Volume 11, Number 1

January 2000

EDITOR
Arun K. Garg, DMD Associate Professor of Surgery Director, Center for Dental Implants Division of Oral/Maxillofacial Surgery University of Miami School of Medicine

EDITORIAL ADVISORS
Editor Emeritus: Morton L. Perel, DDS, MScD Charles A. Babbush, DDS, MScD Head, Section of Dental Implant Reconstructive Surgery Mt. Sinai Medical Center Cleveland Thomas J. Balshi, DDS, FACP Private Practice, Implant Prosthodontics Prosthodontics Intermedica Institute for Facial Esthetics Fort Washington, PA Anita Daniels, RDH Clinical Instructor Center for Dental Implants University of Miami School of Medicine Miami Charles E. English, DDS Staff Prosthodontist Veterans Affairs Medical Center Augusta, GA Jack A. Hahn, DDS Private Practice Cincinnati Kenneth W.M. Judy, DDS Clinical Professor Department of Prosthodontics University of Pittsburgh School of Dental Medicine Jack T. Krauser, DMD Private Practice, Periodontics and Implantology Boca Raton, FL Department of Periodontics Nova Southeastern College of Dental Medicine Davie, FL Richard J. Lazzarra, DMD, MScD Associate Clinical Professor Periodontal and Implant Regenerative Center University of Maryland Private Practice West Palm Beach, FL Robert E. Marx, DDS Professor and Chief Division of Oral/Maxillofacial Surgery University of Miami School of Medicine Carl E. Misch, DDS, MDS Co-Director, Oral Implantology University of Pittsburgh School of Dental Medicine Daniel Y. Sullivan, DDS Private Practice, Implant Prosthodontics McLean, VA; Washington, DC

The Use of BoneSource for Sinus Floor Augmentation with Simultaneous Implant Placement in the Atrophic Maxilla
The placement of dental implants in the posterior maxilla often presents a challenge. Frequently, there is an insufficient amount of bone volume in this region, which is the result of the combination of alveolar bone resorption and pneumatization of the maxillary sinus. Surgical procedures for augmenting the maxillary sinus have evolved during the last decade for cases in which where is insufficient bone volume for implant placement. Until 1998, simultaneous placement of dental implants during sinus augmentation was advocated in cases where 4 mm to 5 mm of alveolar bone was present between the alveolar crest and the floor of the sinus, says Ziv Mazor, DMD, who has a private practice limited to periodontics in Raanana, Israel. This was chosen arbitrarily as the minimal amount of bone, most likely because of its ability to provide initial implant stability and accurate implant location, inclination, and parallelism, explains Michael Peleg, DMD, who has a private practice limited to oral/ maxillofacial surgery in Raanana, Israel. BoneSource (Howmedica Leibinger, Dallas) is a hydroxyapatite (HA) cement that was developed in the early 1980s. Mazor says the original developers of this cement hypothesized and eventually proved that appropriate combinations of certain calcium phosphate salts would form a self-setting cement when mixed with water. This cement would convert into pure carbonated HA in a form that was useful for repairing bone defects. BoneSource is indicated for the repair of neurosurgical cranial bone defects with a surface area that is no larger than 25 sq. cm per defect. One of its indications is obliteration of the frontal sinus following trauma. The ability to use BoneSource safely in the paranasal sinuses, as

This Month Inside

The use of bioactive glass particles of narrow size range .......................5

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well as its ability to convert into a solid material, made us hypothesize that it could be beneficial during sinus lift procedures in cases where there is great difficulty in the initial stabilization of simultaneously placed implants, Peleg says. Mazor and Peleg discuss a clinical study on the use of BoneSource to stabilize HA-coated cylindrical implants. These implants were placed simultaneously during sinus augmentation procedures in 10 patients who had an insufficient amount of bone volume to allow for primary implant stability. patients selected ranged in age from 40 to 55 years. The patients were treated in the dental office under local anesthesia. 300 mg of clindamycin was administered one hour before surgery and then continued at a dose of 150 mg a day for 10 days. (See Figure 1.) The sinus lift technique was performed using the modified CaldwellLuc procedure as described by Kent and Block, Peleg says. A round bur was used in a straight handpiece at 2,000 r.p.m. under copious irrigation

Clinical Study: Patients and Methods

All patients in the study were from the private practice of Mazor and Peleg. The patients were selected after meticulous evaluation of their medical histories and dental examinations, which included panoramic radiographs and dental computed tomography (CT) scans. The 10

Figure 1: Preoperative view of the site to be grafted. Figure 2: Osteotomy created for sinus graft and implants placed.

Dental Implantology Update (ISSN 1062-0346) is published monthly by American Health Consultants, a unit of Medical Economics, 3525 Piedmont Road NE, Building Six, Suite 400, Atlanta, GA 30305. Telephone: (404) 262-7436. Periodical postage paid at Atlanta, GA 30374. POSTMASTER: Send address changes to Dental Implantology Update, P.O. Box 740059, Atlanta, GA 30374. American Health Consultants, in affiliation with Boston University Goldman School of Graduate Dentistry, offers continuing dental education to subscribers. Each issue of Dental Implantology Update qualifies for 1.5 continuing education units. Customer Service: (800) 688-2421. Fax: (800) 284-3291. Hours of operation: 8:30 a.m. - 6:00 p.m. Monday - Thursday; 8:30 a.m. - 4:30 p.m. Friday EST. E-mail: customerservice@ahcpub.com. World Wide Web: www.ahcpub.com. Subscription rates: U.S.A., $449 per year. Students, $200 per year. To receive student/resident rate, order must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the regular rate until proof of student status is received. Outside U.S., add $30 per year, total prepaid in U.S. funds. One to nine additional copies, $269 per year; 10 to 20 additional copies, $180. Missing issues will be fulfilled by customer service free of charge when contacted within 1 month of the missing issue date. Back issues, when available, are $75 each. For 18 continuing education units, add $96 per year. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. Clinical, legal, tax and other comments are offered for general guidance only; professional counsel should be sought for specific situations. Copyright 2000 by American Health Consultants. Dental Implantology Update is a trademark of American Health Consultants. The trademark Dental Implantology Update is used herein under license. All rights reserved. Reproduction, distribution, or translation of this newsletter in any form or incorporation into any information retrieval system is strictly prohibited without express written permission. For reprint permission, please contact American Health Consultants. Address: P.O. Box 740056, Atlanta, GA 30374. Telephone: (800) 688-2421. Group Publisher: Brenda Mooney, (404) 262-5403, (brenda.mooney@medec.com). Executive Editor: Susan Hasty, (404) 262-5456, (susan.hasty@medec.com). Managing Editor: Kevin New, (404) 262-5467, (kevin.new@medec.com). Senior Production Editor: Brent Winter, (404) 262-5401.

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to outline a large buccal window at the maxillary sinus lateral wall. This was done so that the apical aspect of the implants would be completely visible, Mazor explains. Care was taken not to penetrate the sinus membrane. If a minor membrane tear occurred, a collagen membrane patch was used to obliterate the opening. CA) were placed and pushed along half of their total length, Mazor comments. BoneSource was placed at the superior aspect of the sinus, and the implants were fully inserted into the grafted compartment. The distance between the apical portion of the implants was measured and kept equal to the distance between the coronal portion of the implants to achieve mesiodistal parallelism, Peleg elaborates. An additional measurement between the buccal plate and the apical portion of the implants confirmed correct buccopalatal inclination. The sinus buccal window was covered with a resorbable collagen barrier membrane (BioGide, Giestlich, Geneva, Switzerland). The mucoperiosteal flap was closed primarily over the graft and the implants, using 3-0 vicryl (Ethicon, Summerville, NJ) vertical interrupted mattress sutures. Patients were not allowed to use their dentures for the first two weeks after the procedure. Nine months after implant placement, second-stage surgery was performed. Prior to implant exposure, patients were evaluated radiographically. Panoramic, periapical radiographs, and CT scans were used to assess the radiographic features of the BoneSource, the newly formed bone, and their close relation to the implants. Clinical criteria at the time of implant exposure included stability in all directions, crestal bone resorption, and any reported pain or discomfort. Core biopsies were performed at implant exposure. Initial stabilization was achieved in all cases. Parallelism also was achieved in all cases using the technique presented, and angled abutments were not needed during

Sinus Floor Augmentation Technique

Once the outline was completed, a delicate dissection using blunt sinus curets was performed to push the sinus membrane inward and upward. The membrane was released without any tension to provide an adequate compartment for the implants and the bone graft (see Figure 2). The implant sites were marked using a surgical stent, and the osteotomies were performed according to the manufacturers recommendation. BoneSource was prepared according to the manufacturers instructions (see Figure 3). HA-coated spline cylindrical dental implants that were 15 mm long (Calcitek, Sulzer Medica, Carlsbad,

Avoiding Implant Dislocation

The rest of the graft material was then placed on the remaining exposed implant surface (see Figure 4). Each step during placement of the graft material was followed by meticulous application of the graft material. Care was taken to achieve close adaptation of the graft without causing any dislocation of the implants due to the condensation procedure, Mazor explains. The implants were found to be stable in all directions.

Figure 3: Reconstituted BoneSource.

Figure 4: Typical appearance of BoneSource after placement in the surgical site.

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prosthetic reconstruction, Peleg adds. There were no clinically evident complications of the sinuses. Prior to exposure, radiographic evaluation (panoramic and periapical radiographs and CT scans) showed that the implants were embedded in a densely homogenous radiopaque mass. No adverse reactions were noted radiographically. At second-stage surgery, there was no clinical evidence of crestal bone loss around the implants (see Figure 5.) All implants were clinically osseointegrated, meaning they were nonmobile, dull to percussion, asymptomatic, and without marginal bone loss, Mazor says. Histologic evaluation of the core biopsies showed woven bone that was well integrated with the BoneSource and numerous osteocytes directly apposed to the surface. Some of the BoneSource was still present at the end of the core biopsy, and replacement with bone by creeping substitution was still occurring after one year. No adverse response to the BoneSource particles was observed, Peleg clarifies, and no signs of infection were noted. All patients received a fixed implant-supported prosthesis (see Figure 6). The mean follow-up was 18 months and ranged from 12 to 24 months. procedure, performed under local anesthesia in the dental office may optimize the treatment time. According to Mazor, there are two major concerns: initial stability of the implant; maintenance of parallelism to facilitate dental rehabilitation. We have previously shown that one-stage sinus lift surgery with concomitant implant placement in the severely atrophic maxilla is predictable when surgical modifications are used, Peleg comments. The present study describes an additional grafting material for achieving implant stability and parallelism due to the ability of the BoneSource to convert into a solid mass. BoneSource converts into a solid mass through the reaction of tetracalcium phosphate and dicalcium phosphate dihydrate with sterile water, which then precipitates to form solid HA. In addition, this chemical reaction occurs without creating heat, making it safe to place the material in the human body during the reactive phase. The most important feature of BoneSource, aside from its cement form, is that it maintains its shape

Discussion
The sinus lift procedure is becoming a well-established, predictable procedure for the placement of dental implants in the atrophic posterior maxilla, Mazor comments. A variety of graft materials, ranging from autogenous intraoral or extraoral bone to various combinations of allografts and alloplastic materials, have been used with predictable results. The search for an ideal alloplastic grafting material that will prevent autologous bone harvesting is ongoing, Peleg says. This will greatly reduce the morbidity of sinus lift procedures and allow more patients to benefit from them. Peleg continues by stating that the present study showed the advantages of using BoneSource when performing simultaneous implant placement with a sinus lift in a onestage procedure. The one-stage

Figure 5: Implants at stage-two uncovering.

Figure 6: Eight-month radiograph follow-up of the site in which the graft material was placed.

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and volume over time, Mazor establishes. Implant parallelism was achieved in all cases. The fact that no angled abutments were required demonstrated the clinical efficiency of the described approach, Peleg says. To ensure bone graft maturation, the implants were exposed after nine months. will ultimately result in replacement of the BoneSource by new host bone, Peleg says. According to the results from this preliminary study, BoneSource appears to hold great promise as a grafting alloplastic material for sinus floor augmentation, Mazor suggests. Its main advantage is its ability to provide the initial stability required for osseointegration and proper implant location and parallelism. Further clinical and histologic studies are required before it can be recommended for routine use in sinus lift procedures, Peleg concludes. Contact: Ziv Mazor, DMD, #5 Atarot St., Raanana, Israel 43567. E-mail: zivmazor@hotmail.com. endosseous implants. Int J Oral Maxillofac Implant 1996; 11:512-521. Hurzeler MB, Kirsch A, Ackerman KL, Quinones CR. Reconstruction of the severely resorbed maxilla with dental implants in the augmented maxillary sinus: A five year clinical investigation. Int J Oral Maxillofac Implant 1996; 11:466-475. Mazor Z, Peleg M, Gross M. Sinus augmentation for single tooth replacement in the posterior maxilla: A 3-year follow-up clinical report. Int J Maxillofac Implant 1999; 14:5560. Peleg M, Mazor Z, Chaushu G, Garg A. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol 1998; 69:1,397-1,403. Valentini P, Abensur D. Maxillary sinus floor elevation for implant placement with demineralized freeze-dried bone and bovine bone (Bio-Oss): A clinical study of 20 patients. Int J Periodont Rest Dent 1997; 17:233-241. M

Material Demonstrates Excellent Biocompatibility

Histologic evaluation confirmed vital new bone formation without evidence of foreign body reaction or infection. Because BoneSource becomes carbonated HA, it demonstrates excellent biocompatibility. Based on data from animal and human studies, BoneSource does not cause a foreign body giant cell reaction, a sustained inflammatory response, or toxic reaction; it is noncarcinogenic; and it does not cause an immune response, Mazor elaborates. It must be noted that over 60% of the BoneSource implant was in contact with paranasal sinus or mastoid air cells, thereby confirming an inherent resistance to infection, Peleg adds. This biologic property is extremely important in sinus graft procedures. One of the possible complications following sinus lift is acute or chronic bacterial sinusitis. Therefore, the resistance of BoneSource to infection is a considerable advantage compared with other available alloplastic grafts. The histologic appearance of the biopsies taken suggests that BoneSource had been replaced by bone across the majority of the length of the biopsy taken. The osteointegrative and osteoconductive properties of BoneSource have been proven in histologic studies. In animal studies, BoneSource functioned as a substrate for new bone formation. Therefore, it appears that using BoneSource to fill existent bony or surgically created cavities January 2000

Related Readings
Blomqvist JE, Isaksson S. Retrospective analysis of one-stage maxillary sinus augmentation with

The Use of Bioactive Glass Particles of Narrow Size Range in the Third Molar Site
Bioactive glass is a ceramic that can be used as a particulate material to promote bone formation in osseous deformities. In animal studies, it has been shown that compared with hydroxyapatite, more osteoconductive bone growth starting from the wall of the defects was seen around bioactive glass particles of narrow size range (300 m to 355 m). Additionally, trabecular bone growth was seen in the center of the defect, which was associated with the bioglass particles. Roger R. Throndson, DDS, assistant professor at Baylor College of Dentistry in Dallas, used bioactive glass particles of narrow size range (BioGran, Orthovita, Malvern, PA) as osseous fill after removal of impacted third molars in a recent case, which he discusses with Dental Implantology Update.

Case Presentation: Initial Presentation

The patient, a 27-year-old man, presented for the removal of his third molars. For two weeks prior to this visit, he had been experiencing mild symptoms associated with tooth No. 32 (see Figures 1 and 2). Probing distal to tooth No. 31 revealed loss of distal attachment and the ability to probe to the crown of tooth No. 32 at a distance of 4 mm beyond the cementoenamel junction of tooth No. 31, Throndson comments. Because of the large variability Dental Implantology Update

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in predictable osseous fill distal to the second molars after removal of deeply impacted third molars, the patient was offered the option of using a graft material to improve the osseous fill, Throndson elaborates. The patient agreed and was scheduled for surgery. elevated to expose tooth No. 32. The tooth was sectioned and removed. The inferior alveolar neurovascular bundle could not be visualized. The surgical site was curetted of any residual soft tissue, and the distal aspect of tooth No. 31 was scaled. The surgical defect was then grafted using bioglass particles of narrow size range. The material forms a controllable cohesive mass that remains in the surgical site, Throndson comments (see Figure 3). Placement of the material also provides good hemostasis, he continues. The flap was then repositioned and sutured, primarily using 3-0 chromic suture (see Figure 4).

Treatment Outcome
The postoperative period was uneventful. The patient reported less postoperative discomfort associated with the grafted site (tooth No. 32) compared with the nongrafted site (tooth No. 17). It should be

Tooth Extraction and Graft Placement

At the time of surgery, a fullthickness mucoperiosteal flap was

Figure 1: Preoperative radiograph of tooth No. 32 showing a horizontally impacted third molar with communication distal to tooth No. 31.

Figure 2: Preoperative radiograph of the control third molar (tooth No. 17) .

Figure 3: Typical appearance of BioGran after placement in the surgical site.

Figure 4: Primary closure of the surgical site.

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noted that no guided tissue membrane was used and no antibiotics were administered to the patient, Throndson says. Radiographs were obtained at three months, six months, and one year. Soft-tissue measurements also were obtained to document attachment levels distal to the second molar. At three months, the attachment level distal to the second molar was 1 mm below the cementoenamel junction and remained stable through the oneyear follow-up. adequate bony height and excellent soft-tissue attachment. A study by Schepers and colleagues found that filling extraction sockets with bioactive glass granules of narrow size range did not impede later placement of oral implants. According to these authors, the success of implant placement in sites grafted with BioGran can also be explained by the transformation of the glass particles into excavated granules covered by calcium-phosphorus, Throndson elaborates. This is biologically equivalent to the mineral phase in bone tissue and thus contributed to the remodeling processes of the surrounding bone. Throndson concludes that grafting extraction sockets with bioactive glass particles of narrow size range results in a quicker healing period.

Clinically Significant A B S T R A C T
McAllister BS, Margolin MD, Cogan AG, et al. Residual lateral wall defects following sinus grafting with recombinant human osteogenic protein-1 or Bio-Oss in the chimpanzee. Int J Periodont Rest Dent 1998; 18:227-239. Sinus grafting procedures have been used to ensure an adequate amount of bone for implant placement in the posterior maxilla. However, there is great variation in the quality of bone that is attained using sinus augmentation procedures. It is believed that using recombinant bone morphogenetic proteins may increase the rate of mineralization and the quality of the bone attained. Recombinant human osteogenic protein-1, which is also known as bone morphogenetic protein-7, is a differentiation factor that has been shown to be a potent inducer of bone formation. There is little information available on the performance

Use of BioGran Results in Predictable Osseous Fill

There is radiographic evidence of osseous fill distal to the second molar at one year, Throndson comments (see Figures 5 and 6). During the healing period, there were no postoperative complications associated with the placement of the graft material. In this case, I feel that offering a grafting procedure with BioGran to the patient resulted in a more predictable osseous fill distal to the second molar, Throndson says. BioGran fulfilled the desired result of an

Related Reading
Schepers E, Barbier L, Ducheyne P. Implant placement enhanced by bioactive glass particles of narrow size range. Int J Oral Maxillofac Implant 1998; 13:655-665. M

Figure 5: One-year follow-up radiograph of the site in which the bioactive glass particles of narrow size range were placed.

Figure 6: One-year follow-up radiograph of the site in which the graft material was not placed.

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of osteogenic protein-1 for oral and maxillofacial use. In addition, no dosing studies have been performed in this region. The authors conducted an in vivo study using clinical, histologic, and radiographic means to evaluate healing response and bone formation to establish a dose response over time for recombinant human osteogenic protein-1 placement in the maxillary sinus of chimpanzees. The responses achieved with the different doses of recombinant human osteogenic protein-1 were compared with that achieved with Bio-Oss (Osteohealth, Shirley, NY) natural bone mineral. Bilateral sinus augmentation was performed in 15 adult chimpanzees. Sinus membrane elevators were used to position the bony window medially and dissect the schneiderian membrane away from the inferior wall of the sinus. Different graft materials were placed in the floor of the sinus. These graft materials consisted of OP-1 devices in doses of 0.0 mg, 0.25 mg, 0.6 mg, and 2.5 mg of osteogenic protein-1 per gram of collagen matrix, and Bio-Oss bone mineral in doses of 0.25 mm to 1 mm served as the control. Resorbable type I bovine-derived collagen membrane was placed to facilitate graft containment to the localized grafted area of the sinus when small tears in the schneiderian membrane occurred. A barrier membrane was not used in the lateral wall osteotomy site. After suturing of the tissues, positive pressure was applied on the replaced flap with a moist gauze for approximately 15 minutes to maximize graft containment. Evaluation of soft-tissue healing, radiographic evaluation, and tissue biopsy were performed postoperatively at one week, two and a half weeks, two and a half months, three and a half months, four and a half months, five and a half months, six and a half months, and seven and a Dental Implantology Update half months. Flap reflection for residual defect evaluation also was performed at seven and a half months. There were no complications from the surgical procedure or graft placement in all 30 sites. An average of 2.3 gm of graft material was placed into each sinus. There was radiographic and histologic evidence of bone formation in all treatment groups. A statistically significant reduction in the depth of soft-tissue encapsulation and the surface area of the residual lateral wall defect was observed in the Bio-Oss treatment and the 2.5 mg osteogenic protein-1 per gram collagen matrix treatment compared with collagen matrix alone. The authors say the results of this study showed the possibility of soft-tissue encleftation in the osteotomy window, particularly with the use of collagen matrix alone or lower concentrations of recombinant human osteogenic protein-1. It is not known whether the use of membranes could have prevented encapsulation. The authors concluded that the use of Bio-Oss alone or 2.5 mg of osteogenic protein-1 per gram of collagen matrix resulted in almost complete closure of the osteotomy window without the use of an occlusive membrane. M

Calendar
The BioHorizons 2000 International Symposium Jan. 2330, Maui, Hawaii. For more information, call: (205) 967-7880. Academy of Osseointegration March 9-11, New Orleans. For more information, contact: AO, 401 N. Michigan Ave., Chicago, IL 60611-4267. Fax: (312) 245-1080. San Francisco Tenth Annual Implant Symposium March 911. For more information contact ICOI at (800) 442-0525 or (973) 783-6300. Fax: (973) 783-1175. Cutting Edge II: The Cruise April 2-9. For more information, contact: MECC. Telephone: (305) 663-1628. Fax: (305) 663-1644. Jubilee Congress of the German Society for Oral and Maxillofacial Surgery May 3-6, Berlin, Germany. For more information, contact: Prof. Dr. Jurgen Bier. Telephone: 030/45055055. Fax: 030/450-55901.

American Academy of Periodontology May 5-6, Washington, DC. For more information, contact: AAP, 737 North Michigan Ave., Suite 800, Chicago, IL 60611. Fax: (312) 573-3225. American Academy of Periodontology Sept. 17-20, Honolulu. For more information, contact: AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611 Fax: (312) 573-3225. AAOMS 82nd Annual Meeting, Scientific Sessions and Exhibition Sept. 20-24, San Francisco. For more information, contact: AAOMS, 9700 W. Bryn Mawr Ave., Rosemont, IL 60018. Telephone: (800) 822-6637. Fax: (847) 678-6286. American College of Prosthodontists Nov. 15-18, Honolulu. For more information, contact: ACP, 211 East Chicago Ave., Suite 1000, Chicago, IL 60611. M

January 2000

CONTINUING DENTAL EDUCATION TEST

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1. Until 1998, simultaneous placement of dental implants during sinus augmentation was advocated in cases where how much alveolar bone was present between the alveolar crest and the floor of the sinus? A. 3 mm to 5 mm B. 3 mm to 6 mm C. 4 mm to 5 mm D. 4 mm to 6 mm 2. When mixed with water, calcium phosphate salts form a self-setting cement, which converts into: A. Pure carbonated hydroxyapatite (HA) B. Demineralized bone particles C. A substance similar to autogenous bone particles D. None of the above 3. BoneSource is indicated for the repair of neurosurgical cranial bone defects with a surface area that is no larger than: A. 10 sq. cm per defect B. 15 sq. cm per defect C. 20 sq. cm per defect D. 25 sq. cm per defect 4. Which of the following is a major concern with implant placement? A. Initial stability of the implant B. Maintenance of parallelism to facilitate dental rehabilitation C. A and B D. None of the above 5. BoneSource converts into a solid mass through the reaction of tetracalcium phosphate and dicalcium phosphate dihydrate with sterile water, which then precipitate to form solid HA. A. True B. False

6. Which of the following is true about BoneSource? A. It does not cause a foreign body giant cell reaction B. It does not cause a sustained inflammatory response C. It is noncarcinogenic D. All of the above 7. In animal studies, BoneSource failed to function as a substrate for new bone formation. A. True B. False 8. It has been shown in animal studies that compared with hydroxyapatite, more osteoconductive bone growth starting from the wall of the defects was seen around bioactive glass particles of narrow size range (300 mm to 355 mm). A. True B. False 9. It has been shown in animal studies that filling extraction sockets with bioactive glass granules of narrow size range impedes delayed placement of oral implants. A. True B. False 10. The bioglass particles transform into excavated granules covered by: A. Demineralized bone B. Calcium-phosphorus C. Calcium-hydroxide D. None of the above

The Boston University Goldman School of Graduate Dentistry is designated as a nationally approved sponsor by the Academy of General Dentistry. The formal continuing education programs of this sponsor are accepted by AGD for Fellowship, Mastership, and Membership maintenance credit. The current term of approval extends to June 30, 1999.

A supplement to Dental Implantology Update, January 2000