A Histological and Clinical Evaluation of Long-Term Outcomes of Bovine Bone-Derived Xenografts in Oral Surgery: A Systematic Review
Abstract
1. Introduction
2. Materials and Methods
2.1. PICO Question
2.2. Search Processing
2.3. Inclusion Criteria
2.4. Exclusion Criteria
2.5. GRADE Assessment
3. Results
3.1. GRADE Assessment of Evidence
3.2. Risk of Bias Assessment
4. Discussion
4.1. Innovative Techniques: Hydraulic Approach and A-PRF
4.2. Healing Time and Alveolar Ridge Preservation
4.3. Implications for Long-Term Implant Success
4.4. Clinical Utility of the Findings
4.5. Future Research and Clinical Directions
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations
A-PRF | Advanced Platelet-Rich Fibrin |
ARP | Alveolar Ridge Preservation |
BMPs | Bone Morphogenetic Proteins |
BSE | Bovine Spongiform Encephalopathy |
CBCT | Cone Beam Computed Tomography |
DBBM | Deproteinized Bovine Bone Mineral |
DBBM-C | Collagenated Deproteinized Bovine Bone Mineral |
FDBA | Freeze-Dried Bone Allograft |
FGG | Free Gingival Graft |
GBR | Guided Bone Regeneration |
PRF | Platelet-Rich Fibrin |
TGF-β | Transforming Growth Factor Beta |
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Authors and Year | Type of the Study | Materials and Methods | Outcomes |
---|---|---|---|
Huang et al., 2025 [124] | Randomized Clinical Trial | 40 patients with 46 implants randomized into two groups; measurements post-surgery and 12 months post-load; evaluated outcomes via CBCT. | Both groups achieved 100% implant survival, with advanced platelet-rich fibrin (A-PRF) group showing lower infection rate. |
Rodriguez and Nowzari, 2019 [125] | Case Series | 5 patients requiring surgical xenografts removal and reconstruction with autogenous grafts. | Post-treatment complications Resolved only after surgical removal. |
Nowzari, Teoh & Rodriguez, 2022 [126] | Case Series | Bovine-derived xenograft (Bio-Oss) particles used in dental implant surgeries with or without autogenous grafts. | Intact/migrated xenograft particles years after surgery, with complications including chronic inflammation, peri-implant sulcus exposure, and soft-tissue disturbances. |
Mordenfeld et al., 2017 [127] | Randomized Controlled Trial | 20 patients randomized into two groups underwent lateral ridge augmentation using Deproteinized Bovine Bone Mineral (DBBM) mixed with autogenous bone, with bone biopsies collected and analyzed after 9 months. | The study found no significant differences in new bone formation, residual graft material, or connective tissue volume between groups, with the 60:40 group showing slightly less volumetric graft reduction. |
Hashemipoor et al., 2020 [128] | Randomized Controlled Clinical Trial | 25 patients underwent horizontal ridge augmentation using corticocancellous freeze-dried bone allograft, with CBCT and core biopsies for preoperative and 6 months ridge width assessment. | Both groups achieved implant placement, with FDBA + autogenous group showing higher bone width gain and new bone formation, and lower graft resorption, indicating enhanced stability and maturation. |
Schmitt et al., 2012 [129] | Comparative Histological Study | 30 patients underwent bilateral maxillary sinus augmentation with simultaneous implant placement. Four biomaterials were compared: autologous bone, Straumann® BoneCeramic, Bio-Oss®, and Puros®. Bone biopsies were harvested after 6 months for histomorphometric analysis. | Autologous bone showed the highest percentage of newly formed vital bone, while biomaterials like Bio-Oss® and BoneCeramic supported bone formation and implant integration. |
Couso-Queiruga et al., 2023 [130] | Randomized Clinical Trial (RCT) | 42 patients randomly assigned to 3 groups according to healing time after ARP with DBBM-C and collagen matrix sealing: Group A: 3 months Group B: 6 months Group C: 9 months. Evaluation of histomorphometric, clinical, digital imaging, implant-related and PROMs outcomes. | Longer healing time, mineralized tissue, non-mineralized tissue, and residual graft are observed in alveolar ridge reduction, particularly on facial bone. Implant placement is feasible, and patient discomfort and wound healing improve over time. |
Lai et al., 2019 [131] | Randomized controlled clinical trial (RCT) | 44 patients to receive ridge preservation with either Bio-Oss or Zcore cancellous xenograft, with histological and clinical measurements after 18–20 weeks. | The study found no significant difference in new bone formation, residual graft, or connective tissue between bovine and porcine patients, with porcine patients requiring additional grafting. |
Barone et al., 2005 [132] | Randomized controlled clinical trial (RCT) | 18 patients with bilateral maxillary sinus augmentation used a split-mouth design, with bone biopsies taken at 5 months post-implant placement. | A 1:1 mixture of autogenous and porcine bone is as effective as autogenous bone alone for maxillary sinus augmentation in terms of histologic and histomorphometric outcomes. |
Correia et al., 2024 [133] | Randomized Controlled Trial (RCT), split-mouth, 3-year follow-up | 20 patients with bilateral posterior maxillary edentulism underwent sinus lift using autologous bone graft and porcine xenograft, | The study found that xenograft with collagen is a viable alternative to autograft with a 100% implant survival rate, similar marginal bone loss, and no patient preference for one material. |
Hyunjae Kim et al., 2025 [134] | Randomized Controlled Clinical Trial (RCT), single-blind, 3 arm, parallel-group | 54 patients randomized into 3 groups:
|
|
Study | Bias due to Confounding | Selection Bias | Bias in Classification of Interventions | Bias due to Deviations from Intended Interventions | Bias due to Missing Data | Bias in Measurement of Outcomes | Bias in Selection of Reported Results | Overall Risk of Bias |
---|---|---|---|---|---|---|---|---|
Correira et al. (2024) | ||||||||
Barone et al. (2005) | ||||||||
Kim et al. (2025) | ||||||||
Lai et al. (2020) | ||||||||
Couso-Queiruga et al. (2023) | ||||||||
Schmitt et al. (2013) | ||||||||
Hashemipoor et al. (2020) | ||||||||
Mordenfeld et al. (2017) | ||||||||
Nowzari et al. (2022) | ||||||||
Rodriguez et al. (2019) | ||||||||
Huang et al. (2025) |
Domain | Evidence Summary | Clinical Recommendation |
---|---|---|
Implant survival with bovine xenografts | Moderate-quality evidence from RCTs shows high survival, though follow-up periods are often limited. | Bovine xenografts (e.g., Bio-Oss®) can be safely used for short- to mid-term implant survival, but caution is advised for long-term reliance. |
Histological remodeling and graft integration | Low–moderate evidence; biopsies show limited resorption and persistence of particles. | Consider that bovine xenografts provide volume stability but integrate slowly; autogenous or mixed grafts may improve biological remodeling. |
Long-term complications (migration, chronic inflammation, sinusitis) | Low-quality evidence from case series; complications appear underreported. | Inform patients about potential long-term risks; monitor closely and obtain informed consent highlighting the possibility of late complications. |
Comparisons with autografts/porcine grafts | Moderate-quality evidence supports comparable short-term results; porcine grafts show better resorption profile. | Use autografts where feasible (gold standard). Porcine xenografts or platelet concentrates may be preferred alternatives for improved remodeling and safety. |
Risk communication & patient safety | Reports of late removal and chronic inflammation highlight medico-legal and ethical concerns. | Discuss risks transparently with patients; obtain informed consent emphasizing both benefits and limitations of bovine xenografts. |
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Inchingolo, A.M.; Marinelli, G.; Trilli, I.; Del Vecchio, G.; Di Noia, A.; Inchingolo, F.; Del Fabbro, M.; Palermo, A.; Inchingolo, A.D.; Dipalma, G. A Histological and Clinical Evaluation of Long-Term Outcomes of Bovine Bone-Derived Xenografts in Oral Surgery: A Systematic Review. J. Funct. Biomater. 2025, 16, 321. https://doi.org/10.3390/jfb16090321
Inchingolo AM, Marinelli G, Trilli I, Del Vecchio G, Di Noia A, Inchingolo F, Del Fabbro M, Palermo A, Inchingolo AD, Dipalma G. A Histological and Clinical Evaluation of Long-Term Outcomes of Bovine Bone-Derived Xenografts in Oral Surgery: A Systematic Review. Journal of Functional Biomaterials. 2025; 16(9):321. https://doi.org/10.3390/jfb16090321
Chicago/Turabian StyleInchingolo, Angelo Michele, Grazia Marinelli, Irma Trilli, Gaetano Del Vecchio, Angela Di Noia, Francesco Inchingolo, Massimo Del Fabbro, Andrea Palermo, Alessio Danilo Inchingolo, and Gianna Dipalma. 2025. "A Histological and Clinical Evaluation of Long-Term Outcomes of Bovine Bone-Derived Xenografts in Oral Surgery: A Systematic Review" Journal of Functional Biomaterials 16, no. 9: 321. https://doi.org/10.3390/jfb16090321
APA StyleInchingolo, A. M., Marinelli, G., Trilli, I., Del Vecchio, G., Di Noia, A., Inchingolo, F., Del Fabbro, M., Palermo, A., Inchingolo, A. D., & Dipalma, G. (2025). A Histological and Clinical Evaluation of Long-Term Outcomes of Bovine Bone-Derived Xenografts in Oral Surgery: A Systematic Review. Journal of Functional Biomaterials, 16(9), 321. https://doi.org/10.3390/jfb16090321