior alveolar canal.
11
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S0278-2391(17)30225-2
DOI:
10.1016/j.joms.2017.02.016
Reference:
YJOMS 57673
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 14 December 2016 Revised Date:
19 January 2017
Accepted Date: 17 February 2017
Please cite this article as: Pogrel MA, Nerve Damage from Bone Allografts and Xenografts – A Case Series, Journal of Oral and Maxillofacial Surgery (2017), doi: 10.1016/j.joms.2017.02.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Nerve Damage from Bone Allografts and Xenografts – A Case Series
AC C
EP
TE D
M AN U
SC
RI PT
M. Anthony Pogrel, D.D.S., M.D., F.R.C.S., F.A.C.S.*
* Professor, Department of Oral and Maxillofacial Surgery University of California San Francisco 533 Parnassus Avenue, Room UB10 Box 0440 San Francisco, CA 94143-0440 Telephone: 415-476-8225 Fax: 415-476-6305 Email: [email protected] 1
ACCEPTED MANUSCRIPT
Abstract. The concept of socket preservation, by placing a particulate bone allograft or xenograft into a tooth socket or on the alveolar ridge following tooth removal remains a somewhat
RI PT
controversial topic. The concept is that it will preserve the ridge from resorption and make subsequent implant insertion easier, with fewer complications. However, one
particular issue is that these materials, though not directly neurotoxic, appear to be irritant
SC
to nerves if they come in contact with them. We present a case series demonstrating this
AC C
EP
TE D
M AN U
complication.
2
ACCEPTED MANUSCRIPT
The concept of socket preservation, by placing a particulate bone allograft or xenograft into a tooth socket or on the alveolar ridge following tooth removal remains a somewhat controversial topic1-3. The concept is that it will preserve the ridge from resorption and
RI PT
make subsequent implant insertion easier, with fewer complications. However, one
particular issue is that these materials, though not directly neurotoxic, appear to be irritant to nerves if they come in contact with them. We present a case series demonstrating this
M AN U
Materials and Methods
SC
previously unreported complication.
In the past 18 months we have encountered eight patients where alloplast or xenograft bone substitutes came in contact with either the inferior alveolar or mental nerves and caused dysesthesia warranting surgical removal of the material in three cases. They are
TE D
presented in chronological order.
Case #1: A female age 53 underwent socket preservation with a human allograft
EP
following extraction of the lower left first molar. Panorex radiograph showed the socket apices in close contact with the inferior alveolar canal. She suffers moderate dysesthesia,
AC C
controlled with medications. She can detect von Frey hairs down to the 2.36 hair which is within normal limits so has no objective loss of sensation.
Case #2: A female age 38 had socket preservation and buccal plate augmentation with human allograft following removal of the lower right second premolar. This caused severe dysesthesia and also some loss of sensation. With von Frey hairs she could not
3
ACCEPTED MANUSCRIPT
feel below the 4.31 hair representing about a 50% loss of sensation. A panorex type radiograph was essentially normal, but a cone-beam CT (CBCT) scan showed the material both in the socket and on the buccal plate (Figure 1). She underwent surgery 17
RI PT
days later with decortication of the mandible, removal of the allograft which was in
contact with the inferior alveolar nerve via the socket and the mental nerve via the buccal augmentation. It was noted that the epineurium was very friable and almost gelatinous in
SC
nature and very inflamed. Following the surgery, the dysesthesia resolved immediately and findings with von Frey hairs have improved to 3.61 indicating about a 30% loss of
M AN U
sensation.
Case #3: A female age 61 had socket preservation with a human allograft following extraction of the lower right first premolar, which was in close contact with the inferior
TE D
alveolar canal. She suffered mild to moderate dysesthesia, controlled by medications and can feel von Frey hairs down to the 2.36 hair denoting no objective loss of sensation. She
EP
has deferred implant placement.
Case #4: A female age 47 years had a failed implant with peri-implantitis in the lower
AC C
left second premolar site, but no pain. The implant was removed and a bovine xenograft placed in the socket. She suffered from dysesthesia, and following a CBCT scan showing the relationship of the material to the inferior alveolar canal, the alloplast was removed via the socket. This caused partial resolution of the dysesthesia. She could feel von Frey hairs down to the 1.65 hair, which is the very finest hair, denoting normal sensation.
4
ACCEPTED MANUSCRIPT
Case #5: A female age 57 years had a human alloplast placed following extraction of the lower left second molar. She suffered severe dysesthesia following the procedure and radiographs showed the presence of the material in the inferior alveolar canal. The
RI PT
alloplast was removed via a buccal decortication procedure some 12 days later. The
findings on von Frey hairs improved from 3.61 (about a 30% loss of sensation) before the decompression procedure improving to 2.36 following the decompression. At
SC
decompression the epineurium was again shown to be severely inflamed and almost
M AN U
gelatinous in nature.
Case #6: A female age 53 underwent socket preservation with a human alloplast following extraction of the lower left first molar. She suffered severe dysesthesia following the procedure, and examination of a CBCT scan revealed the distal root socket
TE D
of the extracted tooth to be in contact with the inferior alveolar canal and the alloplastic material was seen in the canal (Figure 2). In contrast, a panorex type radiograph was essentially within normal limits (Figure 3). The alloplastic material was removed via
EP
decortication some 13 weeks following its insertion, and the severe dysesthesia resolved immediately (Figure 4). However, she does have tingling in the distribution of the
AC C
inferior alveolar nerve which finds troublesome. Von Frey hairs have remained at 2.36 before and after the decompression.
Case #7: A female age 63 who had socket preservation following removal of the lower right first molar. Radiographs showed a close relationship between the roots of the tooth and the inferior alveolar canal, and she suffers mild to moderate dysesthesia following the
5
ACCEPTED MANUSCRIPT
procedure. She is maintained on medication, and von Frey hairs are at 1.65 denoting normal sensation. She has deferred implant placement.
RI PT
Case #8: A female age 52 had an apicoectomy carried out on the lower left first molar followed by insertion of a human allograft into the apicoectomy cavity. CBCT scans
showed the apicoectomy cavity to be confluent with the inferior alveolar canal and the
SC
alloplastic material to be in contact with the inferior alveolar canal (Figure 5). She has moderate to severe dysesthesia which at present is controlled with medications. The
M AN U
tooth itself was subsequently extracted and attempts made to curette the material via the socket but without any real improvement. Findings on von Frey hairs have remained at 3.22 (about a 25-30% reduction in sensation) both before and after tooth removal. In this case, it is not known whether the nerve symptoms were caused by the apicoectomy
Discussion:
TE D
procedure itself or the alloplast since she has not undergone exploratory surgery.
This issue of nerve involvement from the use of allografts and xenografts
EP
appears to be a recent phenomenon related to the concept of socket preservation, when there is an intimate relationship between the apex of the socket and the inferior alveolar
AC C
or mental nerves. The scope of the problem is unknown so there is no denominator to attempt to get some idea of the incidence of the condition. However, there is virtually no published material on this topic4, though discussion with colleagues has led some to state that they are aware of this complication. In subsequent follow up it appears that in no case was any additional substance, such as bone morphogenic protein or other bone growth factors added or mixed with the allograft or xenograft. It is known that some of
6
ACCEPTED MANUSCRIPT
these materials can cause inflammatory changes5,6. In all cases, local anesthesia had also been given via an inferior alveolar nerve block so it is possible that the nerve involvement could have been related to the inferior alveolar nerve block, although the
RI PT
incidence of this is extremely low7,8. In the cases that we have seen, both allografts and xenografts were involved and we are not aware of any differences in the ability of the
different materials to cause this problem. Of interest is the fact that these materials have
SC
virtually the same radiodensity as bone and rarely show on a panorex radiograph unless the focal beam goes directly through the area. It does appear that CBCT scans may be
AC C
EP
TE D
M AN U
the only way to identify the problem accurately.
7
ACCEPTED MANUSCRIPT
References 1. Walker CJ, Prihoda TJ, Mealey BL, Lasho DJ, Noujeim M, Huynh-Ba G.
RI PT
Evaluation of healing at molar extraction sites with and without ridge
preservation: A randomized controlled clinical trial. J Periodontal Oct 27th 1-14, 2016. Epub ahead of print.
SC
2. Scheyer ET, Heard R, Janakievski J, Mandelaris G, Nevins ML, Pickering SR, Richardson CR, Pope B, Toback G, Velasquez D Nagursky. A randomized
M AN U
controlled, multicenter clinical trial of post-extraction alveolar ridge preservation. J Clin Periodontal 43:1188-1199, 2016.
3. Jambhekar S, Kernen F, Bidra AS. Clinical and histological outcomes of socket grafting after flapless tooth extraction: a systematic review of randomized
TE D
controlled clinical trials. J Prosthet Dent 113:371-382, 2015 4. Meyer RA, Bagheri SC. Etiology and Prevention of Nerve Injuries. InTrigeminal Nerve Injuries Ed. Miloro M, Springer, New York, 2013 Page 50
EP
5. Krafft TC, Hinkel R. Clinical investigation into the incidence of direct damage to the lingual nerve caused by local anesthetic. J Craniomaxillofac Surg. 22:294-
AC C
296, 1994
6. Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc. 131:901-907, 2000.
7. Shen J, James AW, Zara JN, Asatrian G, Khadarian K, Zhang, Ho S, Kim HJ, Ting K, Soo C. BMP2 induced inflammation can be suppressed by the osteoinductive growth factor NELL-1. Tissue Eng Part A. 19:2390-2401, 2013.
8
ACCEPTED MANUSCRIPT
8. Shah MM, Smyth MD, Woo AS. Adverse facial edema associated with off label use of recombinant human bone morphogenetic protein-2 in cranial reconstruction
AC C
EP
TE D
M AN U
SC
RI PT
for craniosynostosis. Case report. J Neurosurg Pediatr. 1:255-257, 2008.
9
ACCEPTED MANUSCRIPT
Legend to Figures Legend to Figure 1. Allograft placed not only in the socket beyond the apex of the extracted lower
RI PT
right second premolar (arrowed) (a) but also on the lateral aspect of the mandible, to give lateral augmentation (arrowed) (b). The material is in contact with the inferior alveolar nerve in the canal and also the mental nerve as it exited the
SC
mental foremen. A panorex type radiograph generated from the cone Beam CT scan shows increased density over the upper border of the mandible in the second
M AN U
premolar area (c), but the panorex radiograph is within normal limits (d). Legend to Figure 2
Allograft (arrowed) shown beyond the apex of the socket of the lower left first molar, and entering the inferior alveolar canal, as seen on coronal Cone Beam CT
Legend to Figure 3.
TE D
scan.
The density of the allograft is similar to the surrounding bone and so does not
EP
show on a panorex type radiograph, which only shows the distal root socket close to the inferior alveolar canal.
AC C
Legend to Figure 4.
Exposure of the allograft and inferior alveolar nerve via a lateral corticotomy (a), removal of the allograft (b), decompression of the nerve and replacement of the
lateral cortex of the mandible and stabilization with one screw (c) Allograft is arrowed.
Legend to Figure 5
10
ACCEPTED MANUSCRIPT
Post apicoectomy on the lower left first molar showing the alloplastic material
AC C
EP
TE D
M AN U
SC
RI PT
(arrowed) in contact with the inferior alveolar canal.
11
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EP
TE D
M AN U
SC
RI PT
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