JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No.

1 (95 - 105): Using 45S5 Bioglass Cones as Endosseous Ridge Maintenance I

Using 45S5 Bioglass Cones as Endosseous Ridge

Maintenance Implants to Prevent Alveolar Ridge
Resorption: A 5-Year Evaluation
Harold R. Stanley, DDS, BS, MS/Matthew B. Hall, DDS, MD/Arthur E. Clark, DMD, PhD/Caleb
J. King III, DDS/Larry L. Hench, PhD/Joseph J. Berte, DDS

Bioglass cones acting as space fillers after removal of tooth roots delay the resorption of
alveolar ridges. In 1987, 242 implants in 29 patients with a mean postimplantation interval of
19.9 months were reported by the authors. Bioglass cones had been fitted snugly at least 2 mm
below the alveolar crest, and dentures were placed no sooner than 6 weeks following tooth
removal; 2.9% had been lost and 3.7% developed dehiscences. The present report on 168
implants in 20 recalled patients (mean postimplantation interval of 63.2 months) revealed a
loss of 14.3% of the implants and 7.7% of the implants requiring recontouring. Literature
indicates highest survival rates for implants in the anterior mandible; however, the present
data demonstrate a statistically significant retention rate in the anterior maxilla. With this
high rate of Bioglass cone retention (85.7%) after 5 years, their placement into fresh sockets to
maintain the alveolar ridge is recommended.
(INT J ORAL MAXILLOFAC IMPLANTS 1997;12:95–105)
Key words: Bioglass, cone, implant, ridge maintenance

I nvestigators have found that implants, which act as space fillers following the extraction of tooth roots,
do delay resorption of residual alveolar ridges. Implants can provide mechanical support as a scaffolding
and prevent the collapse of the labial and lingual plates of bone.1,2 Acrylic resin,3,4 hydroxyapatite
(HA),5 coralline HA,6 carbon, calcium phosphate ceramics,7,8 tricalcium phosphate, and Bioglass9-11
(US Biomaterials, Alachua, FL) are products that have been used for implants.
In 1986, Stanley et al presented the initial results of a Bioglass cone implant study that began as a
clinical trial in 1983 (Stanley HR, Clark AE, Hall MB, King CJ III, Colaizzi F, Spilman D, Hench LL.
Clinical trials of Bioglass implants for alveolar ridge maintenance. 12th Annual Meeting of the Society
for Biomaterials, Minneapolis, MN, 1986). The project was the outgrowth of a 2-year baboon study in
which Bioglass replicas of incisor teeth were implanted in fresh sockets.9,10 In 1987, Stanley et al12
published a follow-up report on 242 Bioglass cone implants in 29 patients. After a mean postimplantation
period of 19.9 months (range 12 to 32 months), seven implants (2.9%) had been lost, and nine implants
(3.7%) had developed dehiscences. The present study reports on the recall of 20 of the original 29
patients after a mean postimplantation period of more than 5 years.
In the 1970s and ’80s, an explanation of how bioactive glasses and glass-ceramics worked was rather
simple.13-15 However, as the learning curve has developed, details of intermediate phases and reactions
have expanded the process from 2 to 11 different reaction stages as summarized in Fig 116-18 (West JK,
Hench LL. Molecular orbital modeling of bioactive glass reactions of stages 3 and 4 [abstract]. Trans Soc
Biomaterials [19th Annual Meeting, Birmingham, AL]. 1993:2).

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A bioactive glass can be regarded as a three-dimensional silica (SiO 2) network, which is modified by
incorporating oxides such as sodium oxide (Na2O), calcium oxide (CaO), phosphorus pentoxide (P2O5),
aluminum oxide (Al2O3), and barium oxide (B2O3), or halides such as calcium fluoride (CaF2).13-20
The grandfather composition, 45S5 Bioglass, is composed of 45% SiO2, 24.5% CaO, 24.5% Na2O, and
6.0% P2O5 in weight percent.
A prerequisite for bioactive glass implants to bond to living bone is the formation of a
carbonate-containing hydroxyapatite (HCA) layer on their surfaces after implantation; this layer bridges
the implanted materials to the host tissue. Some researchers18 (West JK, Hench LL, 1993) refer to it as a
hydroxy carbonate apatite (HCA) reaction layer. Others refer to it as a calcium phosphate (CaP) layer. It
is crucial that the HCA layer be permitted to form without being disturbed at the implant-tissue interface
at the appropriate time to match the repair rate (steps in the sequence of healing) of the implant site.19
When bioactive glasses are contacted by body (tissue) fluids, simulated body fluids (SBFs), or
aqueous solutions, three main reactions occur within a controlled sequence: dissolution; leaching; and
precipitation16-19 (West JK, Hench LL, 1993). It has been shown with FTIR spectroscopy that when the
silicate structure (network) on the surface of a Bioglass implant comes in contact with fluids, there is a
dissolution, or breakdown, of the silicon-oxygen bonds (Si-O-Si) with the release of other elements (Ca,
Na, P) within it (leaching). This leaves behind a silica-rich gel approximately 200 µm thick, which
provides a matrix for formation of the HCA layer. 12,22-26

According to Hench23 and Andersson and Kangasniemi,17 the reactions of glass in general can be
described by two main processes: network dissolution through attack of silica structure by hydroxyl (OH)
ions; and an exchange of alkali ions with H+ or the hydronium ion (H3O+). (H3O+ is the charged ionic
species usually found in water. The concentration of H 3O+ increases as the pH decreases.) Filgueiras et
al18 described the reaction 10 minutes after 45S5 Bioglass was placed in SBFs as a rapid ion exchange
of Na+ on the surface of the glass with H+ or H3O+ from the solutions. The breaking of Si–O–Si bonds
forms silanols (Si–OH) at the glass-solution interface. The condensation and repolymerization of the
surface silanols create the hydrated silica-rich layer, now depleted of alkalis and alkaline earth cations.
Formation of the hydrated silica gel precedes the formation of the HCA layer on the implant surface. 18
The silanol condensation reaction provides an energetically favored pathway for incorporating Ca
from the solution or body fluids onto the hydrated silica-rich surface18,20 (West JK, Hench LL, 1993).
The negatively charged silanol groups (SiOH) provide the base for apatite nucleation by binding the
Ca2+ ions from solution onto the surface. The phosphate groups are kept in the vicinity of the surface by
hydrogen bonding to silanols. These reactions create a local accumulation of both Ca and P about the
surface of the hydrated silica gel, which establishes a supersaturated solution of Ca and P adjacent to a
bioactive glass implant.19 West and Hench 27 proposed that pentacoordinated silicon ions (Si bonded to
five oxygen ions) formed by condensation of silanol groups are responsible for the nucleation of HCA.
Silicon ions with five oxygen atoms are in an energetically metastable state compared with the normal
condition of silicon bonded to four oxygen atoms. This metastable state provides a low-energy pathway
for chemical bonding of Ca2+ ions and the carboxyl end of biologic molecules, such as bone growth
factors
.If the silica structure is sufficiently open, Ca and P accumulation (the precipitation reaction) takes

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place very rapidly (1 to 2 hours) at the glass surface to form an HCA surface layer. When this occurs in
or near bone, new bone firmly attaches to the HCA layer 20,26,28 (Kim CY, Kim J, Chang SY.
Hydroxyapatite formation on bioactive glass in a solution with different pH and P-ion concentration
[abstract]. Trans Soc Biomaterials [19th Annual Meeting, Birmingham, AL]. 1993:4).
Kim et al (1993), using various reaction solutions, found that a disk of bioactive glass became totally
dissolved in pure water after 100 hours at 37qC. During the first few hours, extensive dissolution of the
glass network occurred. According to the composition of the glass and the type of reaction solutions, the
dissolution in the first 8 hours varied between 1 and 4 µm. As the surrounding solution became saturated
with Si, the dissolution rate after about 10 to 15 hours was strongly retarded. This has a favorable aspect,
however, because the failure strength of a bioactively fixed bond is inversely proportional to the
thickness of the bonding zone. Thus, prolonged leaching of the glass results in a poorer fixation20,29
(Hench LL. Bioactive fixation [abstract]. Transactions of the 3rd World Biomaterials Congress. 1988:24).

Li et al19 produced additional data that further support the concept that silica hydrogel must form to
generate formation of the HCA layer. They produced a pure silica gel through a sol-gel process from
tetraethoxysilane and poly(ethylene glycol). Specimens of the silica gel were then immersed in various
SBFs for varying time periods. These SBFs do not precipitate their own mineral content spontaneously
within the first 5 weeks. The silica component must be readily hydrolyzed to produce sufficient silanol
groups for the induction of apatite nucleation. The apatite nucleation begins as a small crystalline
structure with spherulite features similar to those of bone apatite.19 No apatite formation was initiated at
any time in SBFs at a pH of 7.0, but apatite did begin to form on the surfaces of the pure silica gel at 1
week at pH 7.4, at 2 weeks at pH 7.3, and at 5 weeks at pH 7.2. The induction period for apatite
formation was also shortened with increases of Ca or P or both in the SBFs. The results showed that the
gel-derived silica is a potent apatite inducer, and these results are consistent with the findings of Damen
and Ten Cate. 30 The apatite nuclei grow spontaneously at the expense of Ca and P in the surrounding
SBFs once they are stimulated by the gel-derived silica.
At present, Bioglass appears to have the highest rate of HCA formation in vitro and in vivo, and it
appears to have the capacity for the fastest rate (bioactivity) of bone and soft tissue bonding of known
bioactive materials.29 The HCA layer grows rapidly and covers the whole surface of the buried
implant.19 This rapid growth of the HCA layer also encourages the bonding of 45S5 Bioglass to soft
tissues,31,32 and it may contribute to the superior performance (biomechanics) of Bioglass implants
placed in the alveolar ridge.33
Materials and Methods
A complete, detailed protocol has been described previously, 12 and basically it entails selecting healthy
subjects scheduled for treatment involving removable partial or complete dentures after tooth extraction.
A system of matched bone burs and implants was developed. The system consisted of 12 conical
implants with rounded tops and four burs. The implants ranged in size and shape from 4 to 12 mm in
length, 4 to 6 degrees of taper, 1.5 to 2.6 mm in tip diameter, and 1.96 to 4.57 mm in crestal diameters.
The goal of placement was to (1) have the crestal portion of the implants approximately 2 mm below
the crestal bone, (2) maximize bone-implant contact, and (3) avoid any recontouring of the implants. The
technique of placement involved performing routine extractions with minimal or no alveoloplasty. The
appropriate-size drill was selected for each socket in which an implant was to be placed. The implants

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were handled and pressed into the prepared sockets using rubber-tipped forceps. With appropriate
mucoperiosteal flaps, primary mucosal closure was obtained with 4-0 polyglactin 910 sutures (Vicryl,
Ethicon, Somerville, NJ). Denture prostheses were not placed until after 6 weeks of healing to allow time
for the implant-tissue reaction to take place without disturbance.
The cone implants function endosseously to maintain the alveolar ridge; thus, they are called
endosseous ridge maintenance implants (ERMI). The US Food and Drug Administration (FDA)
approved the product in November 1988 on the basis of a 510-K application.
Statistical Analysis. In statistically characterizing the survival history and influence of covariates on
the failure rate of a population of independent objects subject to failure over time, the survival and
covariate status of individual population members and their corresponding times to failure or the most
recent follow-up examination would typically be considered within the framework of standard survival
analysis techniques such as Cox regression or the log-rank test. However, the population of Bioglass
implants observed in the present study consisted of clusters of implants within patients. The survival or
time to failure of an individual implant is unlikely to be independent of the survival or time to failure of
other implants placed in the same patient because of patient-specific factors not necessarily explained by
observed covariates. Although several methods have been proposed to incorporate clustering of
failure-time observations into standard survival analysis techniques,34,35 the sample size and
computational resource requirements of these methods appear to be too extensive for most practical
purposes.
In the absence of practically applicable statistical methods for analyzing the clustered implant
survival and failure times observed in the present study, characterization of the survival history of
individual implants was limited to the construction and visual examination of Kaplan-Meier survival
curves for the entire implant population and for implant strata defined by various observed covariates. No
statistical comparison of individual implant survival curves between strata was carried out because of the
clustering of implants within patients. Statistical characterization of the influence of observed covariates
on implant survival was carried out at the level of the individual patient, with patient-specific implant
failure defined as the occurrence of at least one implant failure in a given patient, and patient-specific
implant failure time defined as the median of all failure times observed in a given patient. The log-rank
test was used to statistically compare patient-specific Kaplan-Meier implant survival curves between
strata for each of the classifying covariates.
Most of the observed covariates used to define strata for implant survival curves could be considered
as being associated with both individual implants and patients. These included patient recall (yes/no),
median patient age at time of implant surgery (older/younger), race (white/black), sex (man/woman),
denture type (RPD/no RPD), median length of interval between surgery and placement (above/below),
and median number of implants placed per patient (above/below). Implant-specific covariates included
implant site (anterior maxillary, posterior maxillary, anterior mandibular, posterior mandibular) and need
for recontouring (yes/no).
Results
Five-Year Follow-up. Twenty of the original 29 patients (244 implants) were followed up in the present
study (1993–1995). The 20 recalled patients originally possessed 168 implants, with postimplantation
periods ranging from 36 to 115 months (mean 63.2 months, over 5 years) (Fig 2 and Table 1).
The 20 recalled patients consisted of 12 men and 8 women. Three were black and 17 were white. The
mean age at the time of surgical implantation was 43.2 years (range 24 to 67 years). Of the 20 patients,

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14 received complete maxillary or mandibular dentures, and 6 received the combination of a complete
maxillary denture and mandibular removable partial denture (Table 2). Of the 168 implants, 82 were
placed in the maxilla (56 in anterior sites and 26 in posterior sites). Eighty-six implants were placed in
the mandible (52 in anterior sockets and 34 in posterior sockets). Only four molar socket sites were used.
Lost Implants. To date, 24 (14.3%) of the 168 implanted cones in the 20 recalled patients have been lost
at various times ranging from 6 to 74 months (mean 36.8 months). Eight (9.8%) of the maxillary implants
were lost. Three (5.4%) of the 56 anterior-site implants were lost, and 5 (19.2%) of the 26 posterior-site
implants were lost. Sixteen (18.6%) of the mandibular implants were lost: 11 (21.2%) of 52 from anterior
sites and 5 (14.7%) of 34 from posterior sites. Of the 24 lost implants, 8 implants supporting maxillary
complete dentures and 9 implants supporting mandibular complete dentures were lost. Seven implants
supporting mandibular removable partial dentures were lost.
In the 20 patients recalled, the maxillary anterior implants had the highest retention rate (94.6%),
followed by the mandibular posterior implants (86.4%), the maxillary posterior implants (80.8%), and the
mandibular anterior implants (76.2%).
Recontoured Implants. Thirteen (7.7%) of 168 implants were recontoured between 4 and 46 months
(mean 17.0 months) after initial implantation. Two implants were recontoured at 4 months and again at
39 months. In the maxilla, 3 (3.7%) of 82 implants required recontouring: 2 (3.6%) of 56 in anterior sites
and 1 (3.8%) of 26 in a posterior site. None of the recontoured implants in the maxilla was lost. In the
mandible, 10 (11.6%) of 86 implants required recontouring: 2 (3.8%) of 52 in anterior sites and 8
(23.5%) of 34 in posterior sites. One mandibular posterior implant was recontoured at 7 months and lost
at 14 months.
Relining Dentures. The need for a prosthesis base reline was not unexpected because the Bioglass cones
were placed approximately (and intentionally) 2.0 to 3.0 mm below superficial, irregular, possibly
diseased alveolar bone. The need for reline was recorded in 17 of the 20 recalled patients. The time
interval between placement of the dentures and the recognized need for reline was a mean of 14.5 months
(range 3 months and 25 days to 22 months and 21 days).
Statistical Analysis. The Kaplan-Meier survival curve for the entire population of individual implants
appears in Fig 3. Vertical marks indicate the most recent follow-up times for implants that had not yet
failed. Visual examination of implant survival curves classified by patient recall, median patient age at
time of implant surgery, race, sex, denture type, median length of interval between surgery and implant
placement, median number of implants placed per patient, and need for recontouring indicated no
apparent differences between strata defined by any of these covariates.
Figure 4 depicts the survival curves for implant strata defined by mandibular and maxillary locations.
These curves suggest that mandibular implants may fail more rapidly than do maxillary implants.
Survival curves for strata defined by anterior and posterior locations appeared similar (data not shown).
The survival curves for implants located in the four sites defined by crossing maxillary-mandibular and
anterior-posterior strata are seen in Fig 5. The rate of implant failure appeared to be greatest in the
anterior mandibular and posterior maxillary strata with up to 72 months of follow-up. The posterior
mandibular stratum had the next greatest failure rate in this interval; the anterior maxillary stratum had
the lowest failure rate. The differences among strata beyond 72 months of follow-up appeared much
more dramatic but should be interpreted cautiously because the number of implants still at risk at this
time was relatively small. Also, caution should be exercised in general when considering the significance
of any of the individual implant survival curves because of the clustering of implants within a patient.
Figure 6 depicts the patient-specific implant survival curve for all patients, with patient-specific implant

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failure defined as the occurrence of at least one implant failure in a given patient. None of the
patient-specific implant survival curves differed significantly between strata defined by patient recall (P
= .445), median age (P = .143), race (P = .450), gender (P = .594), denture type (P = .721), median
implant-to-placement interval (P = .552), and median number of implants (P = .172).
Discussion
In general, the anterior mandible has the highest implant survival rate.36 Smiler37 emphasized that the
success rate is highest in the anterior mandible, and it declines when implants are placed in the posterior
mandible. In the maxilla, implant success is less because of the porous quality of the bone and the
thinness of the labiobuccal cortical plate. James et al38 calculated 5-year mandibular and maxillary
survival rates to be approximately 76% and 70%, respectively. Adell et al 39 reported a 91% survival rate
in the mandible and 81% in the maxilla at 5 to 9 years. In one study by van Steenberghe, 40 only 2 of 45
mandibular molar implants were lost, as compared to 1 of 6 maxillary molar implants. DaSilva et al41
had a 6-year survival rate of 94% for posterior mandibular implants, as compared to 74% for posterior
maxillary implants. Kopp42 suggested that the restoration of bilateral posterior maxillary edentulous
areas with osseointegrated implants was difficult, if not impossible. The results in the present study are
contrary to those in the literature and indicate that Bioglass cones will probably succeed in any location,
provided enough bone is present and they are placed deep enough.
It appears that a Bioglass cone implant with a snug, but not exact, surgical fit in bone may initiate
enough partial or direct contact between the implant and cortical bone to stabilize the implant. But the
more exact the surgical fit, the more appositional lamellar bone will form along the entire implant surface
and improve fixation. Most implants have grooves or ridges to improve bonding. Since the surface of
Bioglass dissolves when contacted by the appropriate fluids, grooves are not necessary.
Although it generally took longer for the student dentist to complete the restorative phase for the
patient with an edentulous maxilla and partially edentulous mandible, it did not appreciably change the
time interval before the need for reline. The mean interval for a reline of the complete maxillary denture
in patients who also had a mandibular removable partial denture was shorter (10.9 months), as compared
to the mean interval for relining a denture in patients with complete dentures in both arches (14.4
months). This is not unexpected in that all other factors being equal, a patient with a well-designed and
fabricated tooth-supported removable partial denture will place more load on the maxillary complete
denture, as opposed to a conventional complete mandibular denture supported only by a tissue base.
Therefore, it does not appear advantageous to fabricate the dentures early once the ERMI cones are
placed, in terms of slowing down the rate of alveolar ridge resorption. The initial early rate of alveolar
ridge resorption involving the remaining bone, down to the level of the implanted cones, continues
regardless of whether the dentures are placed sooner or later.
The placement of Bioglass cones into fresh extraction sockets to maintain the alveolar ridge, whether
an intraoral attachment is to be placed immediately or added subsequently with more extensive
restoration, can be advantageous. Bone resorption will be retarded until the patient completes appropriate
treatment. For situations in which natural teeth are to be used for the abutments of fixed restorations, it
will help prevent approximating pontics from losing ridge contact as the alveolar bone resorbs.These
5-year results appear to exceed the results of other commercial products of a similar nature, either solid
or porous HA. In the present study with Bioglass cones, after a mean postimplantation period of 63.2
months, 14.3% were lost and 7.7% required recontouring.

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In 1984, Cranin and Shpuntoff43 reported that at the end of 1 year in their study, 55% of the cones
were lost. In a study by Quinn et al,5 9.7% of the implants were lost, and 26% required recontouring at
times between 3 and 31 months. Kangvonkit et al44 experienced a loss of 6.2% and the development of
dehiscences in 13.6% after 2 years. Kvon et al45 reported the loss of 27% and developed dehiscences in
53% after 20.6 months, and Filler and Kentros46 indicated that after 1 year, 12% of the cones in their
study had been lost and 50% developed dehiscences. Brook et al47 lost approximately 20% of the cones
after 1 year, and Sattayasanskul et al 48 likewise lost 20% of the cones after 1 year.
All of these percentages were developed from the total number of individual cone implants in the
entire study, not the percentage of success or failure in each patient. In our study, although 14.3% of the
individuals’ implants were lost, only 10 (50%) of the 20 follow-up patients lost no implants (see Table
2). If one were to compare the percentage of patients with no implant loss in our study with those of the
aforementioned literature involving HA implants, our success rate would still be higher. The success rate
with Bioglass cones, as compared to HA implants, may have been enhanced because the cones were
placed deep and dentures were not placed for a mean of 14 months. Furthermore, the success rate may
have been enhanced because the maxilla, where the implant retention rate was higher than that in the
mandible, was used. Several previous studies involved only the mandible, and the dentures were placed
immediately after tooth removal.
Summary and Conclusion
The following recommendations to avoid or minimize dehiscence and exfoliation can be made:
1. Implant cones should fit tightly (snugly, be wedged). Three-rooted sockets and canine sockets are
difficult to fill. Burs that match the implants in size must be used to provide a tight fit.
2. No adjustments can be made on the cone implant itself initially. All cutting, grinding, or shaping of
cones leaves sharp angles, irregularities, or grinding debris, which irritates the mucosal tissues.
Adjustments to the sockets must be minimal.
3. Cone implants must be placed at least 2.0 mm below the lowest level of the circumference of the
bony crest. There is a spontaneous loss of alveolar bone initially, caused not only by fracture of the
alveolar bone during extraction procedures, but also the resorption of bone irregularities resulting
from periodontal disease.
4. Every effort must be made to obtain primary closure of soft tissue over the implanted cone.
5. The placement of removable complete dentures over the treated site should be delayed for at least 6
weeks to minimize mechanical trauma. Fixed prostheses and removable partial dentures can be
placed earlier.
6. Provided the implant is ankylosed, an implant surface should be minimally recontoured as soon as it
becomes exposed. An exposed surface should be left as smooth as possible. It is not necessary to
provide primary closure the second time.
7. The removable dentures should be relined as soon as the need is apparent. This minimizes increasing
mechanical traumas, which enhance dehiscence, bone resorption, and exfoliation.
In conclusion, the lower rates of Bioglass cone implant loss (14.3%) and dehiscence (7.7%)
experienced when the cones are placed into fresh extraction sockets and subjected to functioning

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dentures during a period of 115 months (mean 63.2 months) in 20 recalled patients suggest that favorable
clinical results can be obtained with this procedure.
Acknowledgments
The authors gratefully acknowledge Mr Paul Kubilis for his valuable contribution to the statistical
evaluation of the results.
The research project was supported in part by Division of Sponsored Research, University of Florida,
and US Biomaterials, Alachua, Florida.

Harold R. Stanley

Professor Emeritus, Department of Oral Diagnostic

Sciences and Codirector, Bioglass Research
Center, University of Florida, College of Dentistry,
Gainesville, Florida.

Matthew B. Hall

Professor and Chairman, Department of Oral and

Maxillofacial Surgery, University of Kentucky,
Lexington, Kentucky.

Arthur E. Clark

Professor and Chairman, Department of

Prosthodontics, University of Florida, College of
Dentistry, Gainesville, Florida.

Caleb J. King III

Private Practice,
Gainesville, Florida

Larry L. Hench

Graduate Research Professor, Department of

Footnotes 8
 Materials Science and Engineering, University of
Florida, College of Engineering, Gainesville,
Florida.

Joseph J. Berte

Assistant Professor, Department of

Prosthodontics, University of Florida, College of
Dentistry, Gainesville, Florida.

(CaP) layer

Instrumental methods such as Fourier transform

infrared (FTIR) spectroscopy and x-ray diffraction
can distinguish between a crystalline HCA layer
and an amorphous CaP layer. Hench and
LaTorre(see reference 21) have shown that the
rate of crystallization of the HCA layer from the
amorphous CaP is the critical step in determining
the level of bioactivity of a glass.

FIGURES

Footnotes 9
Figure 1

Fig. 1 Sequence of interfacial reactions involved in forming a bond between tissue and
bioactive glasses. (Reprinted with permission from the American Ceramic Society. Hench LL.
Bioceramics: From concept to clinic. J Am Ceramics Soc 1991;74:1487–1510.)

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Figure 2a-b

Figs. 2a and 2b Portions of panoramic radiographs of maxilla of a 41-year-old man (patient No.
6) who received 12 Bioglass cone implants (July 1984). (Left) Immediately after placement and
wedging of cones into fresh sockets as deeply as possible. Radiolucent areas can be seen
above and below cone implants. (Right) Ten years and 6 months after implantation, five cone
implants are completely surrounded by new bone, and the original socket topography has been
obliterated.

Figure 3

Fig. 3 Overall implant survival.

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Figure 4

Fig. 4 Implant survival by jawbone.

Figure 5

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Fig. 5 Implant survival by jawbone and location.

Figure 6

Fig. 6 Patients experiencing implant failure.

TABLES

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Table 1

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Table 2

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Table 2cont

Using 45S5 Bioglass Cones as Endosseous Ridge Maintenance Implants to Prev

1. Denissen HW, deGroot K. Immediate dental root implants from synthetic dense calcium hydroxylapatite. J
Prosthet Dent 1979;42:551–556.
2. Stanley HR. Implantology and the development of Bioglass. In: Derrick DD (ed). The 1987 Dental Annual.
Bristol, England: John Wright & Sons, 1987:209–230.
3. Lam RV, Poon KY. Acrylic resin root implant: A preliminary report. J Prosthet Dent 1968;19:506–513.

References 16
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (95 - 105):

4. Lam RV, Poon KY. Acrylic resin root implants: Continuing report. J Prosthet Dent 1969;22:657–662.
5. Quinn JH, Kent JN, Hunter RG, Schaffer CM. Preservation of the alveolar ridge with hydroxylapatite tooth
root substitutes. J Am Dent Assoc 1985;110:189–193.
6. Frame JW. Augmentation of an atrophic edentulous mandible by interpositional grafting with hydroxylapatite.
J Oral Maxillofac Surg 1984;42:88–92.
7. James R. Tissue response to dental implant devices. In: Clark JW (ed). Clinical Dentistry, vol 5. Philadelphia:
Harper & Row, 1984:8–9.
8. Misiek DJ, Kent JN, Carr RF. Soft tissue responses to hydroxylapatite particles of different shapes. J Oral
Maxillofac Surg 1984;42:150–160.
9. Stanley HR, Hench LL, Going R, Bennett C, Chellemi SJ, King CJ III, et al. The implantation of natural tooth
form Bioglasses in baboons: A preliminary report. Oral Surg Oral Med Oral Pathol 1976;42:339–356.
10. Stanley HR, Hench LL, Bennett CG Jr, Chellemi SJ, King CJ III, Going RE, et al. The implantation of natural
form Bioglass in baboons—Long-term results. Int J Oral Implantol 1981;2:26–36.
11. Hall MB, Stanley HR, King CJ III, Colaizzi F, Spilman D, Hench LL. Early clinical trials of 45S5 Bioglass for
endosseous alveolar ridge maintenance implants. In: van Steenberghe (ed). Tissue Integration in Oral and
Maxillofacial Reconstruction [Proceedings of an International Congress, May 1985, Brussels]. Amsterdam, The
Netherlands: Excerpta Medica, 1985:248–252.
12. Stanley HR, Hall MB, Colaizzi F, Clark AE. Residual alveolar ridge maintenance with a new endosseous
implant material. J Prosthet Dent 1987;58:607–613.
13. Hench LL, Splinter RJ, Greenlee TK, Allen WC. Bonding mechanisms at the interface of ceramic prosthetic
materials. J Biomed Mater Res 1971;5:117–141.
14. Hench LL, Paschall HA. Direct chemical bond of bioactive glass-ceramic materials to bone and muscle. J
Biomed Mater Res 1973;7(3):25–42.
15. Clark AE, Hench LL, Paschall J. The influence of surface chemistry on implant interface histology: A
theoretical basis for implant materials selection. J Biomed Mater Res 1976;10:161–174.
16. Hench LL. Bioceramics: From concepts to clinic. J Am Ceramics Soc 1991;74:1487–1510.
17. Andersson OH, Kangasniemi L. Calcium phosphate formation at the surface of bioactive glass in vitro. J
Biomed Mater Res 1991;25:1019–1030.
18. Filgueiras RM, La Torre G, Hench LL. Solution effects on the surface reactions of a bioactive glass. J Biomed
Mater Res 1993;27:445–453.
19. Li P, Ohtsuki C, Kokubo T, Nakanishi K, Soga N, Nakamura T, Yamamuro T. Effects of ions in aqueous
media on hydroxyapatite induction by silica gel and its relevance to bioactivity of bioactive glass and
glass-ceramics. J App Biomater 1993;4:221–229.
20. Andersson OH, Rosenqvist J, Karlsson KH. Dissolution, leaching, and Al2O3 enrichment at the surface of
bioactive glasses studied by solution analysis. J Biomed Mater Res 1993;27:941–948.
21. Hench LL, La Torre GP. Reaction kinetics of bioactive ceramics. Part IV: Effect of glass and solution
composition. In: Yamamuro T, Kokubo T, Nakamura T (eds). Bioceramics 5. Kyoto, Japan: Kobonshi
Kankokai, 1992:67–74.
22. Hench LL, Ethridge EC. Biomaterials: An interfacial approach. In: Noordergraaf A (ed). Biophysics and
Engineering, vol 4. New York: Academia Press, 1982.

References 17
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (95 - 105):

23. Hench LL. Stability of ceramics in the physiological environment. In: Williams DF (ed). Fundamental Aspects
of Biocompatibility, vol 1. Boca Raton, FL: CRC Press, 1981:67–85.
24. Hench LL, Clark AE. Adhesion to bone. In: Williams DF (ed). Biocompatibility of Orthopedic Implants, vol 2.
Boca Raton, FL: CRC Press, 1982:129–170.
25. Ogino M, Hench LL. Formation of calcium phosphate films on silicate glasses. J Non-crystalline Solids
1980;38/39:673–678.
26. Andersson OH, Liu G, Karlsson KH, Niemi L, Miettinen J, Juhanoja J. In vivo behavior of glasses in the
SiO2–Na2O2–CaO–P2O5–Al2O3–B2O3 system. J Mater Sci Mater Med 1990;1:219–227.
27. West JK, Hench LL. Reaction kinetics of bioactive ceramics. Part V: Molecular orbital modelling of bioactive
glass surface reaction: In: Yamamuro T, Kokubo T, Nakamura T (eds). Bioceramics 5. Kyoto, Japan: Kobonshi
Kankokai, 1992:75–86.
28. Hench LL. The interfacial behavior of biomaterials. J Biomed Mater Res 1980;14:805–811.
29. Hench LL. Bioactive ceramics. In: Ducheyne P, Lemmons JE (eds). Bioceramics: Materials Characteristics
Versus In Vivo Behavior. Annals of the New York Academy of Sciences. NY: New York Academy of
Sciences, 1988;523:54–71.
30. Damen JJM, Ten Cate JM. The affect of silicic acid on calcium phosphate precipitation. J Dental Res
1989;68:1355–1359.
31. Wilson J, Pigott GH, Schoen FJ, Hench LL. Toxicology and biocompatibility of Bioglasses. J Biomed Mater
Res 1981;15:805–817.
32. Wilson J, Nolletti D. Bonding of soft tissues to Bioglass. In: Yamamuro T, Hench L, Wilson J (eds). Handbook
of Bioactive Ceramics, vol 1. Boca Raton, FL: CRC Press, 1990:1:283–302.
33. Wilson J, Clark AE, Hall M, Hench LL. Tissue response to Bioglass endosseous ridge maintenance implants. J
Oral Implantol 1993;19:295–302.
34. Klein JP. Semiparametric estimation of random effects using the Cox model based on the EM algorithm.
Biometrics 1992;48;795–806.
35. Guo G, Rodriguez G. Estimating a multivariate proportional hazards model for clustered data using the EM
algorithm, with an application to child survival in Guatemala. J Am Statistical Assoc 1992;87:969–976.
36. Schnitman PA, Rubenstein JE, Woehrle PS, DaSilva JD, Koch GG. Implants for edentulism. NIH Consensus
Development Conference on Dental Implants [13–15 June 1988]. 1988:53–56.
37. Smiler DG. Socket-lift procedure with immediate placement of an implant in an extraction socket. Implant
Digest 1990;Summer:2–3.
38. James R, Altman A, Clem D, Lozada J. A critical review of the ‘osseo-integrated’ literature. NY State Dent J
1986;52(10):31–34.
39. Adell R, Lekholm U, Rockler B, Brånemark P-I. A 15-year study of osseointegrated implants in the treatment
of the edentulous jaw. Int J Oral Surg 1981;10:387–416.
40. van Steenberghe D. A retrospective multicenter evaluation of the survival rate of osseointegrated fixtures
supporting fixed partial prostheses in the treatment of partial edentulism. J Prosthet Dent 1989;61:217–223.
41. DaSilva JD, Schnitman PA, Wöhrle PS, Wang HN, Koch GG. Influence of site on implant survival: 6-year
results [abstract 1200]. J Dent Res 1992;71(special issue):256.

References 18
JOMI on CD-ROM (1997 © Quintessence Pub. Co.), 1997 Vol. 12, No. 1 (95 - 105):

42. Kopp CD. Brånemark osseointegration: Prognosis and treatment rationale. Dent Clin North Am
1989;33:701–731.
43. Cranin AN, Shpuntoff R. Hydroxylapatite (HA) cone implants for alveolar ridge maintenance—One year
follow-up [abstract 269]. J Dent Res 1984;63(special issue):200.
44. Kangvonkit P, Matukas VJ, Castleberry DJ. Clinical evaluation of Durapatite submerged-root implants for
alveolar bone preservation. Int J Oral Maxillofac Surg 1986;15:62–71.
45. Kvon HJ, El Deeb M, Morstad T, Waite D. Alveolar ridge maintenance with hydroxylapatite ceramic cones in
humans. J Oral Maxillofac Surg 1986;44:503–508.
46. Filler SJ, Kentros GA. Hydroxylapatite cone implants for alveolar ridge preservation—One year follow-up
[abstract 1140]. J Dent Res 1987;66(special issue):249.
47. Brook IM, Sattayasanskul W, Lamb DJ. Dense hydroxyapatite root replica implantation: Tooth site and success
rate. Br Dent J 1988;164:212–215.
48. Sattayasanskul W, Brook IM, Lamb DJ. Dense hydroxya-patite root replica implantation: Measurement of
mandibular ridge preservation. Int J Oral Maxillofac Implants 1988;3:203–207.

References 19