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Home All issues Volume 31 / No 4 (2025) J Oral Med Oral Surg, 31 4 (2025) 30 Full HTML
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J Oral Med Oral Surg
Volume 31, Number 4, 2025
Article Number 30
Number of page(s) 8
DOI https://doi.org/10.1051/mbcb/2025026
Published online 24 October 2025

© The authors, 2025

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

The use of bone-filling materials (BFMs) in dentistry has a wide range of indications, both in everyday practice and for practitioners specialized in oral surgery. Tooth extraction, and subsequent alveolar preservation, remains one of the most common procedures performed by dentists. The indication for alveolar filling depends on the morphology of the bone defect, the anatomy of the surrounding tissues and the prosthetic treatment plan [1]. It is possible to avoid alveolar preservation if a sufficiently esthetic result and primary implant stability can be achieved. The risk is linked to the presence of a peri-apical granuloma that could compromise implant placement or volume stabilization. It is still debated whether post-extraction filling promotes healing or whether the presence of a simple blood clot is sufficient [2,3]. A large number of studies have already been carried out, based on the use of biomaterials and bone loss criteria in the vertical and horizontal dimensions [4]. In the majority of cases, the use of a graft can reduce bone loss, which is inherent in tooth extraction [5]. According to systematic reviews and meta-analyses, autologous grafting remains the gold standard, while xenograft and allograft materials can also lead to good results of alveolar preservation [4,6].

More generally, the use of biomaterials to fill bony defects in the oral cavity has always been a subject of debate. The complexity arises from two main factors: the wide variety of possible clinical situations and the large number of biomaterials available. Establishing a comprehensive official classification is challenging, as it must consider both mineral bone substitutes [7] and other biomaterials used to guide tissues healing, such as collagen sponges and platelet derivatives [8]. As regularly proven and reiterated in the literature, autologous graft is considered as the gold standard for bone graft [9]. It contains the patient's own cells that will optimize bone healing with no risk of autoimmune rejection [10]. Moreover, the graft cannot be the source of infectious disease, which is a major advantage in terms of safety. One of the drawbacks of autologous grafts is its limited volume available, making it not suitable for some large defects reconstruction [10].

From a theoretical point of view, the ideal biomaterial for bone reconstruction must be osteogenic but, unfortunately, none of the existing materials can be considered as osteogenic. All are at least osteoconductive, some of them may be osteoinductive [11]. Osteoconduction implicates that the biomaterial represents a scaffold on which cells can adhere and proliferate [12,13]. Osteoinduction implies that the material can promote cell differentiation and activity on graft site [13]. Bone substitutes allow colonization by bone and blood cells thanks to their porosity, their surface texture and their composition [14]. They can be from natural or synthetic origin and available as blocks, granules or powders [15].

Some biomaterials are also used to fill oral bone defects in clinical practice, such as collagen matrices and platelet concentrates, even if their osteoconductive properties have not been established: they are not bone substitutes per se, as defined by the Société Française de Recherche en Chirurgie Orthopédique et Traumatologique (SoFROT) as a “biomaterial of human, animal, vegetable or synthetic origin, intended for implantation in humans, with a view to reconstructing bone stock, whether to reinforce a bone structure, fill a loss of substance of traumatic or orthopedic origin, or consolidate a fracture or its equivalent” [16].

In view of the variety of biomaterials available, and the clinical situations that may require their use, it is worth asking which of them are currently used in clinical practice. The objective of this practice-based study was to evaluate the clinical habits of French dentists regarding the use of bone-filling materials.

Methods

Study design

This study was designed as a cross-sectional study, in which data have been collected through a questionnaire based on the daily practice of French dental surgeons. Its progress in time and its report comply with the recommendations of the CROSS checklist [17].

Data collection methods

A three-sections survey has been created on Google Forms website (Google, CA, USA) with a total of 12 questions (Supplementary file 1). It was written in French since it was intended for distribution to French dental surgeons via their main social network, Facebook (Meta, CA, USA).

The first section included 6 questions, both multiple-response and open-response. It focused on dentists' practice status (general practitioners or specialists).

The second section dealt with habits in bone regeneration in daily dental practice (5 questions). All the bone filling biomaterials available for oral surgery in France at the time of the survey were presented in this section, including also collagen sponges and platelet concentrates. These materials were presented with their composition and not with commercial names.

The final section of the survey aimed to understand the reasons to choose a biomaterial for a surgery of bone grafting.

Sample characteristics

Our survey was addressed to French dentists, whether or not they performed surgical procedures in daily practice. At the end of the first section, those who indicated not carrying surgeries were transferred directly to the third section. Dental students were excluded.

Survey diffusion

The questionnaire was distributed to French dentists' professional Facebook groups. Overall, the survey was distributed to 11 groups, with an estimated potential visibility of over 15,000 members, excluding duplicates. The questionnaire was proposed every 15 days over a 3-month period between October 2021 − December 2021. In the study description, the participants were asked not to fill the survey several times.

Ethical considerations

This study complies with regulatory requirements concerning security and confidentiality parameters. In accordance with French government decree #2017-884 published in May 2017, the “evaluation of healthcare professional practice or teaching practices” did not fall within the scope of the “Jardé law” for studies involving the human person and requiring the opinion of a Committee for the Protection of Individuals. Participation to this study was voluntary and anonymous. As a result, consent was included in the participation of dental surgeons. No information was collected that could be used to identify the dental surgeon who responded. All data have been saved on a unique computer with no possibility of being used for advertising purposes or sold to third parties.

Statistical analysis

Answers were collected on a spreadsheet (Excel 2016, Microsoft, WA, USA) and sorted according to whether they represented already-defined categorical variables (from the multiple-choice questions) or variables to be categorized in the free-response fields. The comparisons between the practitioners' specialties were made using a Fisher test at a significance level of 5%.

Results

Respondents' characteristics

After three months, 201 dental practitioners had answered the questionnaire with a majority of men (n = 127; 63.18%). The experience of participants appeared homogeneous even if, one third of the respondents had less than 5 yr of practice. More of than 70% of the participants (n = 144; 71.64%) were general practitioners, one declared an exclusive practice of pediatric dentistry (0.5%), and two were orthodontists (1%). The respondents' characteristics are detailed in Table I. Ten participants (4.98%) had never performed oral surgery (Fig. 1).

Table I

Main characteristics of the participants.

thumbnail Fig. 1

Flow chart of the study with the question path proposed to respondents.

Descriptive results and main findings

The use of bone-filling biomaterials (BFMs) varied among study participants. 25.27% (n = 47) never used this type of materials, 18.82% (n = 35) used them rarely, 32.8% (n = 61) sometimes, 23.12% (n = 43) often and 2.69% (n = 5) declared they used BFMs systematically. The analysis showed no difference (p = 0,061) in practice patterns depending on whether or not practitioners reported a specialty in their mode of practice.

The responses revealed 8 surgical indications to use BFMss (Fig. 2). Some of these indications, such as guided bone regeneration, correspond to procedures for which the use of biomaterials is the main objective of the procedure, while others, such as endodontic surgery, need biomaterials as a complement to surgical procedures. It was not possible to assess what was the most performed surgery in daily practice since participants could check several categories, with no distinction of frequency.

Alveolar preservation following tooth extraction (n = 72) and dental implant procedures (n = 71) were the most frequent interventions including BFMs. Regarding implantology, 43 dentists (60.56%) described the use of BFMs for pre-operative treatments and 56 (78.87%) at the time of implant placement. Guided bone regeneration was described by 46 participants (24.73%) but some may have also considered it as pre-implant surgery. Thirty-five participants (18.82%) had described the use of bone-filling material for sinus lifts, 18 (9.68%) for periodontal surgeries, 5 (2.69%) for cyst reseaction (others than apical), 4 (2.15%) for apposition surgeries and 5 (2.69%) for endodontic/apical procedures.

The analysis of the use of bone-filling biomaterials showed that those of natural origin are most widely used by the respondents (Fig. 3). Xenografts were cited in most of the cases (55.37% ; n = 103), whereas autologous grafts in less than half of responses (n = 78; 41.94%). Interestingly, collagen sponges were retrieved in 94 surveys (50.54%). Platelet derivates were used by 64 practitioners (34.41%), alone (n = 43; 23.12%) or associated with a bone substitute (n = 21; 11.29%).

When focusing on surgical procedures, it appeared that natural grafts (from human origin or not) and collagen sponges were preferred for alveolar preservation, implantology, sinus lifts and periodontal surgeries (Fig. 4). The use of synthetic calcium phosphate ceramics was also described in implantology and for guided bone regeneration. All these descriptive data are available in Supplementary file 2.

Over two-thirds of the French dentists included in this study charged a fee for bone-filling material placement (n = 130; 70.07%). A small proportion (n = 15; 11.54%) only charged the patient for the biomaterial purchase. Among all the dentists who use bone-filling materials, three (1.61%) described the “global act” principle, i.e. they included the price of the BFMs in in the patient's treatment plan. Two others (1.08%) described they adapted the price to the difficulty and duration of the surgery.

Finally, with regard to the decision-making criteria that influence the choice of the material, practitioners responded that they preferred using a product they already knew. Also, the amount of literature available could be a reason of choice (n = 143; 76.87%). Interestingly, BFMs could also be promoted by colleagues (n = 62; 33.33%). Cases presented at training courses and conferences accounted for 46.26% of decision criteria (n = 86) and materials promoted via social networks for 6.12% (n = 11). The origin of the biomaterial was also an important factor in choice for 87 respondents (46.77%).

thumbnail Fig. 2

Schematic representation on a panoramic x-ray of the different surgical procedures for which bone-filling materials can be used by French dentists.
thumbnail Fig. 3

Summary of the use of bone-filling materials by the participants. The more frequently a biomaterial is used, the larger its corresponding surface area. Proportions indicate the number of participants who had highlighted the use of the BFMs; their aggregate exceeds 100% since several answers were possible per person. Areas in light grey represent BFMs of natural origin (animal-derived when dotted), and those in dark grey those of synthetic origin.
thumbnail Fig. 4

Frequency of use for the main bone-filling materials depending on the surgical procedure. Hybrid ceramics associated with polymers, bioglass, calcium sulfates and calcium carbonates have been removed, due to their low use, to improve clarity.

Discussion

This practice-based survey provided an overview of dental surgeons' habits on the use of bone-filling materials in French dental practices. The majority of respondents were general practitioners who performed some oral surgery procedures, mainly alveolar preservation. The use of a BFM seemed to be often driven by the latest scientific findings. Autologous grafting, gold standard in terms of bone filling, was used by less than half of the participants. Synthetic substitutes were less used than those of natural origin. The limited use of autologous transplants may be explained by the need of advanced skills in oral surgery to fully master the different surgical steps. In addition, the associated morbidity could be another reason to limit autologous grafts. [18].

We also observed that there was no specific indication for each biomaterial. This reflects the highly discordant international literature on these topics. For example, in 2015, Sculean et al. had performed a systematic review and concluded that for the treatment of periodontal bone defects, natural grafts, synthetic bone substitutes, or combined materials could be used [19]. In 2021, Liu et al. showed that the addition of PRF (Platelet-Rich Fibrin) to the material resulted in a reduction in pocket depth and improved clinical attachment compared with guided tissue regeneration using bovine porous bone mineral [20]. International literature is rich of hundreds of clinical studies comparing two or more BFMs in oral surgery, and the summaries to be drawn from them are complex. The aim of our questionnaire was not to determine which materials were suitable for each clinical situation but to understand the clinical habits of French dentists. To our knowledge, no prior studies exist for direct comparison with our findings.

Certain limitations in the methodology of our questionnaire may be discussed. The choice of a digital distribution of the survey aimed to reach dentists in all regions of France, including the French overseas departments and territories. Another limitation is the choose of social networks for diffusion of the questionnaire. The majority of the questions were multiple-choice questions with several proposed answers, although these may influence the participant's choice of response [21]. The evaluation of the frequency of biomaterials use and a 5-points Likert scale, ranging from “Never” to “Systematically” with the possibility of indicating an incertitude by scoring the central value [22]. During the analysis, we have chosen to consider the absence of a response as a “Never”, unless the participant indicated in full a trade name corresponding to a line that had not previously been selected.

However, there were also open questions that are more difficult to analyze. The entire questionnaire had to be concise enough to reduce drop-out [21].

The representativeness of the population of dental surgeons who responded to the questionnaire is also limited. Women were less likely to respond to our survey, and distribution via social networks probably excluded many older practitioners who were less connected [23]. It would be interesting to conduct similar studies internationally to obtain a more global view of the use of these biomaterials. In general, there is a need to conduct more studies in ambulatory primary care structures because the majority of research protocols still occur in academic institutions and may miss “real life” practice [24]. The creation of practice-based research networks (PBRN) may generate results from both patients and clinicians, by comparing interventions among participants and representative settings of everyday care [25]. In 2020, 24 Dental-PBRN were identified around the world [26]. It might be interesting to use an international network to widen the distribution of our questionnaire. Above all, this would increase the number of responses to the survey. The last three articles published on PubMed regarding questionnaires sent to French dentists reported 676 [27], 225 [28] and 230 [29] responses. While the total of 201 participants in our case may appear limited, it must be considered in the context of social network distribution and the profile of the respondents. Brun et al. have recently highlighted that the diffusion of surveys through social networks could create a selection bias by reaching only the dentists who are using these tools [28]. While the participants may have a particular interest in the study, this does not invalidate the findings: instead, the results reflect the perspectives of engaged practitioners who may be more aware of the topic.

Conclusion

This study provided an overview of the clinical habits of French dental surgeons for the use of bone-filling materials. Although autologous grafts are recognized as the gold standard, natural-origin materials, particularly xenografts, are most commonly used in practice. This preference may be explained by their ease of use, availability, and success in common procedures like alveolar preservation for implantology. One key finding is the variability in the use of BFMs, with practitioners selecting different materials based on the type of procedure and their familiarity with the products. Given the rapid evolution of biomaterials available on the market, it would also make sense to repeat this questionnaire at regular intervals and future research should further explore the reasons behind these preferences and investigate long-term outcomes associated with different BFMs, in order to establish more global recommendations for their use in oral surgery.

Funding

This work was supported by Toulouse Tech Transfert through “Prematuration” funding.

Conflicts of interest

The authors declare no conflicts of interest in regards to this article.

Data availability statement

Data of this article are available upon reasonable request addressed to the corresponding author.

Author contribution statement

TC and JS: Conceptualization and Methodology, MB and JP: Investigation, Writing original draft. TC: Supervision. JS: Reviewing and Editing.

Supplementary Material

Supplementary file 1. The three steps of the survey.

Supplementary file 2. Type of biomaterials used in oral surgery depending on the type of surgery.

Access here

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Cite this article as: Bareilles M, Perrussel J, Soulie J, Canceill T. 2025. Bone-filling materials of natural origin are the most widely used by French dentists: a practice-based study. J Oral Med Oral Surg. 31: 30. https://doi.org/10.1051/mbcb/2025026

All Tables

Table I

Main characteristics of the participants.

In the text

All Figures

thumbnail Fig. 1

Flow chart of the study with the question path proposed to respondents.
In the text
thumbnail Fig. 2

Schematic representation on a panoramic x-ray of the different surgical procedures for which bone-filling materials can be used by French dentists.
In the text
thumbnail Fig. 3

Summary of the use of bone-filling materials by the participants. The more frequently a biomaterial is used, the larger its corresponding surface area. Proportions indicate the number of participants who had highlighted the use of the BFMs; their aggregate exceeds 100% since several answers were possible per person. Areas in light grey represent BFMs of natural origin (animal-derived when dotted), and those in dark grey those of synthetic origin.
In the text
thumbnail Fig. 4

Frequency of use for the main bone-filling materials depending on the surgical procedure. Hybrid ceramics associated with polymers, bioglass, calcium sulfates and calcium carbonates have been removed, due to their low use, to improve clarity.
In the text

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