Socket Preservation: Optimal Method?

Dr. G Bioplant is composed methyl-methacrylate formed into plastic beads. This is non-resorbable and the manufacturer states that you must have primary closure. It will never convert into bone no matter how long you wait. You hope for is mineralized encapsulation of the plastic beads. If you want to use a resorbable granular product in my opinion the best is beta tricalcium phosphate. There are two on the market- Cerasorb and OsseoConduct(our product). OsseoConduct resorbs quicker (3-6 months). With OsseoConduct I place implants in 3 months. For a faster resorbing graft material that does not require primary closure or a membrane I use Socket Graft (again our product). However, it is only indicated when you have a complete socket. Implant placement in two months with Socket Graft. Greg Steiner Steiner Laboratories

Dr G You need to do a little research about the different types of graft materials available and their properties. The material you used does not get replaced by bone, instead, it gets incorporated in the bone that grows in the extraction socket as it heals. If you are planning to place an implant, it would be ideal if all the graft material that was placed would be turned over into the patient's own bone, since the more synthetic particles present in the grafted area, the less live tissue for osteoblastic activity and osteointegration potential. Any of a great number of materials would work well in your situation since the material is enclosed by walls that supply the osteogenic potential. Resorbable synthetic materials such as beta tricalcium phosphate, collagen plugs, prf plugs, allografts such as demineralized freeze-dried bone, irradiated cancellous bone, DFDB putties, resorbable hydroxiapatite materials, all can be used successfully. Using any of these materials and a barrier makes socket preservation the most predictable bone grafting that the dentist can do. Good luck!

Which hydroxylapatite does resorb? The synthetical or the bovine?

in my experience one of the best material to replace totally the missing bone of any tipe ( post extraction,cistic bone loss,traumatic bone loss etc.) is granualate calcium carbonate . it is resorbable in few months totally and mainteins the originally level of "the day after". in the few cases in which i did the reopening of the site of grafting intervention after one year or more, i didn't found any else that a well structured bone, perhaps better and stronger than the original. in the past i used chemical calcium carbonate but he best results i obtained with natural calcium carbonate like Biocoral or Shepore (my own production, not for sale)that are obtained from marine shells. Naturally are other resorbable grafts products like phosfates, solfates and partially resorbable like bovine hydroxylapatites. concerning chemical hydroxylapatite i must say that is only partially resorbable but has a great affinity with bone and is very important expecially in orthopedic area.

note please: the bovine hydroxylapatite is well resorbable and not partially.

J Long Term Eff Med Implants. Schlegel AK Department of Oral Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany. Abstract BIO-OSS is an allergen-free bone substitute material of bovine origin, used to fill bone defects or to reconstruct ridge configurations. Seventy one patients (39 female, 32 male) received 126 BIO-OSS implantations. Some health parameters or habits were documented to eliminate possible risk factors of influence. The diameter of jaw defects filled with BIO-OSS was measured. There was a significant influence of the defect size on the healing result. In X-ray controls, BIO-OSS served to identify the surrounding native bone. The density of the BIO-OSS areas was higher than in control sites. These radiological results were supported by bone biopsies. Histologically, the permanency of the BIO-OSS was still recognizable after 6 years and longer. The ingrowth of newly formed bone in the BIO-OSS scaffold explained the increased density of the implanted regions. There were no clinical signs of BIO-OSS resorption. Therefore, we can assume that form corrections achieved by BIO-OSS insertions will last. PMID: 10186966 [PubMed - indexed for MEDLINE] Please show me ONE study about resorption of bovine hydroxylapatite in the human bone!

Dr. G No bovine bone grafts are resorbable. Also no allografts are resorbable. DMFDBA includes approximately 3% mineralized tissue and this is not resorbed. Any allograft that is not demineralized is not resorbable. Allografts are considered transplants and are not regulated by the FDA so the companies selling these products can say anything they want about the products. In regard to bovine bone grafts their literature may claim that the product is resorbed but if you read their FDA 510K summary they often clearly state that the product is not resorbable. All companies are required by the FDA to provide you with a 510K summary of the product upon request. If you are considering any particular bone graft and want information you can trust call the company and request a copy of the 510K summary for the particular product. Greg Steiner Steiner Laboratories

To Dr. M There are no synthetic or bovine hydroxlyapatites on the market in the USA that are resorbable. If anyone wants to confirm this send me a bone sample the next time you place an implant in a grafted site and I will do the histology for you at no charge. Greg Steiner

The last two posters are absolutely correct. The resorptive capacity of a graft material is directly proportional to the degree of crystallinity (hardness). Bovine derived grafts have the highest crystallinity and, therefore, the lowest resorptive pattern of any graft available today in oral implantology. While it may be impressive to some to show a radiograph that is beautifully radioopaque (like a great endodontic obturation), the true benefit of an osseous graft is the capacity to turn over into host bone. Some of the worst failures we have seen are where Bio-Oss has been used to repair osteotomy defects in immediate placement sites. These grafts tend to become fibrous encapsulated, creating a site that will come back to haunt us at some future date. In all of the repair case that we have completed to date, we have never found a site where xenografts have incorporated completely around the implant body. Caveat Emptor RJM

In sites where there is an implant to be placed the only benefit of a "good " lookimg X-Ray is far outweighed by the issues associted with the use of HA as both Greg and Robert have pointed out. The material must be turned over to restore the body and thus the BTcP and CASO4 products are best suited here. There are many good products but the future will deliver even better results . HA restored sites are not bone and never will be in the true sense of the word.

Greg just googled you site do you have a European distributor?

Robert Miller: Thank you! I have been saying this for years about BioOss and like materials.

Greg Steiner: Osteogen works very well and is predictable.

Re Availability of resorbable synthetic materials. Dr S stated that Cerasorb and OsseoConduct are the only 2 products that offer a fully synthetic resorbable material. As this is a global forum I feel it worth clarifying that Dr S would be referring to the US market only as elsewhere several more additional products exist which more closely matches the ideal. In Europe newer materials are becoming available which combine the soft tissue barrier and containment properties of a membrane within a fully resorbing synthetic scaffold as an "all in one" solution. One such material has gone a stage further and offers a controlled surface chemistry to speed up the osteogenic potential and is well documented to offer eary loading at 3 to 4 months when cobined with an implant placement. So as to keep in line with the forum guidelines I have not included promotional claims or a trade name but for those interested a link can be found at biocomposites.com

The most important point here independantly of any financial interests from companies: Bio-Oss will never resorb to a humane bone. Finally the FDA is informated by a report. Let us waiting for the decision.

To Dr. Teague Just to clarify, I stated that in my opinion if you want to use granules the beta tricalcium phosphate granules are preferred for this indication but I did not say they are the only resorbable synthetic materials on the market. To Dr. Hughes I thought I knew all of the bone grafts on the US market but I missed that one- I will check it out. Thanks. To Dr. Fairbairn We have had our hands full with the US market so we have not applied for our CE Mark at this time. We hope to start this process soon. Could you give me the name of a distributor you would recommend? Thanks again. Greg Steiner

The bone regeneration after 4 or 3 months whith or whith out bone regeneration material its the same. Use of a membrane only if you have a lot of gingival tissue to cover this membrane. In my experience after a simple extracción, i whait 3 or 4 months (depends age, perodontal general state, patients general health and oral bone zone)and i put my implant, you gone a found bone of 4 degree. I hope this be usefull for you.

HI Greg I speak on synthetic materials and have only used them for the last 800 graft cases (without membrane) and would like to try your product ( could advise on dealer) if you could e-mail me I would be grateful. The benefits of socket grafting with fully bio-absorbable materials is they provide a scaffold and nutrients for the bone regeneration. I feel they are of great use after being an initial sceptic many years ago. Peter

To Dr. Shiraki There a number of differences between sockets that have been grafted and those that have not been grafted. First is that a grafted site will retain approximately 91% of the pre extraction ridge but ungrafted sites result in significantly more resorption and loss of alveolar ridge. Second the amount of mineralization is always inferior to normal cancellous bone. Usually twice the amount of mineralized tissue is found in grafted sites depending on the type of bone graft used. Third is the factor that is seldom discuss and that is the vitality of the bone in the extraction site. In ungrafted sites you have very few active osteoblasts. When you place your implant you have to wake up the few osteoblasts that are present. An ungrafted site can be likened to scar tissue histologically. Some mineralization but poor vitality. If you are using a good graft material you will have a significantly higher rate of implant integration and long term success. Exposing bone to the oral environment results in necrosis of the bone lining the socket and sometimes other adverse events of equal significance. Greg Steiner

@Dr. M.: In fact, there are several studies that show resorption of a bovine hydroxylapatite. - Sartori et al. (COIR 2003) - Traini et al. (JP 2007) There seems to be a remodelling, similar to that in human bone.

???????????????????????????????????? To Mike: Histologically you will never find any resorption of bovine hydroxylapatite; that after many years. - Scarano (2004) et al. - Hallmann et al. Do you a have a microscope? What is humane bone?

And something else: Place bovine hydroxylapatite in a cow and you might see any resorptions.

Is this Mike Parish who used to work for Bio-Oss

@ Dr. G.: - How do you define "resorption"? Maybe here are some misunderstandings. - I do not have a microscope anymore. - Please check out what "human bone" is. If you dont know yet, please do not attempt to preserve an extraction socket! ;-) - Yes, a bovine xenograft certainly resorbs in a bovine organism, too. Or at least, it undergoes a slow remodelling process. @ Far Sai: - No, I am not Mike Parish, neither do I know him. I am just talking about any bovine xenografts.

@ Dr. G.: - Thanks for that Scarano-Paper you mentioned yourself: "BPBM seemed to undergo a very slow resorption" (PMID: 15455746) So, how can you claim, there is NO resorption? - Which Hallmann publication do you mean?

Mike! Scarano (2004) examined a 50 years old patient with an implant fracture after circa 4 years. The histological result was no resorption of Bio-Oss. The particles were unchanged. Please: Read the literature correctly. There are some mistakes in it. And please buy a good microscope and consult a normal pathologist. Please learn and then you will find the truth for augmentation! BONE IS A LIVING ORGANISM!!! You have to understand that.

Everybody who place an implant with Bio-oss augmentation has nothing else like a hard stone and no living bone.

@ Dr. G.: No need to shout here. Was my quote wrong? I checked it again and -no. Why should I buy a microscope? I don't know the reason for that. Your second note shows clearly that you have never dealed with histological results concerning bovine xenografts. There are many photos that show active osteoclasts on the surface of an incorporated xenograft. Do you have any clinical experience with bovine xenografts? What kind of material do you normally use for grafting? Maybe you mean another material when you talk about "hard stone"?

Ask Indian professors. They do know something about studies with non-resorption of bovine HA.

xenogenous HA can be resorbed, depends on the processing. high temperature bovine HA like Endobone or Cerabone is non- or very slow resorbing, mostly as a surfacial reaction. Synthetic HA can be made resorbable, just depending on the cristallinty. Nano-HA is resorbing very fast, e.g. in a pasty consitency (Ostim). A combination of nano HA and other synthetic HA (as in our maxresorb inject) has several phases of resorbtion time. The field of biomaterials is wide and there are a lot of products with different properties, depending on some "small things". HA is not HA is not HA... Best Regards Matthias

Dear Matthias, Do you agree that Bio-Oss does not resorb because of its too hard cristallinty? I have heard the responsible goverment agency of Switzerland "Swissmedic" is informed. They should proof the resorption in "Living Bone". Kind regards Satya

Dear Satya, I agree that it is a very long-lasting and slow process. This is what Geistlich is also telling in their FAQ... For other bovine materials like Cerabone I agree that the very slow resorbtion (which provides a very reliable volume stability) is due to the cristallinity (it is the size of the cristal, not the hardness..) Nevertheless Cerabone (and also Bio-Oss, etc) is well integrated after a while. What do you mean with Swissmedic should proof?

In their FAQ they tell that there are minimal suspicions of resorption. Otherwise the write only integrated in bone. What is the truth? Are there at all any signs of resorption? Who has real HISTOLOGICAL studies? The users and the patients have to know that they will never get a real bone with those biomaterials. Maybe in 10.000 years? In fact: Many years ago for the market launch they wrote something about absolut resorption of Bio-Oss. Then they changed their opinion. By the way: Another very big pharmaceutical concern finished their production and research + development in the late 80th with bovine materials. Why? I think it was a very wise and intelligent desicion. Than somebody had an idea. The roots for a company were in manufactoring edible gelatin and fertilisers for farmers. With pigs and cows somebody had experiences. But the income return was too less. The pharmacy branche has better profits in a growing market. http://www.geistlich.com/?dom=2&rub=48 What about the resorption of Geistlich Bio-Oss®? Geistlich Bio-Oss® is resorbed very slowly. It is not possible to say how long this takes. Studies show that the amount of Geistlich Bio-Oss® in the augmentation material declines steadily. Other studies show that Geistlich Bio-Oss®, like endogenous bone, is subject to slow remodeling (approx. 3 times in a lifetime). This could indicate that Geistlich Bio-Oss® is recognised by the body as natural bone. It used to be believed that a bone substitute had to be resorbed as quickly a possible. These days, it is known that the slow breakdown of Geistlich Bio-Oss® gives the bone augmentation material volume stability.

Please take a look at that link and note the patients suffer with unresorbable bovine materials. http://www.osseonews.com/allergic-reaction-to-bio-oss-is-it-possible/

@bone Hmm,I do not see the prove that the bovine bone cause the reaction... I have also seen this onve or twice, can be caused by allergic reaction on (porcine) collagen... The comments are not wrong, but e.g. BioOss is treated below 800° (above this temperature there is no way for bacteria to survive) instead of eg. Cerabone which is treated with temperatures above 1000° Celsius... Nevertheless Bio-Oss is treated with additional steps to ensure the security&safety of the material... There are different bovine materials available (Cerabone, BioOss, etc), also with a lot of histologies... @truth Right, you will not get "real bone" if you mean remodelled bone. To get this you have to use autologous bone, allografts or resorbable xenografts/alloplastics. The bovine bone as Bio-Oss or Cerabone will be integrated - but this will fulfil the function, did'nt it? So therefore I do not really see the problem.... There are lots of histologies showing the integration of a processed bovine bone.... Anyway, I am always available for discussion via MatMatthes "at" botiss .com

@Matthias Hmm, you should be a dentist or an oral surgeon with real patients and real living bone. Then you would have experiences. Not only in a laboratory.

So , I might be missing the clinical experience, right, but we are talking about material sciences....

Dear Matthias, Your statements amused me and you do not represant your company in a scientifically and practically orientated way. In this discussion forum at "Osseonews" are members who work in science. Some of them wrote about proteins in Bio-Oss and they found biofoulings from cows. 1.) Remember your school career. It might be the 8th class. Have you ever heard the Sinner´s circle? TEMPERATURE, CHEMICALS, MECHANICS, TIME. 800 or 1000 degress Celsius are high. What is about the time? Are there no remains from cows? 2.) Remember your school career again. Did you learn the biology of bones? Please get in contact with scientists of molecular biology. They will teach you in bone and you will be a professional! Your company is located in Germany and you sell your products on the German market. As a tip get in contact with the goverment agency that called BfArM. They are responsible for declarations between medical products and drugs/medications. Matthias, you have to learn very much espacially laws in Germany. Here al link: http://www.gesetze-im-internet.de/bundesrecht/amg_1976/gesamt.pdf Products which have influence by metabolism must be drugs/medications. Therefore you need a permission for selling from the BfArM in Germany. At last: To copy any bovine materials are not clever. Work in a better method. Kind regards Axel

Dear Axel, thank you for remembering me at my school time... Just getting back to your comments: Regarding the Bio-Oss processing please ask Geistlich as they are the manufacturer, I am sure they could give you more information. I am not talking about other comanies products..... Regarding our product - just tell me what you want to know... Secondly, thanks for the hint. Let me know, what I should be taught in your view? As you seem to be a professional maybe you can do it...? Finally, thanks for the link. I do not really see the connection between medical devices as our product is and the pharmaceutical you are referring to, but maybe you can explain it to me. Matthias

I am not talking about other comanies products….. ...Nevertheless Cerabone (and also Bio-Oss, etc) is well integrated after a while... ...BioOss is treated below 800° (above this temperature there is no way for bacteria to survive) instead of eg. Cerabone which... ...if you check the FAQ of BioOss you will find that it is not approved for resterilisation...

Touche :-) But I think you know what I meant... All of those things are easily accessable for everybody, just go to the FAQ.... Anyway, I think this is not the right place to do a personal discussion, as mentioned you can easily reach me via email. Or meet me at several congresses to discuss personally... One thing - do not use my name for your comments.... Regards Matthias

Dear Dr G. Optimal means just right, considering all the factors involved....... not too much, not too little.....just right. The optimal method in preserving an extraction socket may certainly involve the placement of a bone graft, which should ideally turn into real bone. There are different types of bone graft as can be seen by the ongoing discussions. If I have to put a bone graft that is optimal in helping to preserve the extraction socket, I will use calcium sulphate since they are resorbed rapidly and is replaced by real bone provided that there is enough blood supply and soft tissue is held back until bone is formed.... you know GTR and so on. But there is still one thing that will optimally help to preserve socket is the presence of a tooth to provide direct physical stimulation of the socket and thus preserve it. Well, since the tooth is gone, a good substitute will suffice in the form of an implant. I suppose you can place in a regular sized implant that will feel up the socket as much as possible and it will do the job. A most reliable method for preserving the socket and may even cause bone to grow back a bit, is to place in a mini dental implant right into the bottom of the socket and if you wish, slap in a lump of pop sans membrane. Once the pop sets, a membrane is unnecessary. Anyways, I usually don't use any pop from the lab bench, I just leave the mini surrounded by the clotted blood and pr..., I mean wait and let the bone climb up the implant. I could not believe my eyes when I first observed it but check it out and see... and maybe you can help to explain it away. And that... friends may be an optimal way to preserve the extraction socket and restore the tooth at the same time!

...I know that non-resorbable Bio-Oss presents hyperplasia or tissue build up, not conducive to implant support. However, materials that do not resorb or rather take very long (e.g. 10 to 30 years) to leave the body have been identified as ceramic, glass, plastic T.C.P and Bio-Oss. Such materials will be transferred to the lymph nodes, lungs and spleen for farther processing. This type of non-resorbing bone grafts interfere with the function of this organs. Furthermore, the cells in the body that remove such "non-resorbing" materials begin to deplete and eventually your body’s immune system gives up. There are several clinical and scientific papers to mention such findings in animal and human studies including my paper...