Comparative Studies of Bone Graft and Orthobiologics for Foot Ankle Arthrodesis: A Critical Review

Graft materials available to supplement hindfoot and ankle arthrodesis procedures include autologous (autograft) or allogeneic bone graft (allograft) but also bone graft substitutes such as demineralized bone matrix, calcium sulfate, calcium phosphate, and tricalcium phosphate/hydroxyapatite. In addition, biologic agents, such as recombinant human bone morphogenetic protein-2 or recombinant human platelet derived growth factor-BB (rhPDGF-BB), and preparations, including platelet-rich plasma or concentrated bone marrow aspirate, have been used to facilitate bone healing in ankle or hindfoot arthrodesis. The purpose of this review was to summarize the available clinical evidence surrounding the utilization and efficacy of the above materials and biological agents in ankle or hindfoot arthrodesis procedures, with emphasis on the quality of the existing evidence to facilitate clinical decision making.

Comparison of different bone substitutes in the repair of rat calvaria critical size defects: questioning the need for alveolar ridge presentation

OBJECTIVE

This study aimed to evaluate the effectiveness of biomaterials in bone healing of critical bone defects created by piezoelectric surgery in rat calvaria.

METHOD AND MATERIALS

Histomorphologic analysis was performed to assess bone regeneration and tissue response. Fifty animals were randomized into five groups with one of the following treatments: Control group (n = 10), spontaneous blood clot formation with no bone fill; BO group (Bio-Oss, Geistlich Pharma; n = 10), defects were filled with bovine medullary bone substitute; BF group (Bonefill, Bionnovation; n = 10), defects were filled with bovine cortical bone substitute; hydroxyapatite group (n = 10), defects were filled with hydroxyapatite; calcium sulfate group (n = 10), defects were filled with calcium sulfate. Five animals from each group were euthanized at 30 and 45 days. The histomorphometry calculated the percentage of the new bone formation in the bone defect.

RESULTS

All data obtained were evaluated statistically considering P < .05 as statistically significant. The results demonstrated the potential of all biomaterials for enhancing bone regeneration. The findings showed no statistical differences between all the biomaterials at 30 and 45 days including the control group without bone grafting.

CONCLUSION

In conclusion, the tested biomaterials presented an estimated capacity of osteoconduction, statistically nonsignificant between them. In addition, the selection of biomaterial should consider the specific clinical aspect, resorption rates, size of the particle, and desired bone healing responses. It is important to emphasize that in some cases, using no bone filler might provide comparable results with reduced cost and possible complications questioning the very frequent use of ridge presentation procedures.

Histologic evaluation of edentulous alveolar ridge horizontal bone augmentations using a xenogeneic bone substitute and autologous platelet concentrates: a case series

OBJECTIVES

This case series aimed to assess the efficacy of a novel horizontal ridge augmentation modality using histology. Combinations of "sticky bone" and tenting screws without autologous bone were used as augmentative materials.

METHOD AND MATERIALS

Five individuals presenting healed, atrophic, partially edentulous sites that required horizontal bone augmentation before implant placement were enrolled. Patients underwent the same augmentation type and 5 months of postoperative reentry procedures. The first surgery served as implant site development, whereas the biopsy and corresponding implant placement were performed during reentry. The bone was qualitatively analyzed using histology and histomorphometry and quantitatively evaluated using CBCT.

RESULTS

Four individuals healed uneventfully. Early wound dehiscence occurred in one case. Histology showed favorable bone substitute incorporation into the newly formed bone and intimate contact between de novo bone and graft material in most cases. Histomorphometry revealed an average of 48 ± 28% newly formed bone, 19 ± 13% graft material, and 33 ± 26% soft tissue components. The CBCT-based mean alveolar ridge horizontal increase was 3.9 ± 0.6 mm at 5 months postoperatively.

CONCLUSIONS

The described augmentation method appears suitable for implant site development resulting in favorable bone quality according to histology. However, clinicians must accommodate 1 to 2 mm of resorption in augmentative material width at the buccal aspect.

Histological and radiological outcome after horizontal guided bone regeneration with bovine bone mineral alone or in combination with bone in edentulous atrophic maxilla: A randomized controlled trial

OBJECTIVE

To assess the radiological and histological outcome after horizontal guided bone regeneration (GBR) with deproteinized bovine bone mineral (DBBM) alone or in combination with particulate autogenous bone (PAB).

MATERIALS AND METHODS

Eighteen edentulous patients with an alveolar ridge of ≤4 mm were included in this split-mouth randomized controlled trial. Horizontal GBR with a graft composition of 100% DBBM (100:0) on one side and 90% DBBM and 10% PAB (90:10) on the other side were conducted in all patients. Cone beam computed tomography (CBCT) was obtained preoperatively, immediately postoperative, and after 10 months of healing. Width and volumetric changes in the alveolar process were measured on CBCT. Implants were placed after 10 months of graft healing where biopsies were obtained for histomorphometrical evaluation.

RESULTS

The gained widths were 4.9 (±2.4) mm (100:0) and 4.5 (±2.0) mm (90:10) at 3 mm from the top of the crest, and 5.6 (±1.3) mm (100:0) and 4.6 (±2.1) mm (90:10) at 6 mm from the top of the crest. The mean volumetric reductions were 32.8% (±23.8) (100:0) and 38.2% (±23.2) (90:10). Histomorphometry revealed that mean percentages of bone were 50.8% (±10.7) (100:0) and 46.4% (±11.3) (90:10), DBBM were 31.6% (±12.6) (100:0) and 35.4% (±14.8) (90:10), and non-mineralized tissue were 17.6% (±11.7; 100:0) and 18.2% (±18.2) (90:10). No significant differences were evident between in any evaluated parameters.

CONCLUSIONS

There were no additional effects of adding PAB to DBBM regarding bone formation, width changes, or volumetric changes after 10 months of graft healing.

Treatment of Sinus Graft Infection After Sinus Floor Elevation: A Series of Four Case Reports

This report of cases aims to share our treatment experiences in 4 sinus graft infection cases after sinus floor elevation and simultaneous implant placement. The preoperative and postoperative intraoral and radiographic photographs were collected and used to assess the treatment outcomes. The sinus cavity status, bone augmentation results, and implant stability were used as measurements to determine the treatment effectiveness. Four patients received partial graft removal as their surgical treatment for sinus graft infection combined with antibiotic therapy, with or without immediate secondary grafting. After early intervention, antibiotic therapy, and partial debridement of the infected sinus grafts, radiographic and clinical outcomes indicate successful resolution of the graft infection and stable bone graft levels around the implants. The keys to the successful management of the sinus graft infection were: early detection of the infection; early intervention, including partial debridement of the infected graft particles; and antibiotic therapy.

Gene expression, micro-CT and histomorphometrical analysis of sinus floor augmentation with biphasic calcium phosphate and deproteinized bovine bone mineral: A randomized controlled clinical trial

AIMS

The aim of this randomized controlled clinical trial was to compare the gene expression, micro-CT, histomorphometrical analysis between biphasic calcium phosphate (BCP) of 70/30 ratio and deproteinized bovine bone mineral (DBBM) in sinus augmentation.

MATERIALS AND METHODS

Twenty-four patients in need for sinus floor augmentation through lateral approach were randomized into BCP 70/30 ratio or DBBM. After at least 6 months of healing, a total of 24 bone specimens were collected from the entire height of the augmented bone at the area of implant placement and underwent micro-CT, histomorphometric and gene expression analysis. The 12 bone specimens of BCP 70/30 ratio were equally allocated to micro-CT and histologic analysis (test group, n = 6) and gene expression analysis (test group, n = 6). Similarly, the 12 bone specimens of DBBM were also allocated to micro-CT and histologic analysis (control group, n = 6) and gene expression analysis (control group, n = 6). The newly formed bone, remaining graft materials and relative change in gene expression of four target genes were assessed.

RESULTS

The micro-CT results showed no statistically significant difference in the ratio of bone volume to total volume (BV/TV ratio) for the two groups (BCP 41.51% vs. DBBM 40.97%) and the same was true for residual graft material to total volume (GV/TV ratio, BCP 9.97% vs. DBBM 14.41%). Similarly, no significant difference was shown in the histological analysis in terms of bone formation, (BCP 31.43% vs. DBBM was 30.09%) and residual graft area (DBBM 40.76% vs. BCP 45.06%). With regards to gene expression, the level of ALP was lower in both groups of bone grafted specimens compared with the native bone. On the contrary, the level of OSX, IL-1B and TRAP was higher in augmented bone of both groups compared with the native bone. However, the relative difference in all gene expressions between BCP and DBBM group was not significant.

CONCLUSIONS

The BCP, HA/β-TCP ratio of 70/30 presented similar histological and micro-CT outcomes in terms of new bone formation and residual graft particles with DBBM. The gene expression analysis revealed different gene expression patterns between augmented and native bone, but showed no significant difference between the two biomaterials.

[Meta-analysis of autologous bone grafts and bone substitute for the treatment of tibial plateau fractures]

OBJECTIVE

To explore clinical efficacy of autologous bone grafts and bone substitute for the treatment of tibial plateau fractures by Meta analysis.

METHODS

Controlled clinical studies on autogenous bone transplantation and bone substitutes in treating tibial plateau fractures published on PubMed,Web of Science,CNKI,Wanfang and other databases from January 2005 to August 2022 were searched by computer. Literature screening and data extraction were performed according to randomized controlled trial(RCT),and the quality of RCT were evaluated by using intervention meta-analysis criteria in Cochrane manual. Meta-analysis of joint depression,secondary collapse rate of articular surface,blood loss,operative time and infection rate between two methods were performed by Rev Man 5.3 software.

RESULTS

Seven RCT studies (424 patients) were included,296 patients in bone replacement group and 128 patients in autograft group. Operative time [MD=-16.79,95%CI(-25.72,-7.85),P=0.000 2] and blood loss[MD=-70.49,95%CI(-79.34,-61.65),P<0.000 01] between two groups had statistically differences,while joint depression[MD=-0.17,95%CI(-0.91,0.58),P=0.66],secondary collapse rate of joint surface[RR=-0.74, 95%CI(0.35,1.57),P=0.43],infection rate [RR=1.21,95%CI(0.31,4.70),P=0.78] between two groups had no differences.

CONCLUSION

The effects of bone substitute and autograft for the treatment of tibial plateau fracture have similar effects in terms of joint depression,secondary articular surface collapse rate and infection rate. However,compared with autologous bone transplantation,bone replacement could reduce blood loss and shorten operation time.

Assessment of bone regeneration after maxillary radicular cyst enucleation with or without bone grafting materials: a retrospective cohort study

OBJECTIVE

The limitations of spontaneous bone healing underscore the necessity for exploring alternative strategies to enhance bone regeneration in maxillary radicular cyst cases. This retrospective study aimed to assess the impact of a bone substitute material (i.e., Bio-Oss) on bone volume regeneration following maxillary radicular cyst enucleation using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Seventy-three patients with maxillary radicular cysts were divided into two groups: one undergoing guided bone regeneration (GBR) with Bio-Oss and absorbable collagen membrane (n = 35), and the other receiving cyst excision alone (n = 38). Volumetric measurements using Amira software on CBCT scans evaluated bone regeneration, with cystic lesion shrinkage rates calculated. Intergroup comparisons utilized independent sample t-tests (P < 0.05), and linear regression analysis assessed the influence of preoperative cyst volume and group on bone healing.

RESULTS

Both groups showed similar success rates in bone formation at the 12-month follow-up, with no significant differences between them (mean (SD), control: 75.16 (19.17) vs. GBR: 82 (20.22), P > 0.05). Linear regression analysis revealed a negative correlation between preoperative cyst volume and bone regeneration in both groups (P < 0.05).

CONCLUSION

Bio-Oss may not significantly enhance bone augmentation in maxillary radicular cysts. In addition, preoperative cyst volume negatively affected the shrinkage rate of cystic lesions.

CLINICAL RELEVANCE

Clinicians should consider patient-specific factors such as anatomy and lesion size when determining the need for bone substitute materials. Future research could focus on optimizing treatment protocols and alternative regenerative strategies to improve patient outcomes in maxillary cyst cases.

Ridge preservation using a self-retaining block type bone substitute for extraction sockets with buccal dehiscence defects - A preclinical study

OBJECTIVE

To evaluate the effect of a self-retaining block-type bone substitute (srBB) on the dimensional stability of the horizontal ridge width at the coronal level in a buccal dehiscence model.

MATERIALS AND METHODS

Four box-shaped bone defects with a buccal dehiscence were surgically prepared in the partially edentulous mandible (n = 6). Experimental biomaterials were randomly assigned to each site: (1) Control group: no treatment, (2) particle-type bone substitute (PBS) group, (3) collagenated soft block bone substitute (csBB) group, and (4) self-retaining synthetic block bone (srBB) group. In all grafted groups, a collagen membrane covered the biomaterials. At 16 weeks, clinical, histological, and radiographic analyses were performed.

RESULTS

Three of the six blocks in the srBB group became exposed and fell out during the first week after surgery. Therefore, the remaining three specimens were renamed RsrBB group. The RsrBB group showed an increase horizontal ridge compared to the pristine bone width at 2-4 mm below the CEJ, while the other groups showed resorption (augmented width at 2 mm below: 4.2, 42.4, 36.2, and 110.1% in the control, PBS, csBB, and RsrBB groups, respectively). The mineralized bone area was largest in the RsrBB group (4.74, 3.44, 5.67, and 7.77 mm2 in the control, PBS, csBB, and RsrBB groups, respectively.).

CONCLUSIONS

The srBB group demonstrated the highest volume stability at the coronal level. These findings would potentially suggest that self-retaining block bone substitute might be a good candidate for alveolar ridge preservation.

Clinical outcomes and complications of S53P4 bioactive glass in chronic osteomyelitis and septic non-unions: a retrospective single-center study

INTRODUCTION

Dead space management following debridement surgery in chronic osteomyelitis or septic non-unions is one of the most crucial and discussed steps for the success of the surgical treatment of these conditions. In this retrospective clinical study, we described the efficacy and safety profile of surgical debridement and local application of S53P4 bioactive glass (S53P4 BAG) in the treatment of bone infections.

METHODS

A consecutive single-center series of 38 patients with chronic osteomyelitis (24) and septic non-unions (14), treated with bioactive glass S53P4 as dead space management following surgical debridement between May 2015 and November 2020, were identified and evaluated retrospectively.

RESULTS

Infection eradication was reached in 22 out of 24 patients (91.7%) with chronic osteomyelitis. Eleven out of 14 patients (78.6%) with septic non-union achieved both fracture healing and infection healing in 9.1 ± 4.9 months. Three patients (7.9%) developed prolonged serous discharge with wound dehiscence but healed within 2 months with no further surgical intervention. Average patient follow-up time was 19.8 months ± 7.6 months.

CONCLUSION

S53P4 bioactive glass is an effective and safe therapeutic option in the treatment of chronic osteomyelitis and septic non-unions because of its unique antibacterial properties, but also for its ability to generate a growth response in the remaining healthy bone at the bone-glass interface.

Biodegradable biomaterials in orthopedic surgery: A narrative review of the current evidence

BACKGROUND

Biomaterials are routinely used in orthopedic surgery to fill bone defects, improve bone healing, and as degradable fixation material. A wide range of materials are currently in use, and the materials are chosen according to their bioactive properties. Osteoinductive materials stimulate bone healing by promoting osteogenesis. Osteoconductive materials facilitate bone growth on the surface of the material. Despite the many materials in use and an increasing number of published studies, randomized controlled trials on the subject are scarce.

METHODS

This review aims to summarize the history of biodegradable biomaterials and also the published level I evidence currently available on orthopedic biomaterials.

RESULTS

Most of the studies have been superiority trials with non-significant differences compared to conventional treatment options, confirming that several biomaterials are suitable treatment options for multiple indications including bone and/or tendon fixation, filling bone defects, and spinal fusion. Biomaterials help to avoid donor site complications associated with autogenous bone grafts and often eliminate the need for implant removal. However, the surgical technique may in some cases be more demanding than with conventional methods. Careful consideration of the pros and cons is therefore recommended in clinical practice.

CONCLUSION

Biodegradable biomaterials complement the range of available treatment options in several fields of orthopedic surgery. However, some biomaterials performed worse than expected and were not recommended for clinical use, emphasizing the need for high-quality randomized trials. It is also noteworthy that several trials included only a limited number of patients, rendering the interpretation of the results of these underpowered studies challenging.

Quantitative analysis of change in bone volume 5 years after sinus floor elevation using plate-shaped bone substitutes: a prospective observational study

PURPOSE

Tricalcium phosphate (TCP) has osteoconductive ability and reportedly offers similar clinical results as autogenous bone grafts in dental implant treatment. However, few reports quantify temporal changes in augmented bone volume after sinus augmentation. We aimed to establish a three-dimensional (3D) quantification method to assess bone volume after sinus augmentation and to evaluate biocompatibility of the TCP plate.

METHODS

Maxillary sinus floor augmentation was performed employing the lateral window technique, and plate-shaped β-TCP (TCP plate) was used instead of granular bone grafting materials. After lifting the sinus membrane, the TCP plate was inserted and supported by dental implants or micro-screws. The changes in bone volumes in the maxillary sinus before and after surgery were recorded using cone-beam computed tomography, saved as Digital Imaging and Communications in Medicine-formatted files, and transformed to Standard Triangle Language (STL)-formatted files. Pre- and post-operative STL data of bone volume were superimposed, and the augmented bone volume was calculated. Moreover, changes in bone volumes, TCP plate resorption rates, and bone heights surrounding the implants were three dimensionally quantified.

RESULTS

Fifteen implants in nine subjects were included in this study. TCP plates secured long-term space making, with results similar to those of granular bone substitutes. Newly formed bone was identified around the implant without bone graft material. TCP plate was absorbed and gradually disappeared.

CONCLUSIONS

A novel 3D quantification method was established to evaluate changes in bone volume. Clinical application of TCP plate in sinus augmentation could be a better procedure in terms of prognosis and safety.

Volume change after maxillary sinus floor elevation with apatite carbonate and octacalcium phosphate

PURPOSE

Maxillary molars have low alveolar bone height diameter due to the presence of the maxillary sinus; thus, a sinus lift may be required in some cases. Changes in the volume of bone substitutes can affect the success of implant therapy. Therefore, this study aimed to compare the changes in the volume of two different bone substitutes-one based on carbonate apatite and the other on octacalcium phosphate-used in maxillary sinus floor elevation.

METHODS

Nineteen patients and 20 sites requiring maxillary sinus floor elevation were included in the study. Digital Imaging and Communications in Medicine data for each patient obtained preoperatively and immediately and 6 months postoperatively were used to measure the volume of the bone grafting material using a three-dimensional image analysis software. The immediate postoperative volume of octacalcium phosphate was 95.3775 mm3 per piece of grafting material used. It was multiplied by the number of pieces used and converted to mL to determine the immediate postoperative volume.

RESULTS

The mean resorption values of carbonate apatite and octacalcium phosphate were 12.7 ± 3.6% and 17.3 ± 3.9%, respectively. A significant difference in the amount of resorption of the two bone replacement materials was observed (P = 0.04).

CONCLUSIONS

The results of this study indicate that both bone substitute materials tend to resorb. The two bone grafting materials that are currently medically approved in Japan have not been in the market for a long time, and their long-term prognosis has not yet been reported. Further clinical data are warranted.

Bone Graft Substitutes-What Are My Options?

We examine the range of available bone graft substitutes often used in nonunion and malunion surgery of the upper extremity. Synthetic materials such as calcium sulfate, beta-calcium phosphate ceramics, hydroxyapatite, bioactive glass, and 3D printed materials are discussed. We delve into the advantages, disadvantages, and clinical applications for each, considering factors such as biocompatibility, osteoconductivity, mechanical strength, and resorption rates. This review provides upper extremity surgeons with insights into the available array of bone graft substitutes. We hope that the reviews helps in the decision-making process to achieve optimal outcomes when treating nonunion and malunion of the upper extremity.

A randomized clinical trial of phycogenic materials for sinus grafting with hydroxyapatite versus biphasic calcium phosphate: 2 years clinical outcomes

OBJECTIVES

To assess in a prospective randomized trial two phycogenic bone substitutes-biphasic calcium phosphate (BCP) versus almost pure hydroxyapatite (HA)-for their volume stability and clinical implications after sinus floor elevation (SFE).

MATERIALS AND METHODS

Twenty patients requiring lateral-window SFE 6 months prior to implant surgery were randomized to a BCP or HA group. As primary outcome, the grafts were analyzed for volume stability, using four cone-beam computed tomography scans obtained immediately/6/12/24 months after SFE. Secondary outcomes were implant survivval, success, periotest values, oral-health-related quality of life (OHIP-G14), and pain (VAS).

RESULTS

Kolmogorov-Smirnov goodness-of-fit test revealed normal distribution of samples (p = .200). At 6/12/24 months, the augmented volumes decreased to 96/92/90% (HA) or 99/96/96% (BCP). Volume changes were significantly a factor of time (p < .001; generalized linear model with repeated measures) and reached significantly lower values in HA group (p = .018). Significant intergroup difference in volume losses was notable at 24 months (p = .021; t-test for independent samples). Periotest values decreased from -3/-4.1 (HA/BCP) after implant placement to -6.3/-4.5 (HA/BCP) after 6 months. OHIP scores diverged at 2 months (HA: 9.5; BCP: 5.2) and largely resolved by 24 months (HA: 1.3; BCP: 1.9). VAS scores were comparable, 2.2 at 1 week after SFE being their highest mean level.

CONCLUSIONS

After 2 years, both groups experienced no biological or technical complications, demonstrating a consistent healing trajectory without notable symptoms. Although no significant differences were observed in implant stability and survival, BCP demonstrated higher volume stability than HA.

Preclinical evaluation of a new synthetic carbonate apatite bone substitute on periodontal regeneration in intrabony defects

OBJECTIVE

To evaluate the potential of a novel synthetic carbonate apatite bone substitute (CO3 Ap-BS) on periodontal regeneration.

BACKGROUND

The use of various synthetic bone substitutes as a monotherapy for periodontal regeneration mainly results in a reparative healing pattern. Since xenografts or allografts are not always accepted by patients for various reasons, a synthetic alternative would be desirable.

METHODS

Acute-type 3-wall intrabony defects were surgically created in 4 female beagle dogs. Defects were randomly allocated and filled with CO3 Ap-BS (test) and deproteinized bovine bone mineral (DBBM) or left empty (control). After 8 weeks, the retrieved specimens were scanned by micro-CT, and the percentages of new bone, bone substitute, and soft tissues were evaluated. Thereafter, the tissues were histologically and histometrically analyzed.

RESULTS

Healing was uneventful in all animals, and defects were present without any signs of adverse events. Formation of periodontal ligament and cementum occurred to varying extent in all groups without statistically significant differences between the groups. Residues of both bone substitutes were still present and showed integration into new bone. Histometry and micro-CT revealed that the total mineralized area or volume was higher with the use of CO3 Ap-BS compared to control (66.06 ± 9.34%, 36.11 ± 6.40%; p = .014, or 69.74 ± 2.95%, 42.68 ± 8.68%; p = .014). The percentage of bone substitute surface covered by new bone was higher for CO3 Ap-BS (47.22 ± 3.96%) than for DBBM (16.69 ± 5.66, p = .114).

CONCLUSIONS

CO3 Ap-BS and DBBM demonstrated similar effects on periodontal regeneration. However, away from the root surface, more new bone, total mineralized area/volume, and higher osteoconductivity were observed for the CO3 Ap-BS group compared to the DBBM group. These findings point to the potential of CO3 Ap-BS for periodontal and bone regeneration.

Biological performance of a novel bovine hydroxyapatite in a guided bone regeneration model: A preclinical study in a mandibular defect in dogs

OBJECTIVES

This preclinical model study aims to evaluate the performance and safety of a novel hydroxyapatite biomaterial (Wishbone Hydroxyapatite, WHA) on guided bone regeneration compared to a commercially available deproteinized bovine bone mineral (Bio-Oss, BO).

MATERIAL AND METHODS

Twenty-four beagle dogs were allocated to three timepoint cohorts (4, 12, and 26 weeks) of eight animals each. In all animals, four critical-sized, independent wall mandibular defects were created (32 defects/cohort). Each animal received all four treatments, allocated randomly to separated defects: WHA + collagen membrane (M), BO + M, no treatment (Sham, Sh), and Sh + M. At each timepoint, the specimens were harvested for histologic and histomorphometric analyses to determine the newly formed bone and osteoconductivity.

RESULTS

At 4 weeks, bone regeneration was significantly higher for WHA + M (46.8%) when compared to BO + M (21.4%), Sh (15.1%), and Sh + M (23.1%) (p < 0.05); at 12 and 26 weeks, regeneration was similar for WHA and BO. Bone-to-material contact increased over time similarly for WHA + M and BO + M. From a safety point of view, inflammation attributed to WHA + M or BO + M was minimal; necrosis or fatty infiltrate was absent.

CONCLUSIONS

WHA + M resulted in higher bone regeneration rate than BO + M at 4 weeks. Both BO + M and WHA + M were more efficient than both Sh groups at all timepoints. Safety and biocompatibility of WHA was favorable and comparable to that of BO.

Comparative Histomorphometric Analysis of Bone Regeneration According to Bone Graft Type

PURPOSE

To use histomorphometric analysis to evaluate bone reconstruction in rabbit calvaria with autogenous bone, anorganic bovine bone, undecalcified human tooth bone (UdTB), and decalcified human tooth bone (dTB) grafts.

MATERIALS AND METHODS

Extracted human teeth were crushed, and tooth bone with and without decalcification was prepared. Bony defects were made in 10 rabbit calvaria and allocated to one of the following four groups: group 1, in which UdTB was grafted; group 2, in which dTB was grafted; group 3, in which anorganic bovine bone was grafted; group 4, in which autogenous bone was grafted. The rabbits were sacrificed at 2 or 8 weeks postoperatively, and histomorphometric comparison was performed.

RESULTS

Histologically, new bone formation was observed at the defect margin and around all graft materials. The dTB group revealed significantly greater new bone areas at 2 and 8 weeks compared to the UdTB group and the anorganic bovine bone group (P < .05). The dTB group revealed no significant difference in the new bone area at 2 weeks but revealed significantly less new bone area at 8 weeks compared to the autogenous bone group (P < .05). The dTB group also revealed significantly less graft material area compared to the anorganic bovine bone group at 8 weeks (P < .05). The autogenous bone group revealed significantly less graft material area and significantly greater bone marrow area compared to other groups at 8 weeks (P < .05).

CONCLUSIONS

Grafting with dTB resulted in better bone regeneration than UdTB and anorganic bovine bone grafting at 8 weeks and addresses the potential disadvantages of autogenous bone grafting.

Alveolar ridge preservation of damaged or periodontally compromised extraction sockets with bovine- and porcine-derived block bone substitutes: A retrospective case-control study

PURPOSE

Alveolar ridge preservation (ARP) was introduced to minimize postextraction alveolar bone loss and extraction socket remodeling; however, current knowledge of the ARP procedure for nonintact extraction sockets is still limited and inconclusive. This retrospective study aimed to evaluate the difference between using deproteinized bovine bone mineral with 10% collagen (DBBM-C) and deproteinized porcine bone mineral with 10% collagen (DPBM-C) when performing ARP procedures in damaged or periodontally compromised extraction sockets based on clinical, radiographic, and profilometric outcomes.

METHODS

In total, 108 extraction sockets were grafted with 67 DBBM-C and 41 DPBM-C. Changes in radiographic (horizontal width and vertical height) and profilometric outcomes were measured after the ARP procedure and before the implant surgery. Postoperative discomfort (including the severity and duration of pain and swelling), early wound healing outcomes (including spontaneous bleeding and persistent swelling), implant stability, and treatment modalities for implant placement were also assessed.

RESULTS

Radiographically, the DBBM-C group decreased by -1.70 ± 2.26 mm (-21.50%) and - 1.39 ± 1.85 mm (-30.47%) horizontally and vertically, and the corresponding DPBM-C group decreased by -1.66 ± 1.80 mm (-20.82%) and -1.44 ± 1.97 mm (-27.89%) horizontally and vertically at an average of 5.6 months. There were no serious or adverse complications in any of the cases, and none of the measured parameters differed significantly between the groups.

CONCLUSION

Within the limitations of this study, ARP with DBBM-C and DPBM-C showed similar clinical, radiographic, and profilometric outcomes in nonintact extraction sockets.

Bone regeneration property of tooth-derived bone substitute prepared chairside for periodontal bone defects: an experimental study

BACKGROUND

Periodontitis often leads to progressive destruction and loss of alveolar bone, the reconstruction of which remains difficult in periodontal therapy. As a novel bone graft material, tooth-derived bone substitute (TDBS) processed from extracted teeth has been previously reported about its osteoconductivity and promising results in bone regeneration. This study was to investigate the biological effects and bone regeneration properties of TDBS in vitro and in vivo using rat periodontal bone defect model.

METHODS

Three groups of materials were used in the experiments: TDBS, TDBS treated with ethylene diamine tetraacetic acid (EDTA) (TDBS-E), and allogeneic bone materials. Calcium (Ca) and phosphate (P) ion dissolutions were quantified by spectrophotometer for seven days. The releases of bone morphogenetic protein-2 (BMP-2) and transforming growth factor-β1 (TGF-β1) were identified by enzyme-linked immunosorbent assay (ELISA). Human osteoblast proliferation, migration, and differentiation were detected by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, cell counting, alkaline phosphatase activity (ALP), and alizarin red staining (ARS), respectively. Furthermore, the osteogenic effects of TDBS on periodontal furcation bone defects were evaluated at eight weeks postoperatively using micro-computed tomography (Micro-CT) and histological analysis.

RESULTS

The dissolution of both Ca and P ions in TDBS increased over time. The BMP-2 released from TDBS was significantly higher than that from TDBS-E and allografts, while the TGF-β1 release from TDBS and TDBS-E groups was higher than that in the allografts. The TDBS-E group could induce the highest level of osteoblast proliferation compared to other groups. Cell migration with allografts co-culture was significantly induced compared to the blank control. However, all groups demonstrated similar positive effects on osteoblast differentiation. Furthermore, in the periodontal model, all materials could effectively enhance bone regeneration in the furcation defect.

CONCLUSIONS

The TDBS prepared chairside as an autogenous bone graft, demonstrating osteoinductivity, which enhances the osteogenic biological characteristics. Therefore, TDBS is suggested as an economical and biocompatible material for periodontal bone regeneration.

Efficacy of Cal-Cemex as bone substitute for tibial plateau fractures

BACKGROUND

Various factors influence treatment and outcomes in tibial plateau fractures. Bone defects are among them. Many materials have been proposed to address this problem: allograft, bone-cements and various bone substitutes (BSM). Cal-Cemex (β-tricalciophosphate and polymethylmethacrylate) is a new hybrid bi-component BSM. A retrospective multicenter study was conducted based on the clinical experience of three European Hospitals, to demonstrate its clinical effectiveness, versatility and safety.

MATERIALS AND METHODS

From December 2016 to March 2022, 45 displaced tibial plateau fractures were treated with internal fixation and augmentation using Cal-Cemex. The average age was 55.9 years. According to Schatzker classification, we included 13 type II, 24 type III, 3 type V and 4 type VI fractures. The postoperative follow-up (FU) consisted of clinical and radiological examinations at 6 and 12 weeks and 1 year after surgery. A CT scan was performed preoperatively and 1 year after surgery. Full weight bearing was permitted after less than 6 weeks. Clinical data were collected from patient charts, while functional data were evaluated using the Rasmussen knee function score, the KOOS score and the Hospital for Special Surgery knee rating score (HSS), to evaluate the range of motion, axis and functionality of the knee.

RESULTS

The average FU was 42.8 months. CT scans taken at 1 year demonstrated a good surface osteointegration without radiolucent lines or osteolysis with good evidence of interdigitation and even bone ingrowth. At 1-year FU, the mean Rasmussen score was 24.7, the mean KOOS score was 90.7 and the mean HSS was 89.9 and the average full weight-bearing period 34.9. No patients had hardware failure or fracture secondary displacement.

DISCUSSION

Cal-Cemex combines biological features and good mechanical performances. It guarantees biocompatibility and osteoconductivity, although it is not fully reabsorbable; β-tricalciophosphate component gives macro- and microporosity that allow fluids to penetrate inside the material, to stimulate bone ingrowth.

CONCLUSIONS

The study suggests that Cal-Cemex is an option for tibial plateau fractures, where augmentation and support are necessary for early full weight bearing. The absence of major complications, ease of application, the possibility to cut and perforate this material support its extensive use in bone augmentation for trauma cases.

Clinical, radiographic, and histological/histomorphometric analysis of maxillary sinus grafting with deproteinized porcine or bovine bone mineral: A randomized clinical trial

OBJECTIVE

The present study aimed to compare histomorphometrically evaluated new bone formation, radiographically measured graft stability, and clinical implant outcome between maxillary sinus grafting with either deproteinized porcine bone mineral (DPBM) or deproteinized bovine bone mineral (DBBM).

MATERIALS AND METHODS

Thirty maxillary sinuses were initially included and randomly assigned to the test group (TG; DPBM, n = 15) or control group (CG; DBBM, n = 15). After a healing period (6 months), axially retrieved bone biopsies of the molar region were used for histological/histomorphometric analysis of new bone formations. Additionally, radiographically measured graft stability and clinical implant outcome were assessed.

RESULTS

Twenty-three sinus sites with 10 sinuses of the TG and 13 of the CG were ultimately available for data and statistical analysis. In the TG, a slightly, but yet significantly (p = .040) higher proportion of new bone formation (TG: 27.7 ± 5.6% vs. CG: 22.9 ± 5.1%) and a lesser (p = .019) amount of connective (non-mineralized) tissue (TG: 47.5 ± 9.5% vs. CG: 56.1 ± 9.5%) was found than in the CG. However, both xenografts showed comparable (n.s.) residual bone graft (TG: 23.7 ± 7.2% vs. CG: 21.1 ± 9.85.6%), bone-to-graft contacts (TG: 26.2 ± 9.8% vs. CG: 30.8 ± 13.8%), similar graft height reduction over time (TG: 12.9 ± 6.7% CG: 12.4 ± 5.8%) and implant survival/success rate (100%). At the 3-year post-loading evaluation, the peri-implant marginal bone loss (TG: 0.52 ± 0.19 mm; CG: 0.48 ± 0.15 mm) and the peri-implant health conditions (TG: 87.5%/CG: 81.2%) did not differ between implants inserted in both xenografts used.

CONCLUSIONS

The use of DPBM or DBBM for maxillary sinus augmentation is associated with comparable bone formation providing stable graft dimension combined with healthy peri-implant conditions.

Comparison of Nanocrystalline Hydroxyapatite Bone Graft with Empty Defects in Long Bone Fractures: A Retrospective Case-Control Study

BACKGROUND The regeneration of bone defects is indicated to restore lost tissue mass and functionality. Ostim®, an absorbable nanocrystalline hydroxyapatite (NCHA) paste, is indicated to enhance bone regeneration in bone defects due to trauma or surgery. This retrospective study of 110 patients with long-bone fracture defects presenting at a single trauma center between 2010 and 2012 aimed to compare outcomes with and without the use of Ostim® absorbable nanocrystalline hydroxyapatite paste. MATERIAL AND METHODS The study encompassed fractures in 110 patients - 55 patients received any defect augmentation (ED) and 55 patients were treated with NCHA augmentation. Fractures were located at the distal radius (66.4%, n=73), proximal humerus (5.5%, n=6), and proximal tibia (28.2%, n=31). Evaluating the clinical follow-up, the study encompassed post-surgery complications (eg, non-unions, infection). Bone healing was evaluated by conventional radiographs. RESULTS Postoperative complications occurred in 45.5% of patients regardless of the treatment (P=1.0). The non-union rate in both groups was 5.5% (n=8, P=1.0), and the risk for infection was lower in the NCHA group (3.6%, ED: n=3, NCHA: n=1, p=0.62). Patients suffered open fractures were treated in the NCHA group (100%, n=7, P=0.003). Radiological assessment demonstrated comparable healing of the fracture border, fracture gap, and articular surface (P>0.05). CONCLUSIONS The findings from this retrospective study support previous studies that have shown Ostim® absorbable nanocrystalline hydroxyapatite paste enhances outcomes and reduces the risk of complications when used to repair bone defects in long-bone fractures in trauma patients. NCHA paste augmentation is suitable for use in traumatic long-bone fractures.

Alveolar ridge alterations after lateral guided bone regeneration with and without hyaluronic acid: a prospective randomized trial with morphometric and histomorphometric evaluation

OBJECTIVE

To clinically and histologically evaluate the potential effect of a cross-linked, high molecular weight hyaluronic acid (xHyA) on the outcomes of guided bone regeneration performed with a demineralized bovine bone mineral (DBBM) covered with a natural collagen membrane.

METHOD AND MATERIALS

Eleven patients (eight females and three males, mean age 53 years) with a total of 27 surgical sites were treated. Treatments were performed with either DBBM and natural collagen membrane fixed with tacks (group A) or DBBM mixed with xHyA and subsequently covered with natural collagen membrane (group B). Clinical evaluations were made at baseline (T1), immediately after guided bone regeneration (T2), and at the time of implant placement (T3). Additionally, at the time of implant placement, core biopsies were retrieved and submitted for histologic analysis.

RESULTS

Healing was uneventful in all cases. At 6 months, group B revealed a statistically significantly higher crestal ridge dimension compared to group A (P = .007). The histologic analysis revealed a tendency for greater mineralized tissue formation in group B compared to group A (67.5% versus 41.6%) and contained a higher amount of new bone (37.2%) and less DBBM residues (20.9%) than group A (12.8% new bone and 28.8% DBBM residues, respectively).

CONCLUSIONS

Within their limits, the present data indicate that, during guided bone regeneration with natural collagen membrane, the combination of DBBM and xHyA may improve the quality and quantity of bone formed with DBBM alone.

Ossification and Bone Regeneration in a Canine GBR Model, Part 2: Glycated Cross-Linked Collagenated Alloplastic Hydroxyapatite Scaffold vs Non-Cross-Linked Collagenated Xenographic Bone Hydroxyapatite

PURPOSE

To compare bone substitutes composed of glycated collagen with synthetic micro-sized (1 to 10 μm) hydroxyapatite (OB) vs non-cross-linked collagen matrix with large-particle (250 to 1,000 μm) bovine-derived hydroxyapatite (BOC).

MATERIALS AND METHODS

The P1 to P4 premolars were bilaterally extracted from the mandibles of 19 Beagle dogs. After 21 days, osteotomies were created in each dog that received OB or BOC and were covered with a collagen membrane or were left untreated. The animals were randomly divided into three groups based on sacrifice time (4, 12, or 24 weeks). The right and left hemimandibles were trimmed to facilitate imaging and histology, and all tissues were placed in 10% neutral-buffered formalin. Microcomputed tomography (MicroCT 40 Scanner, Scanco) was used to analyze bone sections. Bone volume, residual material volume, and bone mineral density were determined for each treatment site (OB and BOC) based on a volume of interest that encompassed the original defect. Additionally, blinded histopathologic assessment (based on the ISO 10993-6 scoring system) and histomorphometry were performed on sections ground to < 100 μm thick and stained with Stevenel's blue.

RESULTS

No clinical side effects were noted. No statistical differences were observed for OB vs BOC regarding the mineral volume percentage. Compared to OB, BOC had significantly higher mean mineralization densities at 12 weeks (P < .01), but this difference did not extend to 24 weeks. For residual grafting material, bone maturation, alveolar ridge restoration, and inflammatory response, OB showed a residual amount of bone graft and no statistical differences compared to BOC.

CONCLUSION

Both OB and BOC represent valid treatment options for critically sized bone defects. Both bone fillers outperformed the sham-operated, ungrafted (empty) control, demonstrating statistically improved bone growth and ridge restoration.

The impact of deproteinized bovine bone particle size on histological outcomes in sinus floor elevation: a systematic review and meta-analysis

OBJECTIVES

The main purpose of this study was to evaluate whether large granular bovine bone can be as effective as small granular bovine bone in maxillary sinus floor elevation.

METHODS

A comprehensive online search of eligible articles was conducted using PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science, and a systematic review and meta-analysis was performed from establishment to February, 2023. The outcome indicators were the percentage of connective tissue, the percentage of newly formed bone and the percentage of residual xenograft respectively. The meta-analysis was conducted by using the Stata 15.1 (Stata Conpernarn, USA) and Review Manager software5.4.1.

RESULTS

After careful screening and review, a total of 4 studies were included for systematic review and meta-analysis. The data were extracted to compare the histological performance of bovine bones with different particle sizes after maxillary sinus elevation. No significant differences were found in the percentage of connective tissue, the percentage of newly formed bone, and the percentage of residual xenograft.

CONCLUSION

In this study, a systematically review of the previous literature showed that similar histological results were obtained for both large-particle bovine bone and small-particle bovine bone. Therefore, the large granular bovine bone and the small granular bovine bone were equally effective in maxillary sinus elevation. It is difficult to make conclusion from limited evidence from four studies. More clinical evidence was needed.

Complications following alveolar ridge augmentation procedures

Oral rehabilitation through implant supported dental restorations often requires a ridge augmentation procedure (RAP) prior to implant fixture placement since tooth extraction/loss results in alveolar ridge deficiencies. Although RAP-related surgical techniques and biomaterials have been in practice for several decades, outcomes are not always predictable. Post-surgical complications experienced during the early or late wound healing phases may jeopardize the targeted ideal ridge dimensions, required for implant fixture placement, and may have other consequences, such as negatively impacting the patient's quality of life. This review describes reported post-surgical complications following RAP under the following subtitles: complications by tissue type, complications in function and aesthetics, complications by healing time, complications by biomaterial type, and complications by surgical protocol modalities. Specifically, RAP performed by using particulate bone graft substitutes and related complications are explored. Modalities developed to prevent/manage these complications are also discussed.

Efficacy of positive space acquiring membrane and antimicrobial membrane combined with granular bone substitute implantation in guiding oral bone regeneration

Augmentation of the alveolar bone is important before oral implantation. For large bone defects, it becomes necessary to apply guided bone regeneration (GBR) materials, accompanied by filling defect sites with autologous or allogeneic bone, or bone substitutes such as acellular bone powder. In this study, we tested a granular bone substitute and GBR membrane combination therapy in treating MC3T3-E1 and L929 cells in vitro and rat calvarial and alveolar defects in vivo. The recovery conditions of bone defects were monitored by micro-CT, and 3D reconstruction of the CT images was applied to evaluate the bone augmentation semi-quantitatively. Test GBR materials could support the proliferation of MC3T3-E1 cells, poly (p-dioxanone-co-L-phenylalanine) (PDPA)-based membrane could induce apoptosis of L929 cells. Among GBR membranes applied groups, the regeneration condition of defected calvarial defects of PDPA based membrane applied group was the best and this may be caused by its excellent positive space acquiring effect. However, in a complex bacteriogenic environment, the oral bone regeneration-guided efficacy of the PDPA membrane decreased in the post-repair stage with the aggravation of infections. By contrast, the antimicrobial membrane combined with the PDPA membrane exhibited continually increasing GBR efficacy at the later stage of repair owing to its multifunctional properties, which are infection-inhibiting and positive space acquiring. Therefore, multifunctional GBR membranes are preferable for GBR in complex oral environments, and further research should be conducted to determine their efficacy in other models.

Guided bone regeneration in implant dentistry: Basic principle, progress over 35 years, and recent research activities

Bone augmentation procedures are frequent today in implant patients, since an implant should be circumferentially anchored in bone at completion of bone healing to have a good long-term stability. The best documented surgical technique to achieve this goal is guided bone regeneration (GBR) utilizing barrier membranes in combination with bone fillers. This clinical review paper reflects 35 years of development and progress with GBR. In the 1990s, GBR was developed by defining the indications for GBR, examining various barrier membranes, bone grafts, and bone substitutes. Complications were identified and reduced by modifications of the surgical technique. Today, the selection criteria for various surgical approaches are much better understood, in particular, in post-extraction implant placement. In the majority of patients, biodegradable collagen membranes are used, mainly for horizontal bone augmentation, whereas bioinert PTFE membranes are preferred for vertical ridge augmentation. The leading surgeons are using a composite graft with autogenous bone chips to accelerate bone formation, in combination with a low-substitution bone filer to better maintain the augmented bone volume over time. In addition, major efforts have been made since the millenium change to reduce surgical trauma and patient morbidity as much as possible. At the end, some open questions related to GBR are discussed.

Bone Graft Substitutes and Enhancement in Craniomaxillofacial Surgery

Critical-sized bone defects are a reconstructive challenge, particularly in the craniomaxillofacial (CMF) skeleton. The "gold standard" of autologous bone grafting has been the work horse of reconstruction in both congenital and acquired defects of CMF skeleton. Autologous bone has the proper balance of the protein (or organic) matrix and mineral components with no immune response. Organic and mineral adjuncts exist that offer varying degrees of osteogenic, osteoconductive, osteoinductive, and osteostimulative properties needed for treatment of critical-sized defects. In this review, we discuss the various mostly organic and mostly mineral bone graft substitutes available for autologous bone grafting. Primarily organic bone graft substitutes/enhancers, including bone morphogenic protein, platelet-rich plasma, and other growth factors, have been utilized to support de novo bone growth in setting of critical-sized bone defects. Primarily mineral options, including various calcium salt formulation (calcium sulfate/phosphate/apatite) and bioactive glasses have been long utilized for their similar composition to bone. Yet, a bone graft substitute that can supplant autologous bone grafting is still elusive. However, case-specific utilization of bone graft substitutes offers a wider array of reconstructive options.

Retrospective analysis of three different xenografts in maxillary sinus augmentation: histologic and three-dimensional radiologic study

OBJECTIVES

Low bone density and lack of adequate vertical bone dimension as a result of maxillary sinus pneumatization present some of the most problematic cases for endosseous implant applications in posterior maxillary regions that hinder prosthetic rehabilitation. The overall objectives of the study were to assess the histologic, histomorphometric, and radiologic evaluation of biopsies gathered from maxillary sinuses that were grafted with three different bovine bone particles (Bio-Oss, Cerabone, and Ti-Oss) and analyze the volume of the bone graft and the quantity of new bone formation.

METHOD AND MATERIALS

Thirty-six patients with < 4 mm of residual ridge height unilaterally in the posterior maxilla were equally divided into three groups, each of which received different bovine bone particles for maxillary sinus augmentation. Six months later, biopsies were harvested for histologic and histomorphometric evaluations. Volumetric changes in maxillary sinus augmentation were analyzed at 1-week and 6-month time-points following maxillary sinus augmentation surgery.

RESULTS

Histomorphometric and histologic analysis revealed a significant difference between the Ti-Oss group compared with the Bio-Oss and Cerabone groups (P = .011). In terms of residual graft particles and soft tissue, there were no significant differences between groups. 3D volumetric reductions between 1-week (baseline) and 6-month time-points recorded significant graft volume reduction in all groups (P < .05). Significantly greater bone resorption and lower new-bone formation were manifested in the Ti-Oss group in comparison to the other groups.

CONCLUSIONS

Within the limits of this study, histologic and radiologic results indicated that Bio-Oss and Cerabone could be used efficiently in sinus augmentation procedures, while further prospective studies are needed to evaluate the Ti-Oss material in maxillary sinus augmentation.

Retrospective Analysis of Bone Substitute Material for Traumatic Long Bone Fractures: Sex-Specific Outcomes

Male patients often experience increased bone and muscle loss after traumatic fractures. This study aims to compare the treatment outcomes of male and female patients with large bone defects. A total of 345 trauma patients underwent surgery, with participants divided into two groups: one receiving bone substitute material (BSM) for augmented defects (n = 192) and the other without augmentation (empty defects = ED, n = 153). Outcome parameters were assessed among female (n = 184) and male (n = 161) patients. Descriptive statistics revealed no significant differences between male and female patients. Approximately one-half of the fractures resulted from high-energy trauma (n = 187). The BSM group experienced fewer complications (p = 0.004), including pseudarthrosis (BSM: n = 1, ED: n = 7; p = 0.02). Among female patients over 65, the incidence of pseudarthrosis was lower in the BSM group (p = 0.01), while younger females showed no significant differences (p = 0.4). Radiologically, we observed premature bone healing with subsequent harmonization. Post hoc power analysis demonstrated a power of 0.99. Augmenting bone defects, especially with bone substitute material, may reduce complications, including pseudarthrosis, in female patients. Additionally, this material accelerates bone healing. Further prospective studies are necessary for confirmation.

Investigation of Bone Regeneration Efficacy of New Bovine Bone Minerals in a Canine Mandibular Critical Defect Model

This study aims to investigate the bone regeneration effect of bovine hydroxyapatite-processed biomaterials Bone-XB and S1-XB in a beagle mandibular defect model. A total of four saddle-type critical sizes (15 mm × 10 mm) bone defects are created in each dog: two defects in the left mandible and two defects in the right mandible. The defect control (DC) group is kept unfilled, and the other three defects are filled with three different biomaterials as follows: positive control Bio-Oss (Bio-Oss group), Bone-XB (XB group), and S1-XB (S1-XB group). Bone regeneration is evaluated by radiography, micro-computed tomography, and histological analysis. It is revealed that Bone-XB and S1-XB significantly increase newly formed bone, defect filling percentage, and bone healing score compared to the DC group, which is confirmed by bone microstructure augmentation (bone volume/total volume, trabecular number, and trabecular thickness). Interestingly, no significant differences are observed between the Bone-XB, S1-XB, and Bio-Oss groups. It is suggested that Bone-XB or S1-XB stimulates bone regeneration demonstrated by the increase in newly formed bone and bone microstructure, thereby improving bone defect filling, which is equivalent to the Bio-Oss. Therefore, bovine hydroxyapatite-processed Bone-XB or S1-XB can be considered effective biomaterials for correcting critical-size bone defects or fractures.

A prospective, randomized, single-blind study to compare two methods of treating cystic lesions in the jaw

OBJECTIVE

The study aimed to assess the usefulness of a bovine bone substitute material in treating cystic lesions in the jaw with a maximum diameter of <4 cm.

MATERIAL AND METHODS

In this prospective, randomized, single-blind intervention study of 116 patients, 61 underwent cystectomy with a subsequent filling of the defect using a bovine xenograft, and 55 underwent cystectomy alone. Volumetric measurement of the cysts was performed preoperatively and 6 and 12 months postoperatively using the available digital volume tomography data sets. Follow-up appointments were made 14 days and 1, 3, 6, and 12 months postoperatively.

RESULTS

Almost complete regeneration was seen in both treatment groups within 12 months, with no significant difference in absolute volume loss between the 2 groups (P = .521). Examination 14 days after surgery revealed a tendency for more wound healing disorders with the use of a bone substitute (P = .077). It was no longer possible to detect any further differences in later examinations.

CONCLUSION

Using bovine bone substitute material has no radiologically measurable advantage over cystectomy alone without defect filling regarding bone regeneration. In addition, there was a tendency for more wound-healing disorders to occur in the bone substitute group.

The Interplay of Raloxifene and Sonochemical Bio-Oss in Early Maxillary Sinus Bone Regeneration: A Histological and Immunohistochemical Analysis in Rabbits

The study aimed to assess the efficacy of using Raloxifene with ultrasonic processing to enhance Bio-Oss®, a bone graft substitute, for maxillary sinus bone height reconstruction. A total of 24 rabbit maxillary sinuses were distributed into three groups, each receiving different treatments: Bio-Oss® only, sonicated Bio-Oss, and sonicated Bio-Oss® with Raloxifene. Surgical procedures and subsequent histomorphometric and immunohistochemistry analyses were conducted to evaluate the bone formation, connective tissue, and remaining biomaterial, as well as the osteoblastic differentiation and maturation of collagen fibers. Results indicated that the sonicated Bio-Oss® and Bio-Oss® groups showed similar histological behavior and bone formation, but the Raloxifene group displayed inflammatory infiltrate, low bone formation, and disorganized connective tissue. The statistical analysis confirmed significant differences between the groups in terms of bone formation, connective tissue, and remaining biomaterial. In conclusion, the study found that while sonicated Bio-Oss® performed comparably to Bio-Oss® alone, the addition of Raloxifene led to an unexpected delay in bone repair. The findings stress the importance of histological evaluation for accurate bone repair assessment and the necessity for further investigation into the local application of Raloxifene. Future research may focus on optimizing bone substitutes with growth factors to improve bone repair.

Treatment of a Soft Tissue Depression with a Xenograft Bone Substitute at the Second Stage of an Implant Procedure: A Case Report

Following the extraction of a compromised tooth, the edentulous alveolar ridge undergoes physiologic bone remodeling, which may create a bone volume too deficient for implant placement. Guided bone regeneration (GBR) provides a predictable treatment option to increase the alveolar bone volume for implant placement, but a soft or hard tissue deficiency may remain even after this augmentation procedure has been completed. These deficiencies can be especially challenging in the esthetic zone, where patient expectations and esthetics often determine the satisfaction of the treatment outcome. This paper presents a case report of a xenograft bone substitute used at the second-stage surgery and abutment insertion to provide a solution to these deficiencies even after the patient had undergone a GBR procedure, thus improving the esthetic and functional outcomes of the final implant-supported restoration.

[Synthetic bone replacement substances]

Bone substitute materials have been successfully used for bone defects in orthopedics and trauma surgery for a long time; however, there are cases, especially in bone defects with a critical size, in which the treatment is complicated. Nowadays, multiple bone substitute materials are available. Autologous cancellous bone grafts remain the gold standard among the bone replacement materials; however, donor site morbidity and the limited availability of autologous cancellous bone represent restrictions for autologous bone grafting. Allogeneic cancellous bone grafts have also been successfully for years in the treatment of bone defects; however, infection rates of more than 10% have been described for the use of allogeneic cancellous bone. By introducing synthetic bone substitutes further alternatives are currently available to the user for the individual treatment of bone defects. The aim of this study is to demonstrate the advantages and disadvantages of various synthetic bone substitute materials.

Radiographic evaluation of a bone substitute material in alveolar ridge preservation for maxillary removable immediate dentures: A randomized controlled trial

STATEMENT OF PROBLEM

Maxillary bone resorption after multiple extractions can jeopardize the success of an immediate denture, but whether bone volume preservation techniques are effective is unclear.

PURPOSE

The purpose of this randomized controlled trial was to evaluate the efficacy of socket grafting with a xenogenic bone substitute in participants receiving maxillary immediate removable complete dentures in terms of bone volume preservation (height and width of the bone ridge).

MATERIAL AND METHODS

The study was a single-blinded, randomized controlled clinical trial with 2 balanced parallel arms. Thirty-six participants who had Kennedy Class I edentulous posterior areas bilaterally for at least 3 months and required maxillary immediate removable complete dentures were enrolled. Duplicates of the removable complete denture were made and converted into radiographic and surgical guides. Participants allocated to the test group received deproteinized bovine bone mineral blended with 10% porcine collagen (DBBM-C) in the extraction sockets, and participants in the control group received no grafting material. With a radiographic guide in place, cone beam computed tomography scans were made 10 days after tooth extraction, when the immediate removable complete denture was delivered (D10, baseline), after 3 months (D90), and after 1 year (D365). The scans were superimposed, and measurements were made on the cross-sectional plane of each extraction site. The influence of various prognosis factors associated with bone volume preservation, including the location of tooth extraction, smoking habits, periodontal disease, and operator team, were analyzed.

RESULTS

Of 36 participants, 3 were lost to follow-up. The mean ±standard deviation loss of height of the buccal crest was 1.2 ±1.8 mm in the control group and 0.3 ±1.2 mm in the test group after 3 months of healing (P<.001) and 2.1 ±2.0 mm in the control group and 0.7 ±1.4 mm in the test group after 1 year of follow-up (P<.001). Mean ±standard deviation horizontal ridge width change was 1.3 ±1.4 mm in the control group and 0.5 ±0.8 mm in the test group after 3 months (P<.001) and 2.2 ±1.4 mm in the control group and 0.9 ±1.1 mm in the test group after 1 year of follow-up (P<.001). None of the other prognostic factors had a significant effect at either time period.

CONCLUSIONS

Grafting DBBM-C into the extraction socket after removing anterior teeth for immediate removable denture therapy resulted in significantly less vertical buccal crest and horizontal ridge resorption as compared with spontaneous socket healing after 1 year of follow-up. This procedure may be useful for preserving bone, especially when a fixed implant-supported prosthesis is planned.

Utility of 45S5 Bioactive Glass As Bone Graft Substitute for Cavitary Defects in Pediatric Bone Tumors: A Preliminary Study

BACKGROUND

Bioactive glass has become an increasingly used treatment of cavitary bone defects in a number of orthopaedic applications. The purpose of this study was to evaluate the clinical and radiographic outcomes of bioactive glass used for benign cavitary pediatric bone tumors. A specific focus was on radiographic filling of defects and occurrence of complications by tumor class.

METHODS

A single institution retrospective study was performed, which entailed review of the clinical and radiographic data of 21 patients who underwent surgical curettage and grafting of benign or low-grade malignant bone tumors from 2018 to 2020. In all the cases, 45S5 bioactive glass (Fibergraft; Prosidyan, New Providence, NJ) was used to fill the bone defects. For each patient, data on demographic, preoperative diagnosis, defect size, time to mobilization, radiographic filling grade, pain, and complications were obtained. The Wilcoxon-Mann-Whitney test and Kaplan-Meier survival analysis were used for comparisons between tumor classes.

RESULTS

In the 21 patients, 11 bone tumors were latent or active (class 1) and 10 were aggressive (class 2). The mean age was 13.0±3.7 years, 6 (28.6%) were female, and the median and interquartile range for initial tumor size were 18.8 (5.8 to 50.6) cm 3 . Tumors that were class 2 had significantly more complications with bioactive glass use compared with class 1 tumors [0 vs. 1 (0 to 1), P =0.040]. The time of persistent fill grade 1 or 2 defects up to final follow-up was less in class 1 versus class 2 lesions ( P =0.048).

CONCLUSIONS

Bioactive glass agents have utility for treating a broad variety of pediatric bone tumors after curettage. However, focusing these agents' use in treating latent or active subtypes of bone tumors may be ideal in minimizing complications and time to higher fill grade.

LEVEL OF EVIDENCE

Level III - Therapeutic.

Addition of Synthetic Biomaterials to Deproteinized Bovine Bone Mineral (DBBM) for Bone Augmentation-A Preclinical In Vivo Study

(1) Aim: To investigate the effect of synthetic bone substitutes, α-tricalcium phosphate (α-TCP) or bi-layered biphasic calcium-phosphate (BBCP) combined with deproteinized bovine bone mineral (DBBM), on bone formation. (2) Methods: Thirty critical size defects were randomly treated with the following five different treatment modalities: (1) negative control (NC, empty), (2) DBBM, (3) α-TCP + DBBM (1:1), (4) BBCP 3%HA/97%α-TCP + DBBM (1:1), and (5) BBCP 6%HA/94%α-TCP + DBBM (1:1). The samples, at four weeks post-surgery, were investigated by micro-CT and histological analysis. (3) Results: A similar level of new bone formation was demonstrated in the DBBM with α-TCP bone substitute groups when compared to the negative control by histomorphometry. DBBM alone showed significantly lower new bone area than the negative control (p = 0.0252). In contrast to DBBM, the micro-CT analysis revealed resorption of the α-TCP + DBBM, BBCP 3%HA/97%α-TCP + DBBM and BBCP 6%HA/94%α-TCP + DBBM, as evidenced by a decrease of material density (p = 0.0083, p = 0.0050 and p = 0.0191, respectively), without changing their volume. (4) Conclusions: New bone formation was evident in all defects augmented with biomaterials, proving the osteoconductive properties of the tested material combinations. There was little impact of the HA coating degree on α-TCP in bone augmentation potential and material resorption for four weeks when mixed with DBBM.

Shortened Treatment Time for Maxillary Sinus Grafting with Simultaneous Implant Placement: Retrospective Analysis with 10-Year Follow-Up

PURPOSE

The aim of the present retrospective clinical study was to evaluate the outcome of a maxillary sinus lateral window augmentation protocol, which sought to shorten the treatment time.

MATERIALS AND METHODS

This protocol entailed sinus augmentation with deproteinized bovine bone minerals (DBBM) and simultaneous implant placement in patients with minimal residual bone height. A total of 89 sinus augmentation procedures were performed in 74 patients, in whom 160 implants were placed between 2005 and 2013. The mean residual bone height was 2.6 ± 0.6 mm. The healing time before loading was 4.18 ± 0.63 months.

RESULTS

In a first evaluation in 2014 the early implant survival rate (EIsR) was 96.8% after a mean period of 5.4 ± 2.2 years. A second evaluation in 2019 after a mean period of 10.4 ± 2.2 years showed a late implant survival rate (LIsR) of 83.1%. The failures after 2014 were all caused by peri-implantitis, which affected 14.6% and 16.8% of patients and implants, respectively. This prevalence of peri-implantitis does not appear to be higher than that usually observed in nonaugmented sites.

CONCLUSION

This reduction in the duration of treatment compared to the usual duration of 9 to 12 months does not seem to affect the predictability of the technique.

Maxillary Sinus Floor Augmentation with Two Different Inorganic Bovine Bone Grafts: an Experimental Study in Rabbits

OBJECTIVE

To compare the sequential healing of maxillary sinuses grafted with two different xenogeneic bone substitutes processed at either a low (300°C) or high (1200°C) temperature.

METHODS

A sinus augmentation procedure was performed bilaterally in 20 rabbits and two different xenogeneic bone grafts were randomly used to fill the elevated spaces. Healing was studied after 2 and 10 weeks, in 10 rabbits during each period.

RESULTS

After 2 weeks of healing, very small amounts of new bone were observed in both groups, and were mainly confined to close to the sinus bone walls and osteotomy edges. After 10 weeks of healing, new bone was found in all regions, with higher percentages in those close to the bone walls and to the osteotomy. In this period of healing, the proportion of new bone in the 300°C group was 20.0% ± 4.3%, and in the 1200°C group it was 17.2% ± 4.3% (P = 0.162). In the 1200°C group, translucent, dark fog-like shadows in regions of the grafts were hiding portions of new bone (interpenetrating bone network).

CONCLUSION

Both biomaterials provided conditions that allowed bone growth within the elevated space, confirming that both biomaterials are suitable to be used as a graft for sinus floor augmentation.

Tomographic Imaging of Mucociliary Clearance Following Maxillary Sinus Augmentation: A Case Series

Mucociliary clearance (MCC) allows ventilation of graft particles that are displaced through a perforated Schneiderian membrane during maxillary sinus augmentation (MSA). However, it is very rarely confirmed by cone-beam computed tomographic (CBCT) images. It is not yet known how long the dislodged bone graft particles remain in the maxillary sinus or how quickly they are ventilated after MSA. The purpose of these case reports is to introduce tomographic imaging of ventilation of bone graft particles displaced through a perforated Schneiderian membrane after MSA. Four patients, who needed implant placement in the posterior maxilla, received MSA, during which the Schneiderian membrane was perforated but was not repaired. Therefore, some bone graft particles were dislocated into the sinus cavity. The sizes of the perforated membranes were measured and recorded. CBCT scans were taken at multiple time points after the surgery to visualize and trace the ejected material. In addition, the time from when the bone graft substitute was delivered to the sinus until the CBCT scans were taken was recorded. The expelled bone graft particles migrated to the ostium along the sinus wall immediately after MSA on CBCT images taken immediately after the surgery. No displaced graft particles were observed in the maxillary sinus on CBCT scans after 1 week. The CBCT scans at 6 months showed no unusual radiographic images. Within the limitations of the case reports, tomographic imaging revealed an MCC system that allows displaced graft particles to be ventilated into the ostium very early during MSA healing and not stagnate in the maxillary sinus.

Combination Therapy with Connective Tissue Graft, Amelogenins, and Bone Substitutes for Treatment of Deep Intrabony Defects Associated with Gingival Recession: 1-Year Follow-up of 12 Cases

Combined surgical procedures have been introduced that combine periodontal regenerative/reconstructive procedures in intrabony defects with a connective tissue graft to compensate for a deficient bone wall and limit soft tissue shrinkage, but little is known about the reproducibility of these advanced surgical techniques. This 12-case series applies a combined surgical procedure, combining amelogenins, bone substitutes, and connective tissue graft to treat deep intrabony defects associated with gingival recession. Twelve deep intrabony defects with a mean clinical attachment loss of 9.9 ± 2.1 mm, mean probing depth (PPD) of 7.8 ± 1.5 mm, mean recession of the tip of the interdental papilla (TP) of 2.1 ± 1.5 mm, and mean buccal recession (REC) of 2.3 ± 1.8 mm were treated. At 1 year, the average attachment gain was 5.1 ± 1.8 mm (P < .001), the residual PPD was 2.9 ± 0.7 mm (P < .001), no change was observed in the TP (-0.4 ± 0.8 mm, P = .078), and the REC slightly decreased to 1.7 ± 1.5 mm (P = .047). These results suggest that the proposed technique led to predictable clinical outcomes that support regeneration while maintaining or improving the position of the soft tissue margin for the interdental and buccal aspects in deep intrabony defects associated with gingival recession.

The Effect of an Alloplastic Bone Substitute and Enamel Matrix Derivative on the Preservation of Single Anterior Extraction Sockets: A Histologic Study in Humans

This study was designed to assess the effect of enamel matrix derivative (Emdogain, Straumann) and alloplastic bone substitute (BoneCeramic, Straumann) on new bone formation in postextraction alveolar sockets. Twenty-one patients requiring anterior single-tooth extractions and subsequent implant placement were recruited and randomly assigned to one of three treatment groups. Postextraction sockets were filled with either an alloplastic bone substitute (BoneCeramic [BC]), BC combined with Emdogain (EMD+BC), or left to heal spontaneously (SO). Histologic and histomorphometric analyses of the results were performed at 6 months postextraction. A significant increase in the percentage of new bone tissue area was found in EMD+BC compared to SO and BC groups. These findings demonstrate that compared with BC or SO, EMD+BC allowed for better formation of new bone in postextraction sockets after 6 months of healing.

Biological Impact of Alloplastic Bone Graft vs Bovine Xenograft and Allograft Materials in Bone Healing: An Experimental Study

AIM

This study aims to compare the performance of beta-tricalcium phosphate with calcium sulfate (β-TCP/CS) vs a bovine xenograft, freeze-dried mineralized allograft, and spontaneous healing in surgically prepared bone defects in rabbit tibia.

MATERIALS AND METHODS

The grafting materials were implanted in three out of four standardized monocortical bony defects, 3-mm diameter and 3-mm deep, in rabbit tibia while one defect was left empty for spontaneous healing as a control group. Twelve rabbits were euthanized at 2 and 6 weeks after surgery. The bone tissue specimens were histologically evaluated using hematoxylin and eosin, Masson's trichrome and osteoprotegrin (OPG) immunohistochemical staining. Results were quantitatively evaluated.

RESULTS

An enhancement of bone healing was noticed in the defects grafted with β-TCP/CS compared with all other groups at 2 and 6 weeks after surgery as it showed significant increase in OPG expression and a significant decrease in the amount of collagen at 6 weeks after surgery. The residual grafted particles were the least with β-TCP/CS at 6 weeks after surgery.

CONCLUSION

The β-TCP/CS grafting material is a promising bioactive alloplastic bone substitute as it proved to be biocompatible, osteoconductive, and bioresorbable bone substitute.

CLINICAL SIGNIFICANCE

The β-TCP/CS grafting material can be used for guided bone regeneration resulting in pronounced high-quality bone which aids in oral and maxillofacial reconstruction.

Evaluation of biphasic hydroxapatite and β-tricalcium phosphate as a bone graft material in the treatment of periodontal vertical bony defects - A clinical and digital radiological measurement study

AIMS AND OBJECTIVE

The present study aimed to evaluate 2 bone graft materials, that is, biphasic hydroxyapatite and β-tricalcium phosphate, in the treatment of periodontal vertical bony defects. In term of attachment level, probing depth and radiographic bone level changes. Also, a new digital method of radiographic assessment was used for measurement of vertical bone defect.

MATERIAL AND METHODS

Ten subjects with periodontitis and having two or more vertical bony defects were enrolled in the study. Patients were classified randomly into 2 groups. Group I consisted of the experimental site where defect was filled with biphasic hydroxyapatite and β-tricalcium phosphate graft and Group II consisted of control site where only the open flap debridement (OFD) was carried out. Clinical parameters were evaluated at baseline, 3 and 6 months; Radiographs were taken at baseline and 6 months after surgery.

RESULTS

Overall, by the end of 6 months, biphasic hydroxyapatite and β-tricalcium phosphate and OFD treatment groups exhibited a significant reduction in probing depth almost by 75% and gain in clinical attachment level at follow-up. In the biphasic hydroxyapatite and β-tricalcium phosphate group, radiographic bone level gain appeared to be greater than in the OFD group.

CONCLUSION

In the present study, biphasic hydroxyapatite and β-tricalcium phosphate have shown promising results and have showed reduction in probing depth, a resolution of osseous defects and gain in clinical attachment level when compared to open flap debridement.

Histological Examination of Retrieved ePTFE Membranes Following Regenerative Surgery of Intrabony Defects Treated with Platelet-rich Plasma and Bone Substitutes

PURPOSE

Regenerative periodontal therapy using platelet-rich plasma (PRP) and bone substitutes with guided tissue regeneration (GTR) have been proposed as a therapeutic method to enhance the outcome of regenerative surgery. This includes light microscopic evaluation of retrieved ePTFE membranes to assess formation of new connective tissue attachment, and following the regeneration process. The objectives of this study were to evaluate the histological findings of retrieved ePTFE membranes using PRP and bone substitutes, the effect of PRP on graft materials, and the correlation of the findings with the clinical outcomes.

MATERIALS AND METHODS

Seventy-two (72) patients with chronic periodontitis, each of whom had one deep intrabony defect, were randomly included in two studies and treated using the same type of membrane and different bone substitutes. In the first study, 17 cases were treated with a natural bone mineral and a non-resorbable membrane (NBM + GTR), and 17 cases were treated with PRP + NBM + GTR. In the second study, 19 patients were treated with β-tricalcium phosphate and a non-resorbable membrane (β-TCP + GTR), and 19 patients were treated with PRP + β-TCP + GTR. In both studies, tissue integration of the retrieved ePTFE membranes and attached remnants were evaluated histologically.

RESULTS

Histological scores showed that membranes combined with NBM are better integrated than membranes combined with β-TCP; the difference between the two decreased with the addition of PRP. The application of PRP had no significant effect on the quality of membrane integration combined with NBM, whilst significantly improving the integration quality when combined with β-TCP. No correlations were detected between the histological scores and the clinical attachment level (CAL) gain in any of the groups.

CONCLUSIONS

The present results indicate that: a) application of β-TCP and PRP may enhance membrane integration and periodontal healing, and b) histological examination of retrieved membranes may provide valuable additional information with regard to the clinical findings.

Comparative Evaluation of Bone Dimensional Changes in Extraction Sockets Preserved With Calcium Phosphosilicate Bone Substitutes With and Without Platelet-Rich Fibrin: A Randomized Controlled Clinical Trial

This study aimed to evaluate the bone dimensional changes associated with extraction sockets preserved with calcium phosphosilicate (CPS) morsels and platelet-rich fibrin (PRF) at 6 months posthealing. Thirty fresh extraction sockets were randomly allocated to one of the following groups and grafted using PRF: Control (n = 10), CPS morsels (Test I; n = 10), or CPS+PRF (Test II; n = 10). All sites were sealed with PRF as a socket seal. CBCT scans were taken at 1 week postsurgery and at 6 months posthealing. The intergroup comparison showed a statistically significant difference in mean horizontal bone dimensional changes, and no such significance was observed for vertical bone changes. Bone density measured using Hounsfield units (HU) fell within the range of 350 to 850 HU (D3 bone quality) at 6 months posthealing for all three groups. Within the limitations of this study, socket preservation using CPS morsels with and without PRF demonstrated more favorable conditions for future implant placement.