Bio-Oss: Mix Small and Large Particle Sizes?

In BAOSFE procedures, i use a well hydrateted graft material, like Fiosiograft (from Ghimas)according to Pascal' s law on wich the whole BAOSFE technique relies on; actually, the use of a hydrateted filling material enhances the probabilities for doming the sinus membrane without tearing it. Nevertheless, the use of Bio Oss is largely described in literature as grafting option in BAOSFE

Sounds like great selling pitch - buy 2 packages when you only need one. Gold standard for bone grafting is autografts and certainly not xenografts. Why not consider allografts for this procedure. Technique and not particle size will prevent membrane tearing - take your time and elevate slowly using the packed graft material. I find that PUROS is a great grafting material in the sinus that actually has histomorphometric data to support graft resoprtion and new bone formation to a greater degree than BIOOSS in the sinus. Good luck

Regarding Dr. D's question regarding Bio Oss as the gold standard. Why would you prefer a zenograft over an allograft? Autogenous has been the gold standard, however FDBA hydrated in PRP gets pretty darn close in studies of sinus augmentation with immediate implant placement. Dr. Arun Garg's text on Bone Grafting is an excellent resource for this complex but essential topic for the implant surgeon. Hope it helps. Dr. G

Dear Dr. D., I agree with Dr. F. I guess I'm a little more secure in my "vote" as I put in my whole name. Why use a graft that, according to human and animal studies, is non-resorbable. I use either allograft, synthetic or combination graft that will resorb and convert to vital, osseointegratable bone. I don't use a material that, although there is metanalysis data showing implant success in conventional sinus grafting, is only a scaffold. Additionally, if you're going to use a scaffold-type material, why not use one that was shown in our NYU studies to result in 2 times the vital bone formation as BioOss.

I have used 3i's Endobon recently and I would prefer larger particle sizes 500--1000 for sinus lift procedures.

It seems like there is a lot of bio oss bashing in terms of graft material. It is true that bio oss never turns into bone and is good for a "scaffold". Histologically it just doesn't make sense placing implants into bio-oss the more I think about it. My personal preference is a autogenous graft for osteotome sinus lift or any other graft procedure. However, this scaffold action of bio oss in sinus lift procedure is not such a bad thing for lateral window technique since you need so much graft material. I personally use mixture of large particle sized bio oss (for volume), puros, and/or autogenous graft. But then again I did all my sinus lift with bio oss (or some times puros) in my earlier career and had 100% success rate. When I did sinus lift with autogenous graft only, It seems like there was more resorption of the bone compared to mixing it with bio oss. Perhaps technique is more important than choice of material.

I suggestion to you that use by NU_OSS from ACE company this proudact has a gold standard and cheper than bio oss.

How many more studies do you need to have published that shows Bio Oss works the best for any material on the market today. Medline Pascal Valentini's studies that shows the succes of Bio Oss. Hallman 's study in JOMI 2002 shows up to 80 - 100% of a sinus graft can be Bio Oss with great success. Artzi in J Perio 2001 showed the same. Lee's study in IJPRD in May 2006 showed incredible rsults with Bio Oss as well. Aghaloo in IJOMI showed that implants placed in a xenograft showed the highest success rates in longterm follow up with all grafting material compared. These are only a few of the hundreds bio oss may have documenting there product. I would recommended to all my colleagues to sit in on a lecture from NYU's Steve Wallace who shows the science and backs it up with the data that shows why Bio Oss performs the best in sinus augmentations. Dont let marketing hype and paid opionion leaders be your decision factor . Let research and science be the determining factor for our patients. As far as mixing Bio Oss with a Puros type material I cannot comment on because to my knowledge there has been no studies showing good or bad. Why treat our patients as lab rats . Ask your Geistlich/Bio Oss rep to show you comparitive studies on Bio Oss compared to Nu Oss. They are not the same product. Geistlich im sure has a patent on the manufacturing process that prevents it from being the same. Its common sense. Feedback I have gotten from other colleagues that used it mostly switched back to Bio Oss for the predictable results. Just like the knock off implants that say they are the same as the bigger implant makers somewhere somehow corners are cut in the maufacturing process. J Peter

I agree with Dr. Bob Horowitz. Bio-Oss is a scaffold, it does not stimuate bone regeneration in the defect. Most of the synthetic bone grafts (especially calcium sulfate, and to some extent TCP) resorb after placement in defect and stimulate bone formation. So would you rather have implant placed in patient's own vital bone or in scaffold? No doubt you would prefer vital bone. Asking you to buy two sizes of particles is a great way to generate money for the company. Why don't they mix two particle sizes together and sell as a single patient kit? And If you were to mix Bio-Oss with other bone graft, mix it with Medical grade calcium sulfate (there are products out there, one was reviewed on this forum a few months ago). Research shows that it improves handling as well as performance of xenografts and allografts.

Bio Oss may be a little to hard on the lymphatics (takes too long to turn over) , consider using Osteogen (densely packed)

I have moved away from Bio-Oss except in the sinus, but I don't always use it. There is some evidence in the literature that Bio-Oss is slightly osseoconductive. When I use large particle, sometimes it gets stuck together. You might try crushing the large particle a bit to get a mix of particle size. People may think that's crazy, but if you are using a mix of particle size, you aren't that concerned with graft homogenosity

In my hands, Bio Oss doesn't work at all. Any implant failures I have had are all associated w/ Bio Oss. I gets encapsulated and I hate seeing the mush when I reenter. Since I stopped using it 2 yrs ago and switched exclusively to autogenous (gold standard) or U of Miami FDBA (mineralized cancellous 300-500u), I have had zero failures. I look for any opportunity to harvest autogenous - trephine in adjacent site, reduction of exostoses or tori, using chisels, saving bone from my implant drills, etc. Any little bit of autogenous bone you can pick up will make a difference. I once had a patient with large buccal exostoses who needed a lateral sinus lift and was able to harvest about 50% of the bone w/ chisels, trephines. I love it when that happens.

BioOss has a low substutution rate. That's actually why it is so suitable in some implant grafting situations eg labial tissues. Autogenous bone should be used beneath it and against the implant. Most dental grafting situations utilize the osseoconductive properties of grafting materials rather than their osseoinductive or osseogenic properties ie guided bone regeneration.

I will compromise on the above comments. I use Bio-oss initially to pump up the membrane. Then I follow it up with Puros, small particles. If I use the Piezosurgery trumpet, I just use Puros as it does not wash away in the sinus cavity so easily.

Whenever ther is a debate on the "virtues" of bio-oss, there is always one common thread. Many clinicians share their implant failure rate when bio-oss is used in an extraction site. The evidence is clear that this graft does not resorb and the low percentage of vital bone is insufficient to contain the implant in full function. But everyone is quick to quote Steve Wallace's studies on bio-oss in sinus grafts and the success rate of implants after loading. However, these are some of the most seriously flawed studies I have reviewed. In most sinus grafts, there is a zone of autogenous bone from the crest to the sinus floor. When you load an implant, it is the creatal third of the implant where the predominant stress of loading occurs. And this is usually in 100% autogenous bone. It makes little difference what you have in the apical half as the loading is almost inconsequential. How many times have you seen a failed sinus graft with an implant in only the crestal 50% of bone where it survives long term? We see this routinely. Contrast that with sinuses where the floor was congruent with the cortex. THESE cases fail at a very high rate when a non-resorbable graft is used. DO NOT compare the sinus graft study with placing implants in a bio-oss grafted extraction site. The dynamics are completely different.

"only the crestal 50% of bone where it survives long term?" I think it's fair to say that as long as you have a sinus floor that is at least 4-5mm thick, almost any type of material grafted into the sinus will work.

Bio Oss has more than 20 years of scientific results.Cheap or not cheap....is not the question...and many times patients do not want autogenous graft procedures....unfortunately.... But mixing particles and having the oportunity to obtain autogenous bone plus BioGide for sure is the best combination for sucess. Any additional comments, regarding why or not are using BioOss has no sense,because the literature is wide enough about this... Today doctors that are not sponsored by companies are in the seeking of weak arguments to beat serious companies In a battle of Pureoss vs BioOss....BioOss is the winner.....no doubt about it!!!!! Just read colleagues, before write....