Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Julia Plevnia who is here to discuss, do I need a bone graft? Dr. Plevnia, thank you for being here.

Julia Plevnia: Thank you, Bill, for inviting me.

Bill Klaproth (host): Oh, of course. Are you kidding me? It’s great to see you. So, let's jump into this topic. Can you explain to us what is a bone graft?

Julia Plevnia: Well, bone graft can be taken from a patient. You can take it from donor sites, which can come from a human and also animals. You can also use manufactured bone graft that is synthetic material. And it can be placed in places where we need to augment the ridge. And placed in places where we're missing teeth for future implant placement.

Bill Klaproth (host): Okay. So, in those cases, that's why we would need a bone graft. Is that right?

Julia Plevnia: Right. You want to be able to have an ideal site. For dental procedures, when you extract a tooth, sometimes we lose bone, and we need to augment that ridge to place an implant. And sometimes we have to put bone graft on facial trauma patients for reconstruction of their mouth or in their face or in the jaw.

Bill Klaproth (host): Okay. So, then the goal of bone grafting is you have to have this strong foundation. Is that what it is? What is the goal then of bone grafting?

Julia Plevnia: We want to have an area where we have ideal bone, where we have good quantity and good quality of bone. And the site is augmented to place an implant for future form and function. Bone grafting can facilitate with dental implants to improve their ability and their capacity for chewing. It can improve their appearance and implants replace where they're missing teeth. And with improved function and improved esthetics, the bone graft is like the steppingstone to the start of a dental implant procedure.

Bill Klaproth (host): So, you said earlier, you can get bone from various places. What are the factors that come into play when selecting the appropriate bone graft source?

Julia Plevnia: That depends on how much bone you need, how big of a defect there is and how much form and function we need to augment. So, the different places you can get bone, you can get it from the lower jaw called the mandible. And it comes from either the back of the mouth where the wisdom teeth used to be, or it can come from the chin. We can also get a large amount of bone from the hip, and we can take it from the front of the hip or the back of the hip. The back hip is where we get the most bone from. We can also take ribs. We use a lot of rib grafts when we're looking at trying to get some cartilage and some bone. Cartilage can be used with joint augmentation. We can get some bone from the side of the leg, the tibia, which is the shin bone on people. And then we can also take it from the back of the skull.

Bill Klaproth (host): So, for getting the bone graft source if you will, you said earlier you need a bone graft for tooth extractions, dental, implant replacement, facial trauma. If it's something like where someone needs dental implants because they didn't take care of their mouth, chances are, you're not going to get the bone graft from inside the oral cavity because their bone is shot. That's when you go to the hip or other places?

Julia Plevnia: Well, you can take bone from the mouth. And it depends on the amount of bone we need.

Bill Klaproth (host): And the health of the bone?

Julia Plevnia: Well, you're not going to take a bone necessarily out of the area around the teeth, because if they're losing the teeth, they may have periodontal disease. They may already have bone loss. But we can get good healthy bone from the chin and from the back of the jaw where the wisdom teeth used to be. So, if we need a small amount of bone, we can take it from in the mouth. If we need a large defect, like if somebody was in an auto accident, then that's when we're going to harvest bone from the hip and we'll take cortical bone, and we'll also take cancellous. Those are the hard bone and the softer bone, the bone marrow.

Bill Klaproth (host): So, then what other factors come into play when grafting?

Julia Plevnia: The patient's health becomes big component on deciding what kind of graft we're going to use. If the patient's a diabetic, if the patient's overweight, if the patient's a smoker. We have a lot of patients now that get a lot of bone density testing done, and the quality of bone from somebody that has osteoporosis wouldn't necessarily be the ideal patient, but you can get cadaver bone and donated bone to help augment the quality of bone graft that we're going to put into place.

Bill Klaproth (host): So, when someone does get a bone graft, how does that work? How long does the procedure take? I'm sure there's a variability to it, but is it painful? How does it work for someone listening, going, “Oh, God. I've got to have a bone graft. What does that entail?”

Julia Plevnia: Well, that's a great question because most of the time, when you harvest the bone, that's more painful than when you're placing the bone to the recipient site. The donor site on the chin or the back of the mandible, the hip, those can be painful procedures postoperatively. And the recipient site usually is not what the patients complain about. Usually, a couple of weeks recovery after a hip graft or tibial harvest. But the recipient side is not usually the chief complaint of where the pain is.

Bill Klaproth (host): So, when you talk about a graft, don't have the thinking about bones, soft tissue is easier to kind of understand how do you take a piece of bone out and put it somewhere else? Do you, how does that work? Do you, you know, saw a piece of bone out?

Julia Plevnia: Actually, yes. That is how it works.”

Julia Plevnia: So, the soft tissue gets reflected back, whether it's on the hip or on the chin or the back of the jaw and then we get down to the bone. And when we're taking cortical bone, we'll make vertical cuts and we'll take a chunk of the hard bone. And that is usually placed in an area where there's a big defect, reconstruction from a car accident trauma, or if somebody had a lot of bone removed for pathology. And then, the marrow bone gets kind of placed around the hard dense bone in those areas to kind of fill in the cracks, so to speak.

And then the soft tissue is placed back over the graft. the blood supply for the graft to heal comes from the soft tissue that's over the bone. So, when you place soft tissue over the bone, we want to have, it doesn't want to be tight. It doesn't want to be compressed. So, we have to usually reflect back a lot of the tissue. And then cover up the bone so that we get a good blood supply so it heals well.

Bill Klaproth (host): So, you're not taking a big, large chunk of bone that's going to go in someone's mouth or jaw, right? It's a smaller little area of bone. That's how you can cut it out, if you will?

Julia Plevnia: It depends. The anterior hip, you can usually get a two centimeter by three centimeter block of bone. The posterior hip, you can take a five-by-five centimeter of hard cortical bone. And when you have those areas exposed, you can really kinda, it's almost like taking an ice cream scoop and you take out the cancellous bone out of the area where you remove the hard bone and you pack that cancellous.

Bill Klaproth (host): You're forming it with this bone around where you need it to build up the ridge?

Julia Plevnia: Exactly. And then you have to have a lot of laxity of the soft tissue, so you can close the soft tissue over the graft so that you get a good blood supply so it heals. But traditionally, the harvest site where you steal the bone and you place it into the defect into the mouth, the mouth is not usually the more painful portion of the procedures. It's the harvest site that usually is more painful.

Bill Klaproth (host): Yeah. Yeah, cause then you'll have to like suture up the incision where you had to go in and get the bone and you have stitches and things.

Julia Plevnia: Correct. And the patient usually has, it's painful to walk if they take a hip graft, if they take bone from the shin on the tibia. That's tender to walking and pressure when you're carrying the body weight.

Bill Klaproth (host): Well, fascinating. So, thank you for explaining that. I've always wondered that. And I would imagine people listening to are like, “How do they get the bone out? What do they do?”

Julia Plevnia: There's usually, saws, like you said, and little chisels and mallets and instruments that look like little ice, tiny ice cream scoops.

Bill Klaproth (host): So, you come in with the little tiny ice cream scooper and the little bitty hammer and the saw and you get in there.

Julia Plevnia: The patients are usually asleep. They're sedated. If it's smaller procedures where we're taking from the mouth, the chin, the back of the jaw. Those are procedures that we do in the office. And the patients are usually sedated. If we're going to take a hip harvest, which means we're augmenting a big defect, we're going to have the patient in the operating room under general anesthesia.

Bill Klaproth (host): Wow. That's fascinating. So, then what is the healing process after the bone graft?

Julia Plevnia: It varies from patient to patient and it varies from the extensiveness of the procedure. A simple posterior maxilla augmentation is usually a day or two of ache and pain. But, the patients can have, if they do a hip harvest, they may have about two weeks of recovery. Where they have downtime, and it's probably not recommended that they would go to work during that time. So, it depends on the extensiveness of the procedure where we take the harvest from where we steal the bone from.

And then, also how much of the graft that we need. So, a bigger hip procedure, a couple of weeks, small little augmentation in the sinus, a day or two.

Bill Klaproth (host): So, the body will accept that bone when you move it from one area to another. The body integrates that bone. Right? Accepts it. Because then you start getting blood flow into it and you get the soft tissue wrapped around it. Is that right? It becomes one in that area.

Julia Plevnia: Exactly. Your body likes you better than anybody else. So, if you're taking graft from, pig or cow, those are usually—

Bill Klaproth (host): Like, what are you doing to me here? What is this, right?

Julia Plevnia: Well, I tell my patients, once they start moving, it's working. But when you take graft from the patient's own body, their body likes them better than anything else. We also get a lot of donor bone from cadavers and that comes in a bottle. And so, we'll take and augment that with the patient's own blood supply. So, we'll do a blood draw. And we'll use the patient's blood. And it's kinda like jumper cables onto a battery. The patient's blood acts as like jumper cables to a battery. The cadaver bone are particles that patients get from donor bone or bottled bone. And with their platelet rich plasma, we mix that together. The graft becomes sticky and we place it into smaller sites and they heal well.

Bill Klaproth (host): Wow. Again, this is a fascinating, so when it comes to bone grafts, what else do we need to know that I didn't ask you? Anything else you want to add when we're talking about bone grafts?

Julia Plevnia: Grafts are usually simple procedures that can be done in the clinics in the oral surgeon’s office. Open sinus lift, maybe a 30-minute procedure. A hip graft is going to be maybe a two-hour procedure in the operating room. So, from the smaller procedures, those are simple and can be done in under an hour and the patient can go back to work usually in a day or two. Larger ones, it's a little bit longer, more extensive and can be in an outpatient surgery center.

Bill Klaproth (host): Got it. All right. Well, Dr. Plevnia, again, this has been fascinating and very informative. Thank you so much for your time.

Julia Plevnia: All right, thanks for having me, Bill. I enjoyed it.

Bill Klaproth (host): You betcha. That is Dr. Julia Plevnia. And for more information and the full podcast library, please visit MyOMS.org. And if you found the show to be interesting, please share it on social media and don't forget to subscribe. Thanks for listening.