Loose Bio-Oss Particles: Can Implants Be Placed?

I have encountered this situation a few times three months postop and was able to place the implant. I feel comfortable as long as I can ensure primary stability. All implants integrated without any problems. One way I assess the grafted socket is by sounding the bone with a probe after local anesthesia.

It depends on what did you use for bone graft. If you are using Bio-Oss which has a slow turnover you have to wait longer. I personally don't use Bio-Oss often but if I do I wait around 6months, yet I often found loose particles. I recommend that you get to know and use more than one graft material based on clinical situation. If you want the bone graft to stay around longer, like sinus lift or ridge augmentation, you choose a material that resorbs slower such as Bio-Oss. on the other hand if you want quick turnover. like with ridge preservation, you use a material that resorbs faster such as Allograft. by the way a lot of researches show that Bio-Oss stay in the body for a long time "not necessary a disadvantage.

Bio-Oss does not have the ability to regenerate bone. The human body's main objective after an injury is to repair itself. In VERY few cases can the body regenerate lost parts. Therefore, the surgical dentist should use a material that will aid the body to regenerate the bone. There is nothing in Bio-Oss to do that. That doesn't mean the Bio-Oss material is bad, it should be used only as a filler or to repair a defect. The bone adjacent to the implant should be living bone and not a filling material.

I agree with Don and Saad regarding the use of Bio-Oss. Because of slow turnover (or almost no turnover: can take up to years according to literature), I never use it in socket preservation or in lateral ridge augmentation. I find that bio-oss only maintains the space and almost always feels very granular and will tend to separate as particles when you are creating/drilling your osteotomy site for implant placement. I truly believe that we have better regenerative materials (FDBA and DFDBA) available that can do better job for socket preservation/ridge augmentation in preparation for future implant site. The only time I would Bio-Oss is for Sinus lift procedure.

Anon... I would agree with the comments about BioOss. Consider using Cerasorb by Curasan. It is synthetic and histologically mimics autogenous bone closer than other materials. After four months, the socket will be solid. Remember, the center of an extraction socket is the last to mineralize so loose particles indicate a failure of the material to turn over and be replaced by bone.

I would encourage you to brush up on bone physiology and understand the scientific basis before you apply it in clinical practice. Practicing with firm knowledge and surgical principles will yield more consistent results. Understanding from trial and error will cause many headaches. You may also investigate the different biomaterials available to you, such as autograft/autogenous, allograft (PUROS, MTF, Freeze-dried DMB), and synthetic agents (BMP).

While it is true that Bio-Oss turns over very slowly, histological studies have shown implants placed in Bio-Oss are in contact with bone, not Bio-Oss. The problem with loose Bio-Oss particles can have a few causes. First is not having the graft particles well contained, having pressure applied to the graft during healing, especially early stages, not using a membrane to cover the graft, and exposure of the graft. Finally, not waiting long enough for the graft to fully consolidate and mature can result in loose particles at re-entry. It has been suggested that the healing rate for Bio-Oss is 1 mm per month for hard healed sites to form. That is not to say you can't place an implant in Bio-Oss before that time elapses, but you will be placing the implant into softer, less mature graft sites. For predictable, hard, well healed particulate grafts, you need a source of osteogenic cells (blood and cortical fenestrations into cancellous bone or marrow) and complete primary closure and maintenance of closure over the recipient graft site.

Anon, all of the above comments are true, and spoken with good authority from experienced implant surgeons. I personally would not enter a grafted extraction site for at least four months. After the local anaesthetic has set in, I generally press the needle of the syringe into the centre of the grafted site, and it will go almost to where the apex of the extracted tooth was. Using a "cookie cutter" remove the gingival tissue and then proceed with Osteotomes.Some serious resistance will be encountered as you go in with wider instruments. When you have engaged an Osteotome that is close to the final size, and you see there is good stability, it should be safe to screw in the implant. Histologicaslly, I would gather to say that there is a lot of osteoblastic activity taking place, and that the implant is being placed into a site that is very active in a positive way. On occasion, to ensure faster healing, if blood has been drawn at the start of the procedure, it would be an added advantage to place PRP into the osteotomy before screwing in the implant. Gerald Rudick dds Montreal, Canada

Anon, I am curious as to why you didn't place the implants at the time of extraction. If there were very large defects present, and I will assume there were, I believe given the types of graft material that is available, including autogenous bone, I think the Bio-Oss alone was probably not going to glean you the most favorable result. Given that the defects may have been large I would say that 3 months was not adequate time to allow for complete bone maturation. If there were 4 walls present at the time of extraction did you use the Bio-Oss to maintain space? If this was your objective I believe you may have overtreated the site. If you have 4 good walls and you just want bone fill, leave it alone and go back in 3 months and you will be just fine. Your most likely not going to see significant collapse of bone or soft tissue in that time frame. This has been shown very nicely by Dennis Tarnow at NYU. I do however believe your best approach is to place the implant at the time of extraction and bone grafting. The literature on this has been well documented.

Based on literature, grafting a socket at the time of extraction is indicated if the thickness of buccal plate is less than 1.5 mm. The best grafting material recommended is Autograft. The second choice of graft material is a mixture of 75% MFDB Allograft + 25% DFDB Allograft + Clindamycin 300mg liquid. The radiographic criteria for a grafted socket readiness for osteotomy is when in x-ray the lamina dura (Cribriform Plate of Alveolar Socket) has disappeared. It usually takes 3 months for the lamina dura to become disappeared. Osteoinductive materials are prefered to Osteoconductive ones such as Bio-oss which is a Xenograft.

After using many of the available grafting materials, alone and in different combinations, I am returning to the good old "pre-historic" autogenous bone. I find that on re-entry only autogenous bone gives me the solid, bleeding, normal looking bone I am looking for. With the advances in harvesting techniques and the variety of bone mills - obtaining autogenous bone is faster and easier than ever before. Still, long lasting bone substitutes have a role in providing bulk for the autogenous graft or in areas where implants are not planned (s.a. under a pontic). All being said, concerning sinus augmentation I find that everything and anything will work more or less.

I used to have similar results...have read all the other comments and agree...when I did go back in on sevral sockets it was almost as if the bio-oss was a plasticized material but not bone...I would switch your material in the future and use either irradiated cancellous, freeze-dried bone, or purous....I think when you go back in 3 months you will be very pleased

I believe that the most important factor for the implant sucess in the grafted sites, is the primary stability in thr natural bone. If stability can be achived in the residual bone it is advised to immediatly place the implant and use various grafting mateials as filers in order to regenatrate the original form of the bone and avoid the resorbtion of the residual bone, as well as to enable soft tissue support. If primary stability can not be achieved, the best way is to use autogenous bone covered with xenograft and a membrane (sandwich) since the resorbtion rate of the autogenous graft alone is very high. I would recomend waiting at least six months befor reentry and implant fixure.

I agree with most that has been said. I would not question doing a socket preservation here instead of an immediate implant; there are numerous valid reasons to stage the treatment. Bio Oss is a good product for maintaining a socket especially when used with a membrane and other techniques to protect the socket opening during early healing. I find it essential to wait 6 months minimum before implant placement into Bio Oss and longer in a larger socket with a bulky graft. At reentry I typically find loose Bio Oss particles within the deeper layers of the gingival flap and on the ridge crest. These particles can be carefully curetted away prior to starting the osteotomy. Using a cortical crushed allograft is just as effective at socket preservation and it allows you to place the implant after 4 months into much more natural looking bone.

I agree with Don Callan. My experience with Bio-Oss is now limited to filler only and never next to implants. Call it the school of bad memories.

All the talk about Bio-Oss as a filler and not capable of supporting implant integration doesn't match up with the literature which is full of the use of this material being very effective. If it was the case where Bio-oss was ineffective, all the implants that are placed in Lateral Sinus Lift cases should fail. As has been histologically shown, it is autogenous bone that is in contact with the implant, not the Bio-oss. The Bio-oss is within the bony matrix and provides additional density to the matrix. Bottom line is that there are multiple reasons why a graft may not "take". As has been stated, 3 months is not long enough for the bone to mature. If the material is contaminated (saliva), it is not going to perform well. I have found the particles not integrating with Puros or Curasan or Bio-oss. I believe it is primarily a function of maturation time, technique (ie degraulation, decortication, aseptic handling, etc), and patient compliance that makes the difference, not the material.

I agree with Dr Giesey we have immediately placed and loaded in a B tri-ca graft at 3months with no issues materials have moved on..

Ben, Wallace showed at the recent AO meeting histology and Bio Oss never was in contact with the implant. Dr G was right on.

Biooss or Biooss like bovine products are good materials for sinus augmentation as well as all the others(look at Piatelli's publications) yet for socket augmentation I wouldn't use this material for several reasons. Biooss will not remodel and turn into living bone since the osteoclasts do not recognize the particles as foreign bodies therefore you will find these particles intact. I would like my implants to be placed in vital bone.I would recommend using either an allograft or a synthetic resorbable material.

I have found the same thing when I have gone in after placing Bio-os. It takes a long time to turn over. I do not use it anymore and would recommend using a cadaveric bone like Puros or any other brand. Yes, it is more expensive, but the results are better. Also, do yourself a favor and use a resorbable membrane if you can achieve primary closure. If I cannot get primary closure, I mix bone with Fusion bone putty and then place a collaplug with a figure-8 suture to hold it in place. This will give nice D-2 to D3 bone in 4 months. Hope this helps

Ziv is right on bovine products like Bio-oss. Dr.Steve wallace and Dr.Stewart Froum have done tremendous research on different grafting materials in sinus augmentation at NYU. Dr. Wallace in his lectures shows his histo-slides to proove Bio-oss is as good as other grafts in sinus augmentation.And at NYU we have prooven track record. But Bio-oss particles are to large to be phagocitzed in timely fashion. So Bio-oss is not a suitable graft in sockets grafting if ealry entry is desired.Waiting of atleast six months is advised.

When choosing a graft materal, the number of walls in the defect becomes an important consideration. In a sinus or extraction site, the number of walls may be 3-4. Angiogenesis occurs from several directions and the time to generate lamellar bone within the graft decreases substantially. However, I find that clinicians very often use bio-oss as an onlay graft which is a one-walled defect. Extra time must be given to these sites as compared to grafts that resorb more completely. Also, we have experienced delamination and fracture of several xenograft onlay grafts because of the fact that there is substantially less autogenous bone in these sites when placing implants. We now use zenografts only when we want to retain bone volume (i.e. in pontic sites) and not where we intend to place implants.

I am certain that if you will use natural graft material such as decalcified demineralized cortical bone with calcium sulfate you will see a distinct difference. You will grow natural bone and there is nothing better. Always remember the healing process. Don Callan is right. He has the recipe and oh what a sweet one it is.

Some good comments , Having used a Beta tri-Ca Phospate product in a sulphate matrix which allows it to set for the last 5 years and exclusively for the last 4 ( had used allografts for the 10 years prior) we have noticed the benefits of these materials in defect repair. The body wants to heal itself , we only do 5% of the work the boby does the rest , thus we need a material that is fully resorbed at the end of this healing to return the site to its healthy state. We merely need to prevent soft tissue ingrowth , tent the gingiva and provide nutrients (Ca and phosphate) and palce the implant at the time of graft to utilize the semiconductive nature of Titanium. And you know what bone is formed, the only use for HA is in socket preservation ( for Aesthetic reasons) and it can be added cheaply. We utilize thes materials daily with impressive results , shown at lectures. As for sinuses , a reason for them is to lighten the head to enable us to hold our head up. The overfilling or saying the HA is needed to is doubtful , the body determinets the amount of bone needed to support the implants functionally, thus the graft material must be resorbable. Many options work but thes least traumatic and most bio compatoible is a good start

I have recently tried the use of Nu-Oss from Ace Surgical as graft material following extraction sites. I have re-entered these sites between 4 and 9 months later for implant placement to find particules remaining and a soft tisuue ingrowth that I have rarely if ever seen with Purous. In 2007 I placed 302 implants in either unfilled extraction sites or sites filled with Purous and experienced a failure rate of 2 implants last year. Additionally I placed 11 implants in Nu-Oss, the same material as Bio-Oss and have enjoyed a 100% failure rate. Again, I have waited up to 9 months to re-enter these sites on 2 occasions and still have found particulate matter and ultimately both have failed. Needless to say this material has been eliminated from my practice as an extraction site material. I will still use the material with my sinus lifts mixed with Purous and PRP since I have enjoyed a tremendous success rate with this procedure and materials. Is it me or is it the material in this particular application? Reviews of the literature certainly support the possibilty that this may not be the most suitable material for extraction sites when anticipating implant placement. Purous and simular products are tried and proven and PREDICTABLE. I am now recalling 9 other patients that I placed Nu-Oss into their extractions sites and debriing the site of the Nu-Oss, placing Purous and waiting an additional 3 to 4 months before placing their implants. This has been a very frustrating and costly ride for both parties.

The Bio-Oss particles can be placed directly into a bone defect and maintained in position by the blood clot and overlying soft tissue envelope.They have been used in extraction sites to prepare them for future implant placement as early as eight weeks after tooth extraction based on the assumed bone fill in the presence of the material, but in general, the clinical results have not been quite satisfactory. These kinds of materials would be useful in preparing the extraction site only if a long time (more than six months) is anticipated for the placement of an implant. These materials would not be useful in preparing the extraction site for the placement of an implant at the short run because there is always minimal resorption of the material and minimal bone formation in the extraction site. In some cases, the presence of the material even inhibits bone formation. The Bio-Oss particles slowly resorb and may still be present at the area for several months. The Bio-Oss use in three-wall extraction defects or in the presence of thin labial bone to create a new facial cortex when it is missing may be indicated provided that any attempt to palce implants at the site be postponed for a time lapse, at least between six to nine months.

Mixing BioOss with bone is an alternative in case of bone-augmentations for complete autologous bonegrafts. However, I have seen too many late complications (more than 5 years after implantology) with Bonesubstitutes, reffered to us and in our own clinical experience: chronic perimplantitis, chronic soft tissue infections, granuloma sometimes not in direct contact with the implant luckily, complete bone-loss because of chronic infection/irritation. So, my I advise is to use autologous bone-graft or at least demineralized bone-material that fully disintegrates and is (partially) replaced by bone. "Do not reconstruct the Facial skeleton with Tupperware!"

I placed an implant into a BioOs graft in the anterior maxilla afetr 6 months. It was still not entirely dense. At the same time I extirpated the incisive canal which impinged on the implant site and firmly packed BioOs into it, against the mesial wall of the implant. After 6 months, Xray sows that the implant had been pushed lateraly against the 12 and the implant can now not be used. Has anyone any explanation for the movement or have they had a similar case?

As always, I agree with my mentor, Don Callan 9and my good friends - Drs Miller, Mazor and Joshi). BioOss has been shown in human and animal studies, in the absence of added growth factors, to NEVER turnover. In an animal socket study by Artzi and Weinrib, at the 3 month time in dogs (the equivalent of 9 months in a human) the BioOss particles had inhibited socket healing. Human studies show that the particles are integrated in soft tissue, not bone. Even in sinus grafts, sites augmented with Puros show more than 2X the smount of vital bone. Just because the implant surface is not in contact with the graft does not mean that a "better" graft, enabling the formation of more vital bone, would not enable more bone-to-implant contact, faster integration and loading of the implant. Those studies need to be funded by the companies that make the implants and grafts to assist the surgeons in making biologically sensible, not just sales oriented decisions for our patients. SO, look at graft materials that enable/assist in regeneration, not repair. Look at the histology, don't just listen to the speeches, either printed or verbal.

If you are using a graft as a space maintainer prior to placement of implants, why not use one that resorbs completely. There is an incredible disconnect when choosing different graft types. Most people like Bio-Oss BECAUSE of its ability to maintain volume (AKA failure to resorb). If, as Dr. Horowitz just elucidated, we want regeneration of autogenous tissue, then why don't clinicians use bTCP's that resorb at the same rate that autogenous bone is laid down. There is no graft residue AND the free calcium ions potentiate osteoblast development and production of type I human collagen. This will not only get autogenous bone faster, but will also increase the density of bone which results in bone matrix that is more resistant to microfracture.

Great points Dr. Miller, you cut to the chase.

BioOss has the largest evidence in many indications.We have too much problems at the clinic offering cadaver(allograft material) to patients. More today with the scandals of bodies stolen.... Bio Oss is integrated in bone, same as implants,allograft material resorbs too quickly

Again, BioOss' is too large to resorb and may be antigenic.