Dr. Papi: Well, in my opinion large granules are more suitable for sinus lift procedures, while I use small granules in socket preservation, contour augmentation, GBR around dental implants and periodontal regeneration around teeth.
In my expertise, there is no difference in the integration of cerabone® based on the size of the granules – you just need to wait more for sinus lift (6-9 months). I usually perform re-entry surgery after socket preservation at 4-5 months, finding a good quality and quantity of bone.

Dr. Frosecchi: Small particles can be used in all treatments, but generally are more indicated for GBR treatments. Large particles are generally more indicated in sinus augmentation and large self-space making defects, where we want to leave more space for blood clot and less protection from mechanical factors.

Dr. Eslava: In our clinical practice we only use small particles, especially because of the risk of long-term flap perforation with larger particles that are not going to be resorbed. Occasionally we have used them (large particles) in extensive sinus elevations but always in combination with autologous grafts.
The graft integration time does not depend on the particle size, it depends on the porosity of the graft, the crystallinity of the hydroxyapatite and the residual calcium concentration.

Dr. Papi: I hydrate cerabone® with sterile saline solution and then I generally use it alone, without autogenous bone. Sometimes I collect some bone chips from the burs while performing implant placement or using a bone scraper and I mix it in a 50:50 way with cerabone®, however I am a strong supporter of the use of cerabone® alone. In my opinion, there is no need to add autogenous bone.

Dr. Frosecchi: Personally, I use saline solution, blood or tetracycline solution. I use this last antibiotic association in case of infective risk cavities.

Dr. Eslava: We always suggest mixing cerabone® with PRF and with autologous bone obtained from the same surgical site, either by milling or scraping the adjacent bone. cerabone® can be used pure without mixing with any other material in surgical sites where adequate blood irrigation from the surgical site can be guaranteed as occurs in the maxillary sinus or in post-exodontic alveoli with intact bone walls.

Dr. Eslava: Although both are xenografts of bovine origin, from the manufacturing point of view they differ greatly. cerabone® is processed at 1250 Celsius degrees, this is important in the crystalline phase of the hydroxyapatite crystals obtained at the end of the process and the amount of residual calcium carbonates. On the other hand there is the porosity of the particles, where the cerabone® particle is much more porous than that of Bio-Oss®. This is easily evidenced in the hydrophilicity tests with blood in both products, with cerabone being much more hydrophilic than the Bio-Oss®. From the clinical point of view the manipulation of both materials when mixed with PRF and with autologous bone is very similar. But when the surgical re-entry is done eight or ten months after the procedure, the differences are significant. There is more presence of particles in cerabone® than in Bio-Oss®, the integration of graft particles is very similar, but the big difference is in the vitality of the bone around the surgical site. Bleeding from the surgical bed in Bio-Oss® is significantly less than cerabone®.

All bone defects should be measured in cubic centimeters or cubic millimeters because we are treating surgical sites with a defined space. The weight given in grams only speaks of the density of the material but not of the space occupied by it.

Dr. Papi: I usually associate the use of cerabone® with Jason® membrane when performing socket or ridge preservation, however sometimes I do not use a membrane when treating small defects around dental implants or for regenerative treatment of peri-implantitis.

Dr. Frosecchi: Yes, in sinus lift. Sometimes I associate cerabone® with mucoderm® in buccal volume augmentation.

Dr. Eslava: In some selected cases we use it that way, especially in surgical sites where the space is completely delimited by bone walls, for example in maxillary sinuses, post-exodontic alveoli with all bone walls intact. It can also be used in vestibular areas of implants where we want to achieve a stable volume without the need for true guided bone regeneration and we only want to improve the buccal contour of the surgical site.

Dr. Frosecchi: Sausage technique is a recent technique, sufficiently documented with combination of Bio-Oss® and autologous bone. It should work with cerabone® too, but I think we need some specific study to demonstrate a similar outcome. 

Dr. Eslava: Of course, cerabone® should be mixed with autologous bone and absorbable membranes of pericardium can be used to perform Dr. Urban’s Sausage technique, it is an excellent alternative because of the superb stability of the bone graft.

This technique can be carried out with any type of biomaterial, but the degree of reabsorption of the biomaterial to be chosen for this type of procedures must be taken into account, there are some materials that have a high turnover rate generating a volume of new bone quickly, but this same advantage is a disadvantage in this type of procedures, since the resurfacing of this material will be greater with the passage of time and much more once the implants are loaded and the structural strength of biomaterials

Dr. Papi: Well, the two materials are comparable. According to my opinion, the better advantages of cerabone® are its superior hydrophilic nature and different pore size. A difference I have noticed is that cerabone® is more stable than Bio-Oss®: when recalling patients, you can notice a smaller amount of vertical reduction at x-rays examinations.
In my opinion, cerabone® and Bio-Oss® look different on periapical x-rays and CBCT and I think this is due to the granules size and its subsequent different refraction of x-rays. You can notice a more porous aspect of cerabone, which is more similar to autogenous bone.

Dr. Frosecchi: My experience indicate that Bio-Oss® is generally integrated into bone and partially resorbed. cerabone® looks remaining longer without macroscopic resorption. This can influence outcome in both directions: can be useful in case of volume augmentation and can be not so useful in case of more predictable bone formation, as in case of sinus augmentation.
I’m not sure of a different x-ray aspect.

Dr. Eslava: During the manipulation of both grafts mixed with PRF and autologous bone that is our protocol we have not found differences. However, the hydration of both grafts is different, cerabone® being much more hydrophilic than Bio-Oss® due to the porosity of the particle. At the time of surgical re-entry between the 8^th and 10^th month, differences are observed as there are more cerabone® particles than Bio-Oss®, this is due to the crystallinity of the grafts and a notable difference is the degree of blood irrigation of both scarred grafts, being a site with much more irrigation in cerabone® than in Bio-Oss®. With a greater amount of particles remaining in cerabone®, the long-term stability of the graft is greater than that of Bio-Oss®, and you can see the bone vitality by yourself.

In tomographic images, if there are differences, since cerabone® is of greater crystallinity and when more particles remain in the surgical site, the image is observed with a higher density than the image seen in the Bio-Oss treated sites.

Dr. Frosecchi: I observed some non-incorporation into bone. cerabone® was more attached to the soft tissue. This can be considered a failure of bone augmentation. I think that cerabone® should be recommended in cases of buccal volume augmentation, where stability is more important than bone incorporation and new bone formation.

A certain amount of granules separation at re-entry is acceptable. It’s a quantitative problem when too much biomaterial gets separated and not incorporated.

Dr. Eslava: Yes at the beginning of our learning curve with cerabone, year 2011, we made re-entries between the 6^th and 8^th month in places where we had made very extensive regenerations and found that the graft was not yet fully integrated into the surgical site.

On other occasions with very thin periodontal phenotypes the particles can perforate the gingival tissue even years after the surgical procedure. It is very important to note that cerabone® and apical lesions on adjacent teeth are not a good combination. Occasionally we have seen that in sites that have been regenerated with cerabone® many years ago and the adjacent tooth appears with an extensive apical lesion, it is very easy for the graft to contaminate rapidly.

The vast majority of failures with this type of biomaterials are associated with the manipulation of the clinician at the surgical time, the xenografts are not manipulated like the allografts, the healing times are different and the periodontal phenotype of the surgical site must be taken into account to evaluate if it is possible that in the future the remaining particles can pierce the flap.

There are a number of errors that should be avoided by the clinician at the time of using cerabone®: Evaluate with which solution the injero will hydrate (saline solution, blood or PRF). Consider always mixing the graft with autologous bone or with PRF to have A better clinic result. Use of membranes with sufficient resorption or degradation time. Ensure complete immobilization of the graft by means of fixing the membranes with prf or sutures or tacks or screws. Consider the minimum reentry time of six to eight months for post-exodontic alveoli, and eight to 12 months for extensive sinus elevations, and ten to 12 months for extensive horizontal and vertical bone regenerations. Evaluate the milling technique in the surgical site, milling sequence and never perform osseodensification. Avoid provisional contact especially if it is removable with the surgical site. In places where there are apical lesions, be sure to completely decontaminate the site to avoid re-infection of the graft.

It depends on the amount of granules separated, if there are a few, there is no problem, but if the graft is not integrated and easily detaches from the surgical site, the surgical procedure should be considered.