Bone Augmentation and Ridge Preservation

Robert A. Horowitz is a Periodontist who maintains a private practice
limited to Periodontics and implant dentistry in Scarsdale, NY and New
York City. He is a Clinical Assistant Professor in the Department of
Implant Dentistry at the New York University College of Dentistry. Dr.
Horowitz is heavily involved in research, product development and
teaching. Our readers are also encouraged to also read a prior interview with Dr. Horowitz
in which he provided valuable information and clinical tips on
intraoral photography.

OsseoNews: Dr. Horowitz, you are a leading expert on alveolar
ridge preservation and ridge augmentation. How does this relate to
implant dentistry?

Dr. Horowitz: The most important lesson to be learned from the
literature, as well as from my own personal experience, is that when a
tooth is extracted, a bone augmentation or preservation procedure must
be instituted at the time of extraction.

OsseoNews: What happens if the tooth is extracted and no bone augmentation or ridge preservation is accomplished?

Dr. Horowitz: You can expect at least 30-60% bone loss within 6 months around the extraction socket. You can also expect at least 1mm loss of vertical bone height. These numbers are straight out of the peer-reviewed dental literature. That represents a tremendous loss of bone volume that could, if preserved, provide much needed support for implants.

OsseoNews: How serious can the loss of bone be in regard to Treatment Planning?

Dr. Horowitz: To put this in a proper perspective, let us consider a typical scenario. A patient is scheduled to have a maxillary first molar extracted and then replaced with an implant abutment and a crown. This is a situation that is commonly seen. If we extract the molar and perform a socket preservation procedure at the time of extraction, we will preserve the alveolar ridge height and width to a great extent. We may be able to place an implant and restore as planned without any further complications.

But if we extract the molar and a bone augmentation and/or ridge preservation procedure is not performed, the ridge will loose significant buccolingual bone width and vertical bone height within the next 6 months. A sinus lift or other ridge augmentation procedure may then be required to recreate adequate bone support for the implant.

Failing to accomplish bone grafting and ridge preservation at the time of extraction in the long run thus leads to a far more complicated and extensive procedure than preservation of the extraction socket volume at the time of extraction.

OsseoNews: If the Treatment Plan is for extraction to be followed by implant placement, the dentist should be prepared at the time of extraction to perform bone grafting and ridge preservation. If not, the implant site will become compromised and it will be more difficult to place the implants.

Dr. Horowitz: This is well documented in the literature and I see this all the time in my practice, as do ALL dentists who look for this. The goal is to produce the best possible circumstances for implant placement and restoration. In many cases this is as simple as performing bone grafting and ridge preservation at the time of extraction.

OsseoNews: Then it would be a serious mistake to extract teeth, let the sockets heal and then do the bone graft.

Dr. Horowitz: In many cases that would be true, depending on how long you wait after the extraction. You will often end up with a significantly compromised site for implant placement. At that point in time, the surgeon and patient are faced with more extensive and expensive procedures to replace the bone and soft tissue that have been lost.

OsseoNews: What is the best material for accomplishing bone graft and ridge preservation at the extraction visit?

Dr. Horowitz: There are a number of materials that can accomplish socket preservation. One of the best materials for this type of procedure is Cerasorb (Curasan), a tricalcium phosphate synthetic graft material. After the tooth is extracted, Cerasorb is delivered into the extraction socket and then covered with a barrier for 3-4 weeks. This is a new material which I helped to develop.

OsseoNews: How do you prepare the Cerasorb for delivery?

Dr. Horowitz: You mix the Cersorb with blood from the surgical site which is drawn up in a bulb-pipette. You can also mix the graft material with CALMATRIX (Lifecore) which is a calcium sulfate bone containing bone graft binding material. This gives the bone graft material the consistency of soft putty and makes it easy to deliver, maintain in the socket and at the same time enhancing its biologic activity with calcium sulfate.

OsseoNews: What kind of barrier do you place over the Cerasorb bone graft?

Dr. Horowitz: The selection of the barrier depends on the circumstances. Frequently I use CalForma (Lifecore), a putty-like formulation of calcium sulfate which sets even in a bloody field and sets over the graft material. In other instances, a non-expanded Teflon barrier membrane like Cytoplast (Osteogenics Biomedical) or TefGen (Lifecore) is placed over the graft. These can be easily adapted over the graft site, tucked under the periosteum and then the gingival tissues are sutured into place. These materials do not require primary closure which saves a great deal of time and effort. When you are ready to remove the barrier, you can do this without local anesthesia or a second surgical procedure. They come out more easily than removing a suture.

OsseoNews: How do you manage an infected socket? Suppose the tooth has an endodontic or periodontic lesion. Do you still place the Cersorb graft?

Dr. Horowitz: An infected extraction socket is not a problem. After extracting the tooth, the site of infection must be thoroughly debrided manually and possibly with the aid of a laser. After a thorough and vigorous debridement has been accomplished, the graft can be placed. The literature has clearly demonstrated that this can be done successfully.

OsseoNews: How long do you wait to re-enter the grafted area?

Dr. Horowitz: I wait 6 months to re-enter the grafted area. I want the graft to take and for healing to occur. Cerasorb is osteoconductive and a certain amount of time is necessary for new, vital bone to grow in the extraction socket. The grafted areas present with dense, healthy bone on re-entry. The Cerasorb material will resorb over time.

OsseoNews: Do you prescribe an anti-biotic regimen following grafting?

Dr. Horowitz: In most cases I will prescribe amoxicillin or clindamycin for 5-7 days post-operatively, beginning with the premedication dose recommended by the American Heart Association.

OsseoNews: What is the most frequent source of failure that you see with this kind of grafting procedure?

Dr. Horowitz: The most frequent error that I see is failure to isolate the surgical site. Contamination of the surgical site and graft material will likely lead to postoperative infection and failure of the socket preservation procedure. Additionally, if the surgeon who is going to place the implant fails to perform the extraction and grafting procedures, anatomic complications related to socket configuration and dehiscences/fenestrations may not be diagnosed. The areas of missing bone may delay socket healing and timing for implant placement should be adjusted accordingly.

Interview conducted by:
Gary. J. Kaplowitz, DDS, MA, M Ed, ABGD
Editor of OsseoNews.com

46 thoughts on “Bone Augmentation and Ridge Preservation

  1. Agree with some of it, however he seems to be suggesting that infected sockets can be grafted immediately providing they’re cleaned out well and the patient’s given a hefty pre-op dose and a post-op course of antibiotics. Let’s just hope this heavy-handed use of antibiotics leaves us with some effective antibiotics and susceptible bacteria in the future!
    I personally feel that extraction, curettage, a healing period (say 2-4 weeks) and then GBR is a safer alternative. I would also advocate the use of resorbable membranes, if a membrane is to be used at all (I’m yet to be convinced of the merits of membranes at all in many GBR cases).

  2. Grafting of extraction sockets has become a very standard procedure in anticipation of implant placement. When an infected tooth is removed, the bacterial quantity is significantly reduced. debride the socket, place your graft(i use bio oss exclusively mixed wtih calcium sulfate and a resorbable membrane get primary closure cover the patietn with antibiotics and you get a winner. 5 months for a re-entry for fixture placement and you get a winner. Many times the graft is soft and “soft tissuey” at implant placement. Treat the tissue as if it soft bone. At a second stage surgery the bone is now hard.

  3. Our reliance on antibiotics may give us a false sense of security. First, if the area is necrotic with poor circulation, insufficient dosage of the antibiotic may reach the site. Second, if the bacteria are in a vegetative state, no amount of antibiotic will be effective.We have to start thinking outside of the box. Our experience using diode or abaltive lasers such as the Er,Cr;YSGG, indicate they have a bacteriocidal effect on both dividing AND vegetative states. Further, the biostimulatory effect of these wavelengths speeds up bone metabolism. There is ample literature in both dentistry and medicine to support our research. While we will continue to employ antibiotics in our regimen for grafting infected sites, we now routinely finish with the laser. We have found that our post-operative complications have been virtually eliminated. I urge clinicians to seriously consider adding one of these wavelengths to their armamentarium.

  4. Bob, Wonderful information–thank you for being so tuthful. Keep up the good work. You are an asset to the profession.

  5. I know Bob for many years and I can tell you with full confedence that he is not indescriminate user of antibiotics as he is protrayed in some comments.
    He is as concerned as any fine clinician would be for the welfare of patients.

  6. We graft every postextraction socket in the esthetic area.
    If there is a bone wall missing we add a resorbable membrane and a socket sealing surgery procedure closing the socket with a free gingival graft collected from the palate.
    We re entry our grafted sockets 6-9 months after grafting trying to do it flapless in order to obtain maximum aesthetics and minimum discomfort and pain.
    If you wait, you will solve the bacteria problem but then you will deal with an old defct instead of a new one wich have much more regenerative potential.

  7. I am having trouble going in at 4 months finding very mushy bone when I use Bio-oss and sometimes Puros.
    Any suggestion? What materials and relative healing period do u guys recommend.

  8. I agree with Dr. Horowitz, and he has the best human histology I have seen on sockets. Regarding infected sites, barring osteomyelitis,or rare aggressive forms of periodontitis, there is no bacterial invasion of the dermis of bone. Also, as soon as someone swallows and gets saliva in the area (or even breathes), the socket is bacterially infected. With an active infection, there is more vascularity and therefore more potential for regeneration.

  9. To,
    Dr. Fabrizio
    Bio-oss is nothing but hydroxyle appetite particles.
    I do not know about others experience but acording to my own experience,
    It takes lot longer time to resorb.More than 6 to 12 months.
    Wait at least 6 months for re entry.
    Cersorb,Cal-matrix,Osteogen,TCP, DFDB OR IRRADIATED CANCELOUS BONE takes less time.
    I dont have scientific datas.This is just my own clinical observation.

  10. I agree with all Dr Horowitz’s statements and knowing “Mr Socket”‘s histologies all his statements are validated with sound histology.
    Regarding waiting period of reentry it depends on the grafting material used.Using Allograft+CM makes it possible to reenter even after 4 months.

  11. Satish,

    I think one of the beauties of Bio-Oss / Nu-Oss and similar is that they do take longer to resorb. Many doubt that they ever resorb at all, but become integrated as some sort of scaffold.

  12. Yes,
    MS
    I do agree with you. Bio-Oss is fine product.It is our work horse at NYU especially after bad publicity of cadaver bone.

  13. Bio-Oss takes too long to resorb, if it ever resorbs at all in some cases. I find Puros to be a much better product for grafting extraction sites. Implants can be placed in 4 months with good instertional torque and rarely is there a failure.

  14. MS
    Few months ago I inquired about Nu-Oss from ACE Surgical and I was told by their rep. that they carry only cadaver bone in Nu-Oss.

  15. The “success” or complete integration (incorporation) of any grafted material in to the alveolar socket and the “grafted site” being “evaluated” to be ready for receiving an implant may (does) require individual (case by case) analysis under the following headings rather than any manufacturer’s suggested time intervals.
    1.Age, 2.Sex, 3.Systemic condition/s…possitive medical history, 4.Local existing variations at the recipient site, 5.Habits, understanding the procedure and personal care by the patient and finally, 6.The operators depth of knowledge, as to not only, a.When, b.Where, c.What and d.How to use any given material/s, but also a good understanding of the required “principles” of A.anatomy, B.physiology, C.pathology,D.pharmocology, E.surgery and F.a good “bio-material” knowledge of the materials used.

  16. Fabrizio-
    If you look in the literature, you will find no evidence of osteoclasts on BioOss particles not papers that document its’ resorption. (Dr. Zvi Artzi has shown this in humans and animals.) The particles, like Dr. Joshi stated, are highly scaffolded HA and serve as a good base for depositon of vital bone. HOWEVER, if you look histologically at sockets grafted with BioOss, you will find minimal amounts of vital bone at the 4-6 month time period.

  17. Bio-Oss is a Natural Carbonated HA. Nu Oss is a natural HA.

    Bio-Oss has a higher degree of Porosity, larger inner surface area and a microstructure similar to human bone. All that and 20 year of documented history.
    As for socket preservation, just refer to Dr Tony Sclar’s Bio-Col Tecnhnique.

  18. As I have said we only use stnthetics due to patient concerns but the results have been a great source of satisfaction . These materials have changed for the better. if you want a stable graft to allow for bone growth use Beta TCP in a hydroxyl sulphate matrix (allowing it to set)which will resorb in 6to 9 months time and if you want it to stay just mix HA in. These are all readilly available in a lab no need for donor bodies of any sort.

  19. Way to go Bob, However I think everyone missed your point that isolation of the defect from the periosteum and adjacent soft tissue is the key to preserving buccal-ligual width and keratinized tissue. This is only accomplished by GBR using a membrane. Buser and others have shown that there is more vital bone in a non-grafted site, however, the dimensional loss of buccal-lingual and crestal height is significant. Graft materials and membranes stop this and implants can be placed 4-6 months with little or no dimensional loss.

  20. The usual dosage of antibiotics would not reach the infected socket. How much do I increase the amoxi dosage? Do I need injection too?
    Someone says Bio-Oss’s unresorbable property is good to be placed in sinus lift cases. And for the last 5 years it looks works well but What happen after BioOss is completely resorbed.
    I do not experience any other significant merit over in socket. Is there any recommended particles to use sinus lift cases?
    Thank you.

  21. Use Bio-Oss large particle size 1-2mm for sinus procedures. You can also mix large and small (.25-1.0mm) if you desire. The results are well documented. Osteohealth Company also has FDA approval with bTPC and rhPDGF for perio and future on-label indications. The product is called GEM21s.

  22. Is a lawsuit my only recourse? My project began in a prosthodontist’s office. I presented a maxilla containing five natural teeth and heard the words “Nobel Biocare” and “Teeth-in-an-Hour” for the first time. 18 mos and $35k later, my maxilla contains six endosteal implants in numbers 3,4,5,12,13,and 14, and a temporary OVERDENTURE.
    The prosthodontist tells me it will be replaced by a permanent overdenture! This bulky and primitive prosthesis traps copious amounts of food particles and cannot be properly cleaned. It was never discussed, not even as an option. I repeatedly declared a willingness to pay time and money for a fine esthetic outcome, the look and feel of natural teeth, bridge work supported by well carefully placed, well healed implants. An overdenture is a horrific device.

  23. To Pt: Remus

    the over denture may be bulky but by no mean primitive. in fact it is the best prosthesis if you have lost the teeth, gum and bone. the overdenture is bulky because it has to replace not only missing teeth but also missing gum and missing bone.
    if the overdenture is removable it will allow for ease of cleaning and longevity of the “well healed implant”
    If you are totally against the overdenture speak frankly and nicely with your Prosthodontist and he or she should be able to help you.

  24. I believe in simplicity and effectiveness.
    Immediate extraction follwed by removal of the compact layer of lamina dura releases osteogenics from the medullary bone. Osteoblasts and BMP (bone morphogenic protein dicovered at UCLA by an orthodpedic surgeon in the 1960′s) chemotaxis cause new bone to form. I often immediately implant and allow a fibrin clot to seal the cervical portion. I use 1 state implants. I place the implants from a large assortment, and graft with a mixture of autogenous bone and either bio-oss or nu-oss if necessary, but only if the implant is 1mm or more from the prepared bone surface, and I place the implant toward the lingual of the prepared socket. I get the autogenous bone from the implant drill tines, as the sizes increase, using just enough cold sterile saline irrigation to cool the bone below 47 degrees C, while not washing off the accumulating autogenous bone, which is “THE” best grafting material, since it is both osteoconductive and osteoinductive. Even 1% autogenous bone will render an osteoconductive (bio-oss,nu-oss) graft osteoindictive. By the way, Nu-oss is bovine bone. It says so on their package. It is bovine bone from which all the organic components have been removed. Once blood flows (site preparation)I believe the immune system will take care of residual bacteria, although it is paramount to remove any endodontic remnants of sealer or gutta percha, as these may harbor bacterial contamination. In my hands, a surgical curette works nicely for that. The same instrument, or a surgical hoe, if small enough, can also be used. I carry both in my surgical instrument set up. If bone is exposed, I fibrinize a clot and cover with calcium sulfate to seal, rather than a membrane. I use resorbable membranes for onlay bone grafts, after fenestrating the cotical bone, with a small round bur in my implant handpiece with sterile saline irrigation. If it bleeds, bone grafts are placed, again with autongous bone and if needed, xenograft bone (bio-oss). I cover this with the membrane. If the implant threads are exposed, I place 100% autogenous bone over the exposed threads, followed by the bone graft mixture — to contour. Then, I place the membrane, carefully placing its precontoured edges 2 mm under the periosteal perimeter of the flap. I fibrinize this with finger pressure for 30-60 seconds, and place additional membrane shreds if needed, for retention of the major part of the membrane. Then I suture with PGA suture, which resorbs in a few weeks, and feels soft for the patient. I close by primary intention, and if necessary I slit the periosteum or hemostat-undermine the base of the mucous membrane periosteum for release, or both. If primary intenion cannot be achieved, I seal with calcium sulfate paste, lightly. Sometimes, alternatively, I will lift a small sub-epithelial envelope graft from the lateromiddle palate, and suture this over the area which needs coverage, using many interrupted sutures loosely placed to allow for contracture, and place the edges under a nutritive capillary bed, for a suitable blood supply.
    Blood is the “success factor,” rather than mechanics. I avoid these procedures in brittle diabetics, and I watch for diabetes in obesity cases, and quick periodontal breakdown. Also, I avoid smokers who cannot quit.
    Smoking is vasoconstrictive, and toxic as well.

    If I want to wait I scrape the socket lightly, and place the osteoconductive bone graft mixture as before, and calcium sulfate, but no implant. When, after4-6 months, I return, I go flapless (sometimes female patients misconstrue this as meaning “topless”, and I have to warn them that the treatment is limited to the gingival tissues), and before the access punch or incision, I annoint the attached gingival with ophthalmic gentamycin solution, which disinfect the entry site for the implant. Then, I do the osteotomy.

    If I do a sinus lift through the osteotomy site, I wait 6-8 months. My understanding is that Bio-oss et all is completely resorbed in 12 months after placement.

    Except where facial bone is required in an onlay style graft situation, I believe immediate implantation after extraction is best. I use 1 gram penicillin 1 hour pre-op, followed by 500 mg qid for 5 days.

    Occaisionally, I have used collagen plugs post extraction, if I felt that later I would graft, but did not have the time after periotome elevation. This has been successful. I used minimal antibiotics. Sometimes none at all. One month – 2 months later, I grafted and implanted, using the protocol I mentioned previously.

    One last thing: when I feel overwhelmed by a patient’s dental or emotional situation, I refer. Some of my best cases have succeeded because I refer to a practitioner I have high regard for. I have learned so much from my colleagues.

    drs

  25. the above comments are based on a relatively healthy bone socket, and if the implant is placed at the same time, a small fenestration of usually facial bone allowing the implant to “show through.” If either of these 2 factors is not present ideally, the success rate will diminish substantially.
    If the implant threads are coated with genatmycin opthalmic solution, this helps to alleviate concerns about infecting the surface of the implant with microbial contamination of the alveolus.

    The critical factor in immediate implantation is to decorticate the part of the conical alveolus at the widest part – the part which is not shaped by the osteotomy burs. This is potentially a failed osseointegrated surface if insufficient blood supply does not reach this area, due to remaining cortical lamina dura bone being present. No amount of antibiotic will make up for a lack of capillary support.

    Note: by immediate I do not imply loading immediately, although this is possible. If done, it needs to be out of occlusion. But, is this possible with the average patient? Probably not. And therefore the success rate goes down.

    If the preceeding factors are present, a 95%-98.5% success rate can be achieved.

    When implantation has not succeeded for me, it is almost always due to either microbial contamination, or micromovement of the implant.
    That is why I almost never immediately load an implant.

    Immediate implantation may even be preferrable to grafting and delayed implantation, because the bone may not be as supportive, depending on local morphology, as the implant, which is designed to replicate the missing root structure. If this is kept in mind during implantation the result often will be satisfactory.
    Nothing is perfect, however, and patients undergoing implant procedures must condition themselves to this.
    One patient I had wanted to retain a longitudinally fractured tooth. I knew the prognosis was hopeless, but, to help the patient feel better, when they said there must be some way to save the tooth, I replied: “1% is all.”
    And the patient said in return, “Well, that’s OK. I’ll be the 1% of your patients. Let’s save it!”

    (I removed the tooth that day. I can’t remember if an immediate implant or graft and wait was done. If success is the goal, probably graft and wait is the preferred method.)

  26. Can you help me with references? I personally have not found any well-designed human studies that would fully merit grafting each and every site. Most of the literature consists of case reports or poorly, designed, small number studies. Thanks.

  27. Scooby,

    Check out Lekovic, JPerio 1996, and Nevins recent article. Both show tremendous bone loss, 40-60% in Lekovics paper. Nevins shows a loss of 6mm of buccal height in the first 40 days in the anterior maxilla. Grafting stops this, but you have to use the right biomaterial. DFDBA in a grafted site under a pontic does little, however dense HA under a pontic will be there forever. Lindhe shows that an implant bone microgap will heal on its own. However if you read the paper he discloses that in his study they lost 56% of the buccal lingual width. I would consider that a complication. As far as good human studies, there really is none, first of all how could you have standardized extraction sites, and standardized patients? That is proving a negative, we all see bone loss everyday.

    MSG

  28. I can’t understand how a clinician could honest recommend socket grafting when there is no good study that shows it works better compared to not grafting or conventional grafting when the ridge is indeed found to have undergone resorption.

  29. The early studies using bmp used gelfoam as the carrier and gelfoam only as the control. Both showed ridge preservation. I now routinely place gelfoam in the socket and I feel it helps. Cost to patient-zero. Has anyone heard of the new powered periotome coming out?

  30. I agree, I’ve yet to see the study that shows grafting an extraction site has a significant advantage over non-grafting in normal circumstances. I’ve personally extracted thousands and thousands of teeth and after taking incidental x-rays months later have seen little bone loss (if any). Now that study seems as valid as saying “I place bone in every extraction site and see a well-preserved ridge 3 months later”. The other issue I have found is that placing allogenic bone can actually result in a lesser quality bone in the short-term then had the socket been left to heal on its own.

    Moreover, if the socket is left to heal, I can expect good quality bone to place an implant within 6-8 weeks. Rarely have I found that to be the case with placing mineralized bone substitute in the socket. Not to mention that the “bone” graft potentially serves as a nidus for infection since it is initially avascular and foreign. And, the allogeneic bone isn’t the cheapest thing in the world now is it? Also, isn’t there an ADA code for ridge preservation now? I thought there was.

    And yes, the study can be done. It’s a matter of power of the study. No, you can’t easily extract tooth #8 and then #9 under identical situations and graft versus not graft on many of the same patients. If you could, you wouldn’t need many patient to have a valid study if the effect was measurable. BUT, you can take hundreads of patients and measure the effect with or without bone grafts. If there is a notable difference it will be validated. Is there some fear of seeing this study?

  31. I am not sure of the exact study but one that I recall during the maxicourse (all were peer reviewed studies and hundreds were cited over the duration of the course) determined that there was a 1.7mm gain in vertical height when grafting as opposed to not grafting. At almost 2mm, that is a potential 20& difference if you are considering a 10mm implant as opposed to an 8mm. generally. The geometry will allow for more potential BIC, generally speaking. I personally think that is huge. Not insignificant. And if you can add that to a sinus graft, there is less needed to graft the sinus and I think more predictable. Just my thoughts. Im no professor, just a wet fingered dentist from Mississippi. I graft whereever I can and I have not been disappointed with MFDB. Its pink in 4 months but, yes, sometimes grainy. Maybe I need to wait the full 6 as recommended earlier. I lean on the consrvative side mostly. Bill

  32. Two recombinant BMPs are now available for clinical use; rhBMP-2 and rhBMP-7 (osteogenic protein-1 or OP-1). They both have the ability to induce cell proliferation and chemotaxis, but only rhBMP-2 has been shown to cause the differentiation of both primitive mesenchymal stem cells and preosteoblasts.OP-1 has been found to be as effective or superior to autograft in achieving bone formation.RhBMP-2 combined with various carriers has been highly successful in animal studies when compared with autograft. In nonhuman primates, rhBMP-2, when utilized in combination with a collagen sponge or hydroxyapatite/tricalcium phosphate carrier, demonstrated superior bone formation activity compared with autograft. These studies also led to the need of development of more robust compression-resistant carriers to withstand the compressive forces of mastication in certain areas of the mouth after studies found that a collagen sponge carrier failed to provide an optimum bulk of bone due to its lack of resistance to the above-mentioned compressive forces. There are two randomized, prospective FDA approved studies evaluating the effectiveness of rhBMP-2 versus ICBG in skeletal bone formation when combined with two different carriers, a HA/BCP carrier (rhBMP-2/BCP) and a compressive resistant matrix (CRM) consisting of a collagen sponge combined with 15% hydroxyapatite/85% tricalcium phosphate. There were similar shorter operative times, less blood loss and absence of bone graft site pain, but when the fine cut sagittal and coronal reconstructive CT scans were thoroughly examined, it was found that there was a significantly higher incidence of bridging bone in the rhBMP-2/CRM study group compared with the ICBG group. Of course, the highest bone formation rates have been achieved by combining rhBMP-2 with autograft.

  33. I agree with dr Miller about the use of lasers and not the use of antibiotics. Very well said! The use of antibiotics just helps to prevent the patient to get a bacteremie because of the procedure. So your patient doesn’t have a malaise after surgery. With the Er-Yag laser you prevent bacteria entering the circulation because of its action and stimulate the healing!
    The same results you see when using laser for periodontic treatments. The patient has less pain and feel must greater after the procedure, because the lack of bacteria entering the circulation and giving your patient a nasty bacteremie

  34. As far as the use of Lasers don’t leave out the Nd:Yag

    Harris at UCSF in A.A.D.R. March 2003 showed Kill rate of P.Ging for the Nd:Yag was 16 times greater than CW/gated pulsed 810 diode at a depth of 2mm into the tissues, whereas the diode was a surface effect only.

  35. I agree with satish. Bio-oss is much slower to resorb. Cerasorb is an exellent grafting material among the others that he mentioned. It was referred to me by my colleagues so I am passing it forward.

  36. In November of 2006 I had two extractions, number 18 and 20. At the time of the extractions, the implantologist did a bone graft (I do not know what substance he used). He advised me to wait a year to replace the teeth with implants. In September of this year (2007) my periodontist advised me that the bone graft had not osseointegrated. In October my general dentist confirmed this information with another Xray. I am scheduled for two implants in November. What is your advice with regard to the failed bone grafts and whether to proceed with placing the implants in November? Thanks.

  37. Many of you have post question on the NuOss from ACE Surgical, a product that is comparably with Bio-Oss at a mush lower cost. There are no difference on products, they have the same properties. Take a look at an independent study that compares Bio-Oss vs. NuOss. Look up “NuOss-BioOss” on google.

  38. Tony Woo and Marcus, you are correct. No rational surgeon would place a graft in a socket. There is absolutely no support for its use. Read Araujo, lindhe etc. papers. And if you want your implant to osseointegrate, the only way to go is with native bone, not allo/xeno materials. Don’t buy into the many gimmicks that companies want to sell and be careful what you read cause a lot of the literature out there is worthless and can mislead anyone who doesn’t critically analyse it. Socket grafting is a great way to rip off patients.

  39. There is no good support for grafting sockets. be careful of what you read out there (commercial propaganda and tons of poor studies). just because someone famous uses it doesn’t mean it’s rational. read the araujo, lindhe etc papers. bottom line: a socket is going to heal how it’s going to heal regardless of what you put into it. why not let it heal, regenerate and then place your implant into native bone or do an immediate placement. why would you want an implant placed into allo/xeno materials and be unsure of osseointegration. i’ve seen these grafts placed and you go back in and it’s basically mush and the particles spoon right out. i think it’s a dis-service to patients and only puts more money in the pockets of the surgeon. also, there is no good evidence that any grafted bone formed over the implant fenestration is of any value to the patient. in a highly aesthetic case grafting dehisceneces may help keep soft tissue height and papilla fill. mid or apical fenestrations are of no consequence.

  40. i had a front tooth extracted. i had no idea what i was in for. looked shockingly bad first day. now 3 weeks later my gums look a tad weird. like a small gap by my temp flipper and my gums are indented. im thinking about grafting to make it look better. do you think its worth it? Talking in regards to pain and results. im 42 female still very much into looking great.

  41. Thank you J Blackman for the truth, and for Google to quote you in the topic bite. Bone repair occurs first at the opposite side of the injury and the repair process occurs more quickly without the hindrance of foreign body materials. Who gains the most from grafting a simple extraction socket? The provider that places the material and makes the patient pay for the service, or the graft recipient who gets to pay and then have the stuff drilled right back out in a few months. What nonsense.

Comments are closed.