Postoperative Problems Associated with Iliac Transplants

by

ROBERT G . SCHALLHORN

PREVIOUS REPORTS have depicted the potential thera­peutic value of autogenous cancellous bone and marrow transplants from the ilium in periodontal osseous de­fects.1-7 Although mention has been made of several postoperative problems associated with this modality of treatment,4, 6 , 7 clarification of these and other problems encountered is deemed desirable. The purpose of this report is to identify the postoperative problems and, where feasible, to suggest methods of avoiding their occurrence. Postoperative problems in this clinician's experience have fallen into five categories. These are as follows:

1. Infection

2. Exfoliation-sequestration

3. Varying rates of healing which occasionally com­plicate restorative plans

4. Root resorption

5. Rapid recurrence of defect

For ease of discussion, these will be considered sepa­rately.

INFECTION

Inherent in all surgical manipulations of the oral re­gion is the potential for infection. Although the rationale for prophylactic antibiotic therapy in conjunction with periodontal surgery is controversial, several reports8 , 9

coupled with personal experience have been deemed of sufficient merit to warrant their usage on a routine basis with flap and osseous surgery. This is considered to be especially important in osseous grafting procedures wherein several complicating factors are present. These include alveolar bone exposure and intramarrow pene­tration techniques seeding bacteria into sites vulnerable to osteomyelitis, placement of material which for the most part will become necrotic and serve as a favorable environment for bacterial colonization, the replacement over the rough implant of fragile papillary tissues which, if infected, may slough and expose the implant, and presumably, the desirability of eliminating microorgan­isms from the prospective site of regeneration.

In spite of prophylactic antibiotic therapy, immediate or delayed infections may occur either as a result of organisms not sensitive to the antibiotic employed or to the combination of premature termination of antibiotic therapy in the presence of virulent organisms and/or an altered local resistance of the host. A case in point is the development of a localized osteomyelitis in an im­plant site three weeks postoperative resulting in an oral-antral communication (Fig. 1).

The patient was a 43-year-old Caucasian male with an unusual dermatologic condition (Pustular Bacterid of Andrews). Following initial mouth preparation and re-evaluation he underwent multiple iliac transplants with tetracycline as a prophylactic antibiotic.

Only one site developed postoperative complications. Tetracycline resistant enterococci were cultured and, under appropriate antibiotic coverage, the site was re­entered for debridement. In addition to sequestering the graft and a portion of adjacent alveolar process, alve­olar support was lost over the facial aspect of a prom­inent root. Whether this dehiscence was related to the infection or to osteoclastic resorption following full mucoperiosteal flap reflection is questionable. The site was re-grafted using back-up iliac material stored for the patient and the ensuing course was uneventful.

The case presented illustrates the error in assuming that prophylactic antibiotics preclude infections. It further illustrates that surgical therapy in itself may cre­ate greater problems than the reason it is employed, i.e., creation of root dehiscence and oral-antral communica­tion. The therapist must be ever cognizant of potential hazards with his instrumentation in a manner analagous to potential undesirable side effects associated with medication.

SEQUESTRATION

The most common postoperative problem associated with osseous grafting procedures is the exfoliation and/ or sequestration of bone. It has been observed as early as the first postoperative visit and has been noted sev­eral months to several years following therapy. The fate of the material implanted is variable. Several possibil­ities are:

1. Immediate complete exfoliation with no improve­ment of defect.

2. Complete "take," maintenance of viability and eventual reorganization.

3. Partial "take" and partial exfoliation.

4. No "take" or improvement of defect but implant becomes encased in soft tissue (bone being either viable or nonviable). Professor and Chairman, Division of Periodontics, University

of Colorado School of Dentistry, Denver, Colorado 80220. 3

4 Schallhorn J. Periodontol. January, 1972

FIGURE 1. A. Preoperative roentgenogram of graft site mesial to tooth No. 3. The osseous defect was primarily a one-wall configuration with three-walls at its base. B. Coronal view looking into exposed defect. C. Roentgenogram three weeks postoperative. Sequestration appears to be occurring at the coronal portion of the alveolar process distal to the pre­molar. D. Roentgenogram three weeks postoperative with gutta-percha point demonstrat­ing oral-antral communication. E. Re-entry four weeks postoperative with debridement of bony sequestra. Note the dehiscence of the mesial-facial root of tooth No. 3. The root was shaved to reduce its prominence and the site regrafted. Pocket and osseous charting of the area two years later revealed 1-2 mm sulcular depth and acceptable osseous contours. Regeneration of the facial plate over approximately two-thirds of the re-entry dehiscence occurred.

a. Remains as such indefinitely.

b. Resorption.

c. Eventual exfoliation.

5. No "take" but gradual fill of defect with resorp­tion of implant or eventual exfoliation (induction phe­nomenon) .

6. Recurrence in area of "take" with sequestration or resorption.

Thus, it is apparent that exfoliation or sequestration can occur with five of the six possibilities listed. The first two represent the extremes of failure and success. However, the most common type encountered has been

number three wherein part of the implant exfoliates. Relative success varies with the type of defect, the amount of implant material placed, the degree of pack­ing (compressibility), the degree of overfilling, the character of the soft tissue cover (fragile or dense), the coaption of the flap over the implant, etc. Considering these multiple factors, it is understandable that appreci­able material becomes necrotic due to the distance from a nutrient source and to bacterial contamination and that portions of this material exfoliate. As long as the objectives of grafting therapy are satisfied, it merely becomes an annoyance to the therapist and an incon­venience to the patient in the performance of his plaque control procedures. To minimize these considerations, one may wish to avoid an overfill technique or to mani-

5 Iliac Transplant Problems Volume 43 Number 1

cure the exposed bone in a manner previously de­scribed.6 To attempt removal by other means may result in loss of considerable material undergoing reorganiza­tion attached to the exposed portion. The situation is somewhat analagous to an iceberg with only a small portion of its total volume exposed. However, if the material is sectioned into small pieces prior to implanta­tion, this concern would be unnecessary.

V A R Y I N G R A T E S OF H E A L I N G

Another annoying problem associated with osseous transplants is the variable time required to assess the success or failure of the procedure. In cases requiring replacement therapy, such delays may complicate the restorative treatment plan. This is especially true when the restorative plan hinges on the retention of involved abutment teeth for fixed or removable prostheses.

While provisional replacement or splinting therapy may negate esthetic and masticatory difficulties during this interval, such treatment may complicate plaque control procedures and may be prohibitive financially for many prospective patients. Hence, as in other facets of treatment planning, the therapist must weigh all the factors involved and determine the therapeutic approach which he feels is in the best interests of his patient. Thus, although grafting might be feasible, resective techniques or selective extraction might be deemed the better treatment approach in specific cases.

ROOT RESORPTION

Root resorption has been demonstrated to occur as a result of many factors including occlusal trauma, anky­losis, orthodontic therapy, "reattachment procedures," etc. Morris in several studies has indicated the potential of viable hematopoietic marrow to induce the phenom­enon when placed in juxtaposition to notched root frag­ments and implanted subcutaneously in the rat. 1 0 - 1 2 In addition, root resorption has been noted in human sub­jects treated with iliac transplants.4, 6, 7, 1 3 , 1 4 These cases have ranged from minimal apparently self limiting re­sorption to a progressive condition resulting in excessive resorption and pulpal-periodontal communication. A l l cases observed to date have appeared to initiate at or coronal to the bony crest rather than immediately adja­cent to the bony implant. This is in contrast to Morris's findings. However, viable marrow elements might be present in this region and be related to the resorption phenomena on the root with or without replacement with cancellous bone.

Several factors present themselves as being potentially important. The first is the maintenance of viability of the marrow elements in the transplant. If Morris's find­ing can be extrapolated to the human, it would appear desirable to modify the marrow elements in some way

so that its bone induction properties would be retained while its dentinoclastic activity would be curtailed. Stor­age techniques such as those previously described may have this effect.1,6 Studies now in progress will hope­fully shed light on this hypothesis. Until results are available, it remains as an unfounded speculation. How­ever, it should be noted that root resorption has not been observed by this author or reported in the litera­ture in clinical cases treated with frozen material. While most cases treated with direct transplants have not demonstrated root resorption, it seems likely that mar­row elements adjacent to the root surface and at the coronal portion covered by a fragile papillary flap would become necrotic and eventually be replaced by repair tissues. Perhaps in those cases demonstrating root re­sorption, viability was maintained for a variety of rea­sons including expertise of tissue handling on the part of the clinician and dentinoclastic activity was in some way triggered.

A second factor which may have bearing on the vul­nerability of root resorption is the degree of root prepa­ration which has preceded implantation. Tissue reat­tachment studies have indicated that when cementum is removed, dentin resorption precedes cementogene-sis. 1 5 - 1 8 Thus, dentin exposure by itself or in conjunction with hematopoietic marrow grafts may potentiate ab-berations of dentin resorption. Although the patient may present himself for therapy with previously de­nuded dentin in an area of regenerative therapy, it may be desirable to minimize root reduction during therapy to enhance retention of any remaining cementum. On several cases demonstrating root resorption, extensive root planing was accomplished which presumably re­moved any remaining cementum at the time of surgery. Studies are also in progress to validate or invalidate the premise that cementum retention or chemical alteration of exposed dentin may lessen root resorption potential.

A third factor which may have some bearing on root resorption is the relative mobility of the treated tooth during the postoperative healing period. While this con­sideration seems minimal by comparison to marrow viability and root preparation, several of the available cases have shown either splinting with virtual lack of movement of involved teeth or rather marked mobility patterns, i.e., class II + mobility of the treated teeth. Perhaps a "physiologic" movement pattern is less con­ducive to abberations in repair. This speculation, how­ever, carries no supportive findings and no studies are in progress to acquire pertinent information.

Regardless of its etiology, closely monitored roent-genographic assessment of grafted sites would appear to be in order during the first year—especially in the first six months—post implant. If resorption is noted supra-crestally and appears to be progressive in nature, sur­gical entry, placement of a restoration in the site and

6 Schallhorn J. Periodontal. January, 1972

FIGURE 2. A. Probe depicting extent of defect between teeth Nos. 26-27. It was a two-wall crater type with a crypt extending on the lingual aspect of tooth No. 27. B. Re-entry eight months postoperative showing fill of crater defect. C. Probe on bony crest. Resorption notch (arrow) clearly visible to 2 mm marking supracrestally. D. Area of resorption fol­lowing preparation and placement of amalgam restoration (arrow). E. Preoperative roent­genogram showing extent of lesion. Tooth No. 26 responded normally to pulp vitality test­ing. F. Roentgenogram six weeks postoperative with suggestion of supracrestal root re­sorption on distal of tooth No. 26 and mesial of tooth No. 27 (arrow). G. Roentgenogram three months postoperative with definite evidence of supracrestal root resorption on tooth No. 27 (arrow). A slowly progressive resorption over the following five months prompted re-entry and placement of an amalgam restoration.

7 Iliac Transplant Problems Volume 43 Number 1

FIGURE 3. A. Two-wall osseous defect distal to tooth No. 26. The lesion sluiced to the lin­gual. B. Recurrent lesion appreciably greater than the original defect 25 months following grafting therapy. The patient moved to a different community eight months previously and failed to maintain his recall schedule at his new location. Furthermore, his history re­vealed that he developed a periodontal abscess in the area approximately four months previously after eating popcorn. He established drainage with a toothpick and had been relatively asymptomatic since that time. C. Original preoperative roentgenogram. D. Twenty-five month roentgenogram showing recurrent lesion of considerably greater mag­nitude than the original lesion. Tooth No. 26 responded normally to pulp vitality testing. E. Roentgenogram 20 months past second procedure. F. Roentgenogram 54 months fol­lowing initial grafting therapy and 29 months following second stage graft. A suggestion of ankylosis has been present on the distal aspect of tooth No. 26 for 26 months.

apical repositioning of the tissues may prevent further sequelae and maintain the integrity of the involved tooth. The only case encountered by this author in over 500 iliac autografts in a five year time span was man­aged in this fashion (Fig. 2).

It should also be noted that a roentgenographs sug­gestion of ankylosis has occurred in several cases in the series mentioned. While no evidence of root resorption has been noted in these sites to date, normal osseous turnover may make these areas vulnerable to eventual root resorption.

Several cases have demonstrated such findings more than two years following transplant therapy. Each pa­tient had gone through an initial preparation period and was re-evaluated for tissue response, ability to maintain plaque control, and attitude before grafting therapy was contemplated. One case had recurrence to a greater degree than the original defect due to foreign body im­paction in the graft site, periodontal abscess formation with drainage established by the patient, and eventual chronicity of the condition due to patient neglect in seeking care for his acute exacerbation and in maintain­ing his recall appointment schedule. Although such neglect on the patient's part is of primary concern, the therapist shares in the culpability of the problem by apparently not engendering in the patient the proper attitude toward the importance of regular recall exam-

R A P I D R E C U R R E N C E OF D E F E C T

Few things are more disheartening to a therapist than to observe a successful result to therapy deteriorate.

8 Schallhorn J. Periodontal. January, 1972

FIGURE 4. A. Roentgenogram one year postoperative. B. Roentgenogram 30 months post­operative showing less density and surface breakdown at the graft site. In spite of osseous changes, crevicular depth was less than 2 mm. C. Roentgenogram 48 months postoperative showing additional resorption in the graft site. Pocket scores of 4 to 6 mm were also present.

inations and emergency examination when the need arises. Periodontal patients are rarely cured and this concept is to be discouraged on the patient's part. How­ever, many patients acquire this belief regardless of endeavors to the contrary on the part of the therapist. Fortunately, in this case, the site responded favorably to additional transplant therapy and has been stable for over two years following this experience (Fig. 3). The patient has also been faithful in his subsequent mainte­nance and recall schedule.

Another case in point is a progressive failure that was considered a success at the 18-month postoperative evaluation but showed signs of breakdown following the two year check. The etiology in this case was construed to be inadequate plaque control resulting in recurrence of the lesion (Fig. 4). It was of particular interest to note the apparent lability of the graft site in contrast to other areas in which plaque control was also lacking. While other local factors may have been present, an­other consideration which may account for the relative disparity in response to irritation relates to the character of the healed wound and the influence of nutritional factors. Studies by Pirami, 1 9 Stahl,20 and others have alluded to the susceptibility of healed wounds to nutri­tional deprivation of ascorbic acid and protein with resultant dehiscence of the "healed" wound. The pa­tient in question was reassessed at 30 months post im­plant therapy when roentgenographic signs of deteriora­tion were first detected. At that time he had a fasting plasma ascorbic acid level of 0.2 mgm % and his di­etary pattern was not in keeping with that recommended by the National Research Council. The patient rejected dietary counseling and supportive nutritional therapy, was erratic in maintaining his recall schedule, and con­sistently was negligent in achieving interproximal plaque

control. Psychiatric referral was attempted but the pa­tient refused such consultation. Continual roentgeno­graphic evidence of gradual breakdown has been noted over an additional 1½ year period since recurrence was first observed.

Both cases illustrate the importance of evaluation of a patient's attitude and ability to control plaque before establishing a comprehensive treatment plan. However, even when this evaluation proves favorable, as was deemed in these cases, one must be cognizant of transi­ent behavioral changes by patients to accommodate their acceptance by the therapist. Following active ther­apy they may revert to pre-treatment behavioral pat­terns and regress. In any event, if a patient is insuffici­ently motivated to maintain plaque control and a recall program, surgical therapy involving osseous grafts is not deemed to be in the patient's best interest. Possible ex­ceptions may be handicapped individuals who are re­ceiving oral hygiene assistance by another responsible party.

A thought provoking question also arises. Namely, what is the role of nutritional factors in the stability of surgically treated cases? Perhaps the impact of nutri­tional considerations is prominent in the etiology of recurrent lesions in contrast to its seeming lack of im­portance in the etiology of the initial lesion. A re­assessment of nutritional factors in this area of perio­dontics is urgently needed.

S U M M A R Y

Several postoperative problems encountered with autogenous iliac transplants have been discussed with suggested hypotheses for their occurrence and specula­tions regarding their prevention. As with all modalities

9 Iliac Transplant Problems Volume 43 Number 1

of treatment, the clinician must weigh the existing body of information available on specific techniques and exer­cise judgment regarding the selection of the therapeutic approach he feels offers the greatest service and least potential risk for his patient. No single endeavor should be universally applied to all cases.

BIBLIOGRAPHY

1. Schallhorn, R. G.: Eradication of Bifurcation Defects Utilizing Frozen Autogenous Hip Marrow Implants. Perio­dontal Abstracts, 15:101, 1967.

2. Schallhorn, R. G.: The Use of Autogenous Hip Mar­row Biopsy Implants for Bony Crater Defects. J. Periodont., 39:145, 1968.

3. Johansen, N . C : Human Block Sections in the Evalu­ation of Iliac Crest Grafts. Presented at the Spring Meeting, American Academy of Periodontology, New Orleans, Lou­isiana, May, 1969.

4. Rhodes, P.: Reconstructive Periodontal Surgery. The Iliac Crest Bone Marrow Autograft. Presented at the 55th Annual Meeting, American Academy of Periodontology, Philadelphia, Pennsylvania, October, 1969.

5. Seibert, J.: Reconstructive Periodontal Surgery: Case Report. J. Periodont., 41:113, 1970.

6. Schallhorn, R. G., Hiatt, W. H. and Boyce, W.: Iliac Transplants in Periodontal Therapy. J. Periodont., 41:566, 1970.

7. Schallhorn, R. G.: Additional Observations on Hip Marrow Implants. Presented at the Spring Meeting, Amer­ican Academy of Periodontology, New Orleans, Louisiana, May, 1969.

8. Schafer, T. L., Collings, C. K., Bishop, J. G. and Dor-man, H. L.: The Effect of Antibiotics on Healing Following Osseous Contouring in Dogs. Periodontics, 2:243, 1964.

9. Ariaudo, A. A.: The Efficacy of Antibiotics in Perio­dontal Surgery: A Controlled Study with Lincomycin and Placebo in 68 Patients. J. Periodont.-Periodontics, 40:150, 1969.

10. Morris, M . L.: Implantation of Human Dentin and Cementum with Autogenous Red Marrow in the Rat. J. Dent. Res., 49 (Supplement): 180, 1969.

11. Morris, M. L.: The Implantation of Human Dentin and Cementum with Autogenous Bone and Red Marrow into the Subcutaneous Tissues of the Rat. J. Periodont.-Periodontics, 40:259, 1969.

12. Morris, M . L.: The Implantation of Human Dentin and Cementum with Autogenous Red Marrow into the Sub­cutaneous Tissues of the Rat. J. Periodont.-Periodontics, 40: 571, 1969.

13. Siebert, J. S.: Personal Communication. 14. Johansen, N . C : Personal Communication. 15. Persson, P. A.: The Regeneration of the Marginal

Periodontium after Flap Operation. An Experimental Study on Dogs. Acta Odont. Scandinavica, 20:43,1962.

16. Hiatt, W., Stallard, R., Butler, E. and Badgett, B.: Repair Following Mucoperiosteal Flap Surgery with Full Gingival Retention. J. Periodont., 39:11,1968.

17. Stallard, R. and Hiatt, W.: The Induction of New Bone and Cementum Formation. I. Retention of Mineralized Fragments within the Flap. J. Periodont., 39:273, 1968.

18. Paik, S., Kennedy, J. and Zander, H.: Subcutaneous. Tooth Autografts in Rats. I.A.D.R. Program and Abstracts, of Papers #274, March, 1971.

19. Pirami, C. L. and Levenson, S. M. : Effect of Vitamin C Deficiency on Healed Wounds. Proc. Soc. Exp. Biol. (N.Y.), 82:95,1953.

20. Stahl, S. S.: Influence of Prolonged Low-Protein Feeding on Epithelized Gingival Wounds in Adult Rats. J. Dent. Res., 45:1448,1966.

Announcements

Dr. D. Walter Cohen, University of Pennsylvania, receiving the Gold Medal Award from Dr. Walter Gottsegen, Presi­dent of the Academy.

UNIVERSITY OF MARYLAND

The University of Maryland announces the following continu­ing education courses:

February 12 and 13, 1972: Clinical Application of Occlusion Relative to the Natural and Restored Dentition—Dr. Lawrence F. Halpert and Dr. I. N. Brotman.

March 8, 1972: Temporomandibular Joint Problems: Diagno­sis and Treatment—Dr. Marvin Graham.

March 15, 1972: The Preventive Power That Pays—Dr. Omer K. Reed, (location: Hunt Valley Inn).

March 30 and 31, 1972: Concepts of the Preliminary Diag­nostic Work-up and Periodontal Instrumentation for Dental Hy-gienists—Miss M. J. Healey.

April 19 and 20, 1972: Basic Periodontics for the Practitioner —Staff, Department of Periodontics, University of Maryland.

May 17, 1972: Periodontics—New, Used and Abused—Colo­nel J. Seibert, D.C., U.S. Army.