A Concept for the Treatment of Various
Dental Bone Defects
ony defects in the jaw occur
B for various reasons. They are
caused by infections, tumors,
or cysts. Each year approximately 50
million tooth extractions in the U.S.
and a large number of apicectomies
leave bone defects (Millennium Re-
search Group, Report DI0003, 2000).
Only a few of them are treated with
bone substitute or bone regeneration
material to preserve the bone level.
Depending on the size, spontaneous
bone regeneration in untreated de-
fects is limited to a small distance
because of the much more rapid pro-
liferation of surrounding soft tissue.
The replacement of the defect with
connective tissue often leads to a
loss of stability, accompanied by
functional limitation and anatomical
alteration. In addition, the result of
tooth removal is shrinkage of the
bone at the extraction site, with a
subsequent loss of 40% to 60% of
bone height and width within 2 to 3
years, followed by an average loss
rate of 0.5% to 1.0% per year for
life.1 Further bone defects occur after
cyst removal or as a sequel to peri-
odontal disease. The latter, if it re-
mains untreated, often leads to the
loss of the teeth concerned. To main-
tain those teeth or to provide suffi-
cient bone height for later implanta-
tion or prosthesis supply, the filling
of bone defects is necessary. Almost
95% of rejections of implant candi-
dates are not because of medical or
financial reasons but because of an
inadequate supply of alveolar bone.2
Therefore, ridge preservation after
tooth extraction becomes an impor-
tant tool to prevent the loss of jaw
ISSN 1056-6163/02/01101-073$3.00
Implant Dentistry
Volume 11 • Number 1
Copyright © 2002 by Lippincott Williams & Wilkins, Inc.
Ady Palti, DMD, Thomas Hoch, DMD
Untreated dental bone defects
usually lead to resorption of alveo-
lar bone. Filling these defects with
bone substitute material prevents
resorption of bone, preserves the
alveolar ridge, and provides suffi-
cient bone for immediate or subse-
quent implant placement. A variety
of bone substitutes is available.
They differ in origin, consistency,
particle size, porosity, and resorp-
tion characteristics. We have
treated almost 1000 bony defect
sites in 267 patients with the bone
bone;3 or, more generally, for all
types of bone defects.
First reports of filling bony de-
fects using bone autografts go back
to the 19th century. Later, autografts
were followed by the use of allo-
genic bone. Over the decades au-
tografts developed as the so-called
“gold standard” (which they are still
regarded to be), without any random-
ized, double blind surveys generally
demanded for any material to com-
pare with it. During the last three
decades more and more synthetic
and xenogenic bone substitute mate-
rials have come into use. Each of
those bone substitute materials, in-
cluding the “gold standard,” has its
individual advantages and disadvan-
tages. Autologous bone provides os-
teoconduction combined with os-
teoinductive effects, but its
availability is limited. Additionally,
it always requires a secondary surgi-
cal procedure with all its risks. More
than 50% of the patients have had
problems at the donor site 1 year
after operation,4 and 18.7% reported
pain more than 2 years postopera-
tively.5 Allogenic and xenogenic ma-
IMPLANT DENTISTRY / VOLUME 11, NUMBER 1 2002
regener-ation material Cerasorb.
Being resorbed simultaneously with
the formation of new bone, it is
completely replaced by the pa-
tient’s own vital bone within 6 to
12 months. The representative
cases described in this paper dem-
onstrate the successful use of the
pure-phase ␤-tricalcium phosphate
ceramic in the treatment of all den-
tal bone defects. (Implant Dent
2002;11:73–78)
Key Words: augmentation, bone
substitute materials, sinus elevation
terials fulfill the osteoconductive
task, but a risk of immunologic reac-
tions or transmission of infections
and diseases cannot be completely
excluded. Proteins have been found
in bone substitute material of bovine
origin.6 An expert conference of the
World Health Organization (WHO)
stressed that “the ideal situation
would be to avoid the use of bovine
materials in the manufacture of me-
dicinal products, as well as the use
of materials from other animal spe-
cies in which transmissible spongi-
form encephalopathies (TSEs) natu-
rally occur.7
The availability of synthetic
bone substitute materials is unlim-
ited. They are free of any risk of
transmitting infections or diseases by
themselves, and a second surgery at
the donor site is unnecessary. They
each differ in their resorption charac-
teristics. Minimal or nonresorbing
bone substitutes include hydroxyapa-
tite ceramics, hard tissue replacement
(HTR) polymers, and bioactive
glasses. Hydroxyapatite, which is
closely related to natural bone, is
only incorporated by newly built
73

Fig. 1. Distribution of patients in different
age groups. Total number of patients is
267.
Fig. 2. Distribution of patients by gender.
Fig. 3. Distribution of indications among the
cases treated in this study. For each
indication the total number of treatments is
shown versus the number of treatments
without any complications.
bone. It does not undergo significant
resorption; as such, it is no part of
natural bone remodeling. In contrast
␣- and ␤-tricalcium phosphates
(TCP) are soluble bone substitute
materials. Although the two sub-
stances are chemically identical, they
behave differently under physiologi-
cal conditions. ␣-TCP is resorbed
slowly and remains detectable for
many years. In contrast the pure-
phase ␤-TCP Cerasorb (Curasan AG,
Kleinostheim, Germany) is com-
pletely resorbed simultaneous with
bone formation and is replaced by
74 DENTAL BONE DEFECTS
vital host bone without residue 156 patients a total of 492 implants
within 6 to 12 months.8,9 The mode were inserted. This led to a total
of bone formation for Cerasorb is number of 958 treatments in the pa-
osteoconduction. Particle size and tients included in the study. In all
shape, porosity, chemical structure, cases, Cerasorb was used to fill the
and composition are of great influ- defects. Only 21 cases presented
ence on resorption and substitution.10 with complications because of the
Cerasorb provides the required prop- occurrence of fistulas or because of
erties to be not only an optimal bone the need for explantation. Overall,
substitute material, but also a bone this corresponds to a success rate of
regeneration material. The rounded 97.8%. In Fig. 3, the distribution of
surface of the granules prohibits me- the cases is presented in graphic
chanical irritation of the surrounding form. For each indication the number
tissue and reduces inflammatory re- of cases treated is compared with the
actions. The high mechanical stabil- number of cases treated without
ity prevents premature degradation of complications.
the granules into microparticles and
inhibits undesirable macrophage ac- CLINICAL USE OF CERASORB
tivity. Interconnecting micropores
For a complete regeneration of
allow rapid infiltration of Cerasorb
bone defects—as free of complica-
with collagen fibers and blood ves-
sels to provide the supply of nutri-
tion and oxygen for an unrestricted
regeneration of bone tissue and the
prevention of penetrating soft tissue.
The successful use of Cerasorb is
documented in the literature for the
treatment of bony defects in the jaw
region.8,9,11–14 We have been using
Cerasorb for more than 4 years fol-
lowing the recommendation of the
WHO and providing a “restitutio ad
integrum” to our patients. Mean-
while we have successfully treated
almost 1000 defects in various situa-
tions. The distribution is presented in
the following statistics.
STATISTICS
The trial on the cases treated
with ␤-tricalcium phosphate since
1996 in our practice includes 267
patients. The distribution of patients
in age groups is shown in Fig. 1.
The majority of them were aged be-
tween 35 and 64. The percentage of
men and women was almost equal
(women 48.3%, men 51.7%, see
Fig. 2).
The distribution on the single
indications, treated in this study, was Fig. 4. X-ray of region 46/47 of a 44-year-
as follows (multiple mentionings are old woman. Diagnosis: parodontitis
possible): 54 periodontal defects, 30 marginalis profunda.
lesions because of apicoectomy, and Fig. 5. X-ray of region 46/47 after filling with
96 lesions because of cystectomy Cerasorb post surgery. The granules can
easily be recognized.
were filled. Two hundred forty-one Fig. 6. Region 46/47, 18 months
alveolar defects gave reason for aug- postoperative. The Cerasorb granules are
mentation, 45 cases were indicated completely resorbed.
for a sinus floor elevation, and in
 solutions of Natriumchloride or anti-
biotics must be avoided.
The following studies demon-
strate, in representative cases, the
successful use of Cerasorb for regen-
eration of lost bone structures. The
first part of the investigations use
Cerasorb for the treatment of peri-
odontal diseases, the most common
disorder of the jaw. The minimal
requirement for treatment with Cera-
sorb was an initial probing depth ⱖ
6 mm. After the pretreatment, in-
cluding scaling twice and instruc-
tions for dental hygiene, a gingival
flap was prepared to remove in-
flamed tissue and to perform root
planing. The cleaned defects were
filled with the bone regeneration ma-
Fig. 7. Orthopantomogram (OPT) of a 15-year-old girl. An extremely shifted canine tooth 13 terial. The gingivae were then reposi-
can be observed. tioned around the neck of the tooth
Fig. 8. Preoperative clinical situation and incision. and secured with sutures. In these
Fig. 9. Clinical appearance of the extremely shifted canine tooth 13. cases, histologic samples after the
Fig. 10. Region 12/13 after extraction of shifted canine tooth 13.

tions as possible—some points

should be observed. The first impor-
tant step is a thorough debridement
of the defect to remove granulation
tissue, fibrin, and other residues. The
blood, thus, obtained from the defect,
containing bone-forming cells (eg,
osteoblast precursors, mesenchymal
stem cells) and thrombocytes, should
be mixed with Cerasorb before appli-
cation. The thrombocytes penetrate
the micropores of the granules. In-
duced by the calcium ions of Cera-
sorb, the clotting of the blood is ini-
tiated and the growth factors are
released. These activate macrophages
and granulocytes in the intergranular
cavities, releasing growth factors
themselves. Fibroblasts, osteoblasts,
and osteoblast precursors are at-
tracted into the defect and are acti-
vated by the growth factors. The
three-dimensional structure of the
fibrin clot acts as a guide-rail. The
induction of angiogenesis provides a
sufficient supply of blood and nutri-
ents for bone regeneration. A posi-
tive side effect is a gel formation
after approximately 10 minutes that Fig. 11. Canine tooth 13 post extraction, stabilized by a titanium pin.
provides an application complex with Fig. 12. Region 12/13 after reimplantation of canine tooth 13. The defect is filled with Cerasorb.
Fig. 13. Same region after wound closure and suturing to prevent entry of saliva.
significantly improved manageability. Fig. 14. Postoperative x-ray control.
If no blood from the defect is avail- Fig. 15. Orthodontic fixation.
able, venous blood can be used. A Fig. 16. Clinical situation, 6 months postoperative.
dry application or an admixture of

IMPLANT DENTISTRY / VOLUME 11, NUMBER 1 2002 75


Fig. 17. Initial OPT showing the position of the drill templates.
Fig. 18. Preoperative clinical situation.
Fig. 19. Prepared bone window for mobilization of the Schneiderian membrane.
Fig. 20. Holder to keep implant position and direction.
treatment were not obtained for ethi-
cal reasons. Measurement of the new
attachment was performed with a
periodontal probe.
CASE REPORT 1
Fig. 4 shows an x-ray of region
46 of a 44-year-old woman. The di-
agnosis was parodontitis marginalis
profunda with a vertical pocket depth
of 10 mm at 46 distal and 8 mm at
47 mesial. In Fig. 5, the same region
is shown postoperatively. The Cera-
sorb granules can be readily recog-
nized. The patient did not have any
complications, and 18 months after
filling the defect the pocket depth
was reduced to 4 mm. The Cerasorb
granules were completely resorbed
(Fig. 6).
CASE REPORT 2
In a 15-year-old girl, we found
an extremely shifted canine tooth
13 (Fig. 7). The space between 12
and 14 was kept clear orthodonti-
cally. The clinical situation before
and after opening is shown in Figs.
8 and 9 and after extraction in Fig.
10. Tooth 13 was stabilized by a
titanium pin (Fig. 11) and reim-
planted. The defect was filled with
Cerasorb (500 –1000 ␮m, Fig. 12)
and tightly sutured (Fig. 13). An
76 DENTAL BONE DEFECTS
x-ray control was performed to
prove position of the implanted
tooth (Fig. 14). Four weeks postop-
erative, no irritations were present.
Tooth 13 was fixed orthodontically
(Fig. 15). Six months after treat-
ment we observed an excellent
clinical situation and a perfect fit
of the papillae (Fig. 16).
Fig. 21. Implant rising into maxillary sinus.
Fig. 22. Augmented sinus area filled with Cerasorb.
Fig. 23. Tight wound closure.
Fig. 24. Postoperative OPT control.
CASE REPORT 3
A 55-year-old man decided on a
complete reconstruction of his max-
illa to secure a permanent denture. A
total of ten implants were planned,
but intraoperative we had to deter-
mine that only 8 implants could be
inserted. The position of the drill
templates can be seen in the ortho-
pantomogram (OPT) (Fig. 17, D1).
The primary stability of the im-
plants in the molar region required
bilateral sinus floor elevations. Fig.
18 shows the clinical situation in
situ. After preparation of the bone
window (Fig. 19) and cranial mobi-
lization of the Schneiderian mem-
brane, the maxillary sinus was
filled with Cerasorb (1000 –2000
␮m). In region 15 (2nd premolar),
an esthetic abutment was used to
keep position and direction of the
implant to be inserted later on (Fig.
20). The implant rising into the
open maxillary antrum is easily
observable in Fig. 21. The space
around the implant was filled with
Cerasorb (Fig. 22) and sutured
tightly (Fig. 23). The subsequent
recorded OPT (Fig. 24) displays
the regions filled with the bone
regeneration material.
CONCLUSION
Among the various bone substi-
tute materials available at present,
Cerasorb fulfills all requirements for
being a bone regeneration material
rather than a bone substitute. Regard-
ing the large number of cases suc-
cessfully treated, Cerasorb can be
construed to be a safe and easily
manageable bone regeneration mate-
rial to be used for the treatment of
various dental bone defects. Its avail-
ability is unlimited. It is free of any
material-based risk of transmitting
infections or diseases and makes a
second surgery at the donor site un-
necessary. The complete conversion
of Cerasorb into the patient’s own
vital bone within 6 to 12 months
provides the best prerequisite for
implant integration and leads to ex-
cellent esthetic and functional results.
DISCLOSURE
The authors claim to have no
financial interest in any company or
any of the products mentioned in this
article.
REFERENCES
1. Ashman A. Ridge preservation: Im-
portant buzzwords in dentistry. General
Dent. 2000;48:304–312.
2. Ashman A. Ridge preservation: The
new buzzwords in dentistry. Implant Soc.
1995;6:1–7.
3. Christensen GJ. Ridge preserva-
tion: Why not? J Am Dent Assoc. 1996;
127:669–670.
4. Wippermann BW. Komplikationen
der spongiosaentnahme am becken-
kamm. Chirurg. 1997;68:1286–1291.
5. Goulet JA, Senunas LE, DeSilva
GL, et al. Autogenous iliac crest bone
graft. Complications and functional as-
sessment. Clin Orthop. 1997;339:76–81.
6. Schwartz Z, Weesner T, van Dijk S,
et al. Ability of deproteinized cancellous
bovine bone to induce new bone forma-
tion. J Periodontol. 2000;71:1258–1269.
7. World Health Organization. Report
of a WHO Consultation on Medicinal and
other Products in Relation to Human and
Animal Transmissible Spongiform En-
cephalopathies. WHO/EMC/ZOO/97.3 -
WHO/BLG/97.2.
8. Foitzik C, Stamm M. Einsatz von
phasenreinem ␤-tricalciumphosphat zur
auffüllung von ossären defekten - biolo-
gische materialvorteile und klinische er-
fahrungen. Die Quintessenz. 1997;48:
1365–1377.
9. Foitzik C, Stamm M. Einsatz von
phasenreinem ␤-tricalciumphosphat zur
auffüllung von ossären defekten - biolo-
gische materialvorteile und klinische er-
fahrungen. Die Quintessenz. 1999;50:
1049–1058.
10. Misch CE, Dietsh F. Bone-grafting
materials in implant dentistry. Implant
Dent. 1993;2:158–167.
11. Bilk D. Augmentieren mit throm-
bozytenreichen plasma (PRP) und Cera-
sorb - eine erfolgreich kombination in der
implantologie. Oralchirurgie J. 2001;2:12–
19.
12. Foitzik C, Staus H. Parodontale
defektauffüllung mit phasenreinem
␤-trikalziumphosphat. ZWR. 1999;6:378–
383.
13. Reinhardt C, Kreusser B. Retros-
pektive studie nach implantation mit Si-
nuslift und Cerasorb-augmentation. Dent
Implantol. 2000;4:18–26.
14. Wiltfang J, Merten HA. Verwend-
ung von permanenten und resorbierbaren
keramiken in der genioplastik. ZWR.
1998;107:546–551.
Reprint requests and correspondence to:
Ady Palti, DMD
Bruchsaler Strasse 8
D-76703 Kraichtal/Germany
Phone: 0049 (0) 7251–96980
Fax: 0049 (0) 7251– 69480
E-mail: dr.palti@t-online.de

Abstract Translations [German, Spanish, Portuguese, Japanese]

AUTOREN: Ady Palti, D.M.D., Thomas Hoch,
D.M.D. Schriftverkehr: Ady Palti, DMD, Bruch-
saler Strasse 8, D-76703 Kraichtal/Germany.
Telefon: 0049 (0) 7251-96980, Fax: 0049 (0)
7251-69480. eMail: dr.palti@t-online.de
ZUSAMENFASSUNG: Bleiben Zahnknochenschädigungen unbehandelt, führt dies nor-
malerweise zu Resorption des Alveolarknochens. Dies kann durch Auffüllung mit
knochenähnlicher Substanz verhindert werden, so dass der Alveolarkamm erhalten bleibt
und somit ausreichende Knochensubstanz für sofortige oder spätere Implantierung
vorhanden ist. Verschiedene Knochenersatzsubstanzen stehen hierbei zur Auswahl, die
sich nach Ursprung, Konsistenz, Partikel- und Porengröße sowie Resorptionseigen-
schaften unterscheiden lassen. Bei 267 Patienten wurde zur Behandlung von ca. 1000
Fällen von Zahnknochendefekten als Material zur Knochenregeneration Cerasorb verwen-
det. Da dieser Stoff gleichzeitig mit der Bildung neuen Knochens vollständig resorbiert
wird, findet innerhalb von 6-12 Monaten ein kompletter Austausch des Stoffes mit eigener
Knochensubstanz statt. Die repräsentativen Fallbeschreibungen dieser Abhandlung liefern
einen Nachweis über die erfolgreiche Behandlung beliebiger Knochendefekte durch
Einsatz der auf rein phasischem ß-Tricalcium-Phosphat basierenden Keramik.

SCHLÜSSELWÖRTER: Aufbau, Knochenersatzsubstanzen, Sinusanhebung

AUTORES: Ady Palti, D.M.D., Thomas Hoch,
D.M.D. Correspondencia a: Ady Palti, DmD,
Bruchsaler Strasse 8, D-76703 Kraichtal/Ger-
many. Teléfono: 0049 (0) 7251-96980, Fax:
0049 (0) 7251-69480. Correo electrónico:
dr.palti@t-online.de
ABSTRACTO: Los defectos del hueso dental sin tratamiento usualmente llevan a la
reabsorción del hueso alveolar. Rellenar estos defectos con material sustituto del hueso
previene la reabsorción del hueso, preserva el borde alveolar y proporciona suficiente
hueso para una colocación inmediata o posterior del implante. Se dispone de una variedad
de sustitutos del hueso. Difieren en origen, consistencia, tamaño de las partículas,
porosidad y características de reabsorción. Hemos tratado a casi mil situaciones en 267
pacientes con el material de regeneración del hueso Cerasorb®. Ser absorbido simultánea-
mente con la formación de nuevo hueso, resulta completamente reemplazado por el propio
hueso vital del paciente en 6 a 12 meses. Los casos representativos descriptos en este

IMPLANT DENTISTRY / VOLUME 11, NUMBER 1 2002 77


AUTORES: Ady Palti, D.M.D., Thomas
Hoch, D.M.D. Correspondências devem ser
enviadas a: Ady Palti, DMD, Bruchsaler
Strasse 8, D-76703 Kraichtal/Germany. Tele-
fone: 0049 (0) 7251-96980, Fax: 0049 (0)
7251-69480. e-mail: dr.palti@t-online.de
78 DENTAL BONE DEFECTS
trabajo demuestran el uso exitoso de la cerámica de fase pura, fosfato â-tricalcio en el
tratamiento de todos los defectos de huesos dentales.
PALABRAS CLAVES: Aumento, materiales sustitutos del hueso, elevación del seno
SINOPSE: defeitos do osso dentário, quando não tratados, normalmente levam à reab-
sorção do osso alveolar. O preenchimento destes defeitos com material de substituição
óssea evita a reabsorção do osso, preserva a crista alveolar e fornece osso suficiente para
a colocação imediata ou subseqüente de implante. Vários substitutos ósseos estão dis-
poníveis. Eles diferem em relação à origem, consistência, tamanho de partícula, poro-
sidade e características de reabsorção. Temos experiência com o tratamento de quase mil
situações em 267 pacientes com material de regeneração óssea Cerasorb®. Reabsorvido
simultaneamente com a formação de novo osso, tal material é completamente substituído
pelo osso vital do próprio paciente em um prazo de 6 a 12 meses. Os casos representativos
aqui descritos demonstram o uso com sucesso da cerâmica de fosfato â-tricalcico de fase
pura no tratamento de todos os defeitos de ossos dentários.
PALAVRAS-CHAVES: ampliação, materiais de substituição óssea, elevação sinusal