I had the privilege of being a learner yesterday as an attendee of the Seattle Study Club Annual Symposium. This morning Dr. Michael Pikos presented on bone and soft tissue augmentation, and gave us the recipe. Although I do almost no surgery in my practice it is part of a large majority of my comprehensive treatment plans, and Dr Pikos’s explanation this morning was so powerful that I feel like I can now evaluate surgical sites in a whole new way. Whether through a process of natural healing or an intentional process of regeneration the recipe for growing bone and soft tissue is always the same: cells, signal and matrix.
Having cells, specifically stem cells or pluripotential cells is the first ingredient we add to the recipe. A someone who bakes, for me it is like the flour in a bread recipe: It is the base. Once we have cells we need to signal those cells to cause capillary ingrowth, cell proliferation, cell specification or differentiation and to up-regulate cellular function. The signal causes the cells to become a specific type of tissue, to grow and to become self-sustaining. The signal is provided by cytokines, specifically growth factors and differentiating factors. The last ingredient in our recipe is the matrix, a scaffold or latticework that holds the cells in a form or shape we need for the final tissue or bone.
Blood is an excellent source of all three ingredients, providing cells, releasing growth factors from platelets, and creating a matrix from the fibrin and fibronectin in the plasma. Although blood is an excellent source of all three ingredients, it isn’t always capable of growing bone or tissue in enough quantity or quality, so many surgeons augment the process today. For years I have listened to both the oral surgeon and periodontist I work with talk about using graft materials, titanium mesh or enhancing surgical outcomes with platelet rich plasma (PRP), plasma rich fibrin (PRF), plasma rich in growth factors (PRGF) and bone morphogenic protein (BMP). I now understand each of these additions is simply amplifying the natural recipe and adding cells, signal or matrix to augment the regenerative process. Understanding the recipe and optimizing the three ingredients is the key to successful augmentation.