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Localized Lateral Alveolar Ridge Augmentation with Block Bone Grafts: Simultaneous Versus Delayed Implant Placement: A Clinical and Radiographic Retrospective Study

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  • Instituto Murciano de Investigaciones Biomedicas

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Purpose: To retrospectively evaluate the 1-year outcome of implant therapy involving localized lateral alveolar ridge augmentation with block bone grafts, and to compare outcomes of implants inserted simultaneously with grafting or after a healing period. Materials and methods: Consecutively treated patients undergoing alveolar ridge augmentation with autogenous intraoral block grafts before or simultaneous with implant placement between 2005 and 2010 in the Oral Surgery Unit of the University of Valencia were included. The selection of procedure (simultaneous vs delayed implant placement, donor site) was based upon the criterion of the surgeon and thorough evaluation of each patient. All grafts were obtained with piezosurgery. Complications related to augmentation, implant survival, implant success, and peri-implant marginal bone loss were assessed. Results: Forty-two patients were included; 45 sites were augmented and 71 implants were inserted (33 delayed and 38 simultaneously). Complications (temporary paresthesia, wound dehiscence with bone graft exposure, and exposure of osteosynthesis screw) occurred after bone harvesting in nine patients; four were in the simultaneous group and five were in the delayed group. Six grafts were not successful; four were lost and two provided insufficient bone (after resorption) for ideal implant placement. The implant survival rate was 98.5% (100% for simultaneous and 96.9% for delayed implants) and the implant success rate was 92.9% (89.5% for simultaneous and 96.9% for delayed implants). Average marginal bone loss 1 year after loading was significantly higher for simultaneously placed implants (0.69 ± 0.67 mm) than for delayed implants (0.20 ± 0.50 mm). Conclusions: In lateral bone atrophy, block bone grafts provided sufficient bone for implant therapy, with few complications. Both simultaneous and delayed implant placement yielded high implant survival and success rates. Average marginal bone loss was significantly higher around simultaneously inserted implants.
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846 Volume 28, Number 3, 2013
Localized lateral ridge augmentation is performed
frequently with autogenous block bone grafts
from intraoral donor sites to increase the height and/
or width of the alveolar process before or concomitant
with implant placement. The main criteria to consider
when choosing the grafting procedure are the residual
bone volume needed to allow correct implant position-
ing and angulation and the bone density needed to
achieve primary implant stability.1 Recently published
systematic reviews of implants placed in laterally aug-
mented sites show high rates of implant and prosthe-
sis survival.2,3 According to a recent review of Aghaloo
and M oy,4 implant survival may be a function of residual
bone, rather than grafted bone, supporting the implant.
The purpose of the present retrospective study was to
evaluate the 1-year outcome of implant therapy involv-
ing localized lateral alveolar ridge augmentation with
autogenous block bone grafts, and to compare clinical
outcomes following simultaneous and delayed implant
1 Associate Professor of Oral Surgery, Master of Oral Surger y
and Implantology, Valencia University Medical and Dental
School, Valencia, Spain.
2 Master of Or al Surger y and Implantology, Valencia University
Medical and Dental School, Valencia, Spain.
3 Student of Master of Oral Surgery and Implantology, Valencia
University Medical and Dental School, Valencia, Spain.
4 Professor of Oral Surgery, Director of the Master of Oral
Surgery and Implantology Program, Valencia University
Medical and Dental School, Valencia, Spain.
Correspondence to: Dr Miguel Peñarrocha-Diago, Clínicas
Odontológicas, Gascó Oliag 1, 46021 Valencia, Spain.
Fax: +34-96-3864139. Email: miguel.penarrocha@uv.es
©2013 by Quintessence Publishing Co Inc.
Localized Lateral Alveolar Ridge Augmentation
with Block Bone Grafts: Simultaneous Versus
Delayed Implant Placement: A Clinical and
Radiographic Retrospective Study
Maria Peñarrocha-Diago, DDS, MD, PhD1/Amparo Aloy-Prósper, DDS2/
David Peñarrocha-Oltra, DDS, MD, PhD2/Jose Luis Calvo Guirado3/
Miguel Peñarrocha-Diago, MD, PhD4
Purpose: To retrospectively evaluate the 1-year outcome of implant therapy involving localized lateral alveolar
ridge augmentation with block bone grafts, and to compare outcomes of implants inser ted simultaneously
with grafting or after a healing period. Materials and Methods: Consecutively treated patients undergoing
alveolar ridge augmentation with autogenous intraoral block grafts before or simultaneous with implant
placement between 2005 and 2010 in the Oral Surgery Unit of the Universit y of Valencia were included.
The selection of procedure (simultaneous vs delayed implant placement, donor site) was based upon the
criterion of the surgeon and thorough evaluation of each patient. All grafts were obtained with piezosurgery.
Complications related to augmentation, implant survival, implant success, and peri-implant marginal bone loss
were assessed. Results: Forty-two patients were included; 45 sites were augmented and 71 implants were
inserted (33 delayed and 38 simultaneously). Complications (temporary paresthesia, wound dehiscence with
bone graft exposure, and exposure of osteosynthesis screw) occurred after bone har vesting in nine patients;
four were in the simultaneous group and ve were in the delayed group. Six grafts were not successful;
four were lost and two provided insufcient bone (after resorption) for ideal implant placement. The implant
survival rate was 98.5% (100% for simultaneous and 96.9% for delayed implants) and the implant success
rate was 92.9% (89.5% for simultaneous and 96.9% for delayed implants). Average marginal bone loss 1 year
after loading was signicantly higher for simultaneously placed implants (0.69 ± 0.67 mm) than for delayed
implants (0.20 ± 0.50 mm). Conclusions: In lateral bone atrophy, block bone grafts provided sufcient bone
for implant therapy, with few complications. Both simultaneous and delayed implant placement yielded high
implant survival and success rates. Average marginal bone loss was signicantly higher around simultaneously
inserted implants. Int J Ora l MaxIllOfac IMpl ants 2013;28:846–853. doi: 10.11607/jomi.2964
Key words: alveolar ridge augmentation, bone graf ting, dental implants
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Peñarrocha-Diago et al
The International Journal of Oral & Maxillofacial Implants 847
placement. Complications related to the augmentation
procedure were assessed, along with graft success, im-
plant survival, implant success, prosthesis survival, and
radiographic peri-implant marginal bone loss.
MATERIALS AND METHODS
The present study is reported in accordance with the
STROBE statement.5
Patients
Consecutively treated patients who underwent local-
ized lateral alveolar ridge augmentation with autog-
enous intraoral block bone grafting before or at the
time of implant placement between 2005 and 2010 in
the Oral Surgery Unit of the University of Valencia were
included in the study. All surgical procedures were per-
formed by the same surgeon, who had extensive clini-
cal experience in regenerative procedures. Patients
were fully informed about the surgical procedures and
treatment alternatives, and signed informed consent
was provided. Preoperative analysis included a com-
plete medical history and clinical and radiographic
examination. Patients were included if they were par-
tially or completely edentulous with severe atrophy
of the alveolar ridge (Cawood and Howell Class IV, ie,
knife-edge ridge with adequate height but inadequate
width of 4 mm or less). The selection of the performed
procedure (grafting simultaneous with or prior to im-
plant placement, choice of donor site) was based upon
intraoperative evaluation of each case. The width of
the bone ridge was assessed, and if the implants could
be expected to achieve primary implant stability with
adequate positions and angulations (bone ridge width
between 3 and 4 mm), they were inserted at the time
of bone grafting. If the alveolar ridge was narrower
than 3 mm, primary implant stability was considered
dicult or impossible to achieve, and implants were
placed in a subsequent procedure. A delayed implant
placement approach was also used in cases of high es-
thetic risk (anterior maxilla).
Bone grafting was not performed if a patient had
systemic or local conditions to contraindicate it (eg,
previous chemotherapy, previous irradiation of the
head and neck region, progressive periodontitis, im-
munosuppression, human immunodeciency virus in-
fection), had poor oral hygiene, or was pregnant. Oral
hygiene was assessed in the rst appointment and
classied into good, average, or poor. Cases of vertical
alveolar ridge augmentation or those with incomplete
protocol information were excluded from the study.
No more than 10 days before bone grafting, oral hy-
giene instructions and professional debridement were
delivered to all patients.
Surgical Procedures
Bone Graft Harvesting. All regions were augmented
with autogenous block bone grafts harvested from in-
traoral sites: the lateral aspect of the mandibular ramus,
the retromolar area, the mandibular symphysis, the site
adjacent to the defect, or the maxillary tuberosity. All
grafts were obtained using the ultrasonic Piezon Mas-
ter Surgery System (EMS Electromedical Systems).
When the lateral ramus was used as the donor site,
an incision was made from the anterior part of the ra-
mus and continued into the alveolar sulcus of the man-
dibular second and rst molars. The lateral part of the
ramus was exposed, and a mainly cortical bone graft
was harvested from the lateral cortex of the ramus, as
described by Misch.6 The technique to obtain bone
from the retromolar area was similar to that used for
the lateral ramus, but the distal releasing incision was
shorter, and bone was obtained from the region corre-
sponding to the third molar. Bone from the mandibu-
lar symphysis was harvested through an incision from
canine to canine, about 5 mm below the mucogingival
line. The anterior part of the mandible was exposed
and a monocorticocancellous bone block was harvest-
ed, with a margin of 5 mm from the teeth apices, the
basal border of the mandible, and the mental foramina
maintained for safety. Blocks from the maxillary tuber-
osity were harvested by performing a crestal incision
that began at the tuberosity and continued into the
alveolar sulcus of the maxillary second or rst molar.
Lateral Augmentation. The surgical procedures for
lateral augmentation performed before or at the time
of implant placement are illustrated in Figs 1 and 2,
respectively.
The surgery was performed under local anesthesia
(4% articaine, 1:100,000 adrenalin; Inibsa) and intrave-
nous conscious sedation with 1% propofol solution.
An incision was initially made slightly palatal/lingual to
the alveolar crest. One or two releasing incisions were
made at adjacent teeth, and a mucoperiosteal ap was
raised. The exposed alveolar bone was curetted to re-
move all soft tissues.
The cortical bone at the recipient site was perforat-
ed at multiple sites with a thin cylindric bur to increase
bleeding. The bone block was adjusted to the bone con-
tour at the recipient site and xed with one or two os-
teosynthesis screws (Osteoplac, Donostia) to immobilize
the graft. Moreover, the block grafts were always covered
with a thin layer of particulate autogenous bone that was
obtained from the donor site with a scraper and mixed
with beta-tricalcium phosphate (Kera-Os, Keramat). The
augmented site was further protected with a textured
collagen membrane (Lyostypt, B Braun, Aesculap). Peri-
osteal incisions were made to allow ap mobilization and
tension-free primary wound closure. Flaps were closed
with horizontal sutures (Polisoft4/0, Sweden & Martina).
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Peñarrocha-Diago et al
848 Volume 28, Number 3, 2013
Implant Placement. TSA Avantblast surface im-
plants (Phibo Dental Solutions) were placed using a
standard procedure according to the guidelines of
the manufacturers. Implants were placed simultane-
ously with the block bone graft or after an average
healing period of 6.8 months (range, 5 to 8 months).
All implants in both groups were placed with adequate
primary stability (≥ 35 Ncm). According to a two-stage
protocol, cover screws were placed, and aps were
closed with Polisoft4/0 sutures (Sweden & Martina).
All patients received postoperative antibiotic treat-
ment: amoxicillin 500 mg/125 mg clavulanic acid three
times for 1 week after block bone grafting, and amoxi-
cillin 500 mg three times daily for 1 week after delayed
implant placement with particulate bone grafting.
Ibuprofen (600 mg, three times daily) was prescribed
to all patients to be taken as required. Patients were
instructed to rinse with 0.2% chlorhexidine digluco-
nate three times daily for 2 weeks after bone grafting
and implant placement surgeries. Patients were not
allowed to use removable prostheses for 3 weeks af-
ter bone grafting. A soft diet was recommended for
1 week, and patients were advised to avoid brushing
and trauma on the surgical sites. Sutures were re-
moved 2 weeks postoperatively. Stage-two surgeries
were performed 2 months after implant placement,
and the denitive removable or xed prostheses were
placed 1 month later.
Fig 1a Preoperative frontal view. Fig 1b Bone defect visualized after ap
elevation.
Fig 1c A block bone graft was harvested
from the retromolar region; simultaneous
surgical extraction of the mandibular left
third molar had been perfor med.
Fig 1d Fixation of the block bone graft
with osteosynthesis screws.
Fig 1e Delayed implant inser tion in the
maxillar y right central incisor position.
Fig 1f Healed sof t tissues 3 months af-
ter implant insertion.
Fig 1g The denitive prosthesis was placed 4 months after im-
plant inser tion.
Fig 1h Intraoral radiograph
taken at prosthesis place-
ment.
Fig 1i Twelve-month control
intraoral radiograph.
Figs 1a to 1i A bone graf t is harvested from the retromolar region and implants are placed af ter healing.
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Peñarrocha-Diago et al
The International Journal of Oral & Maxillofacial Implants 849
Follow-up Protocol and Outcome Measures
All patients were included in a maintenance program
involving annual examinations. The following out-
come measures were recorded:
Complications related to the augmentation proce-
dure: sensory disturbances (paresthesia, hypoesthe-
sia); wound dehiscence with bone graft exposure or
exposure of the osteosynthesis screw without graft
exposure; infection; graft loss.
Graft success: The graft was considered successful
when there was no infection or graft loss and suf-
cient bone volume was obtained to allow implant
placement.
Implant survival: Implant failure was dened as
implant mobility or removal of stable implants be-
cause of progressive peri-implant marginal bone
loss or infection.
Implant success: Implant success was based on the
clinical and radiographic criteria of Buser et al7:
(1) absence of clinically detectable implant mobil-
ity, (2) absence of pain or any subjective sensation,
(3) absence of recurrent peri-implant infection, and
(4) absence of ongoing radiolucency around the im-
plant after 6 and 12 months of prosthetic loading.
Prosthesis survival: Failure was dened as a prosthe-
sis that could not be placed or had to be removed
because of implant failure.
Fig 2a Preoperative occlusal view of the atrophic posterior mandible.
Fig 2b Lateral atrophy of the graft has led to buccal dehiscences of the implants
in the mandibular lef t rst and second molar positions.
Fig 2c A block bone graft is harvested from the area distal to the implants.
Fig 2d Fixation of the block graft with an osteosynthesis screw.
Fig 2g Intraoral radiograph at implant
loading.
Fig 2e Healed soft tissues at the
3-month follow-up.
Fig 2f Prosthesis placement 4
months af ter implant inser tion.
Figs 2a to 2g Implant inser tion in the mandibular posterior region and simultaneous block bone graf t harve sted from adjacent area.
a b c
d
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Peñarrocha-Diago et al
850 Volume 28, Number 3, 2013
Radiographic peri-implant marginal bone loss: In-
traoral radiographs were made at prosthetic load-
ing (baseline) and at the 1-year control visit using
the XMIND intraoral system (Groupe Satelec-Pierre
Rolland) and an RVG intraoral digital receptor (Dürr
Dental) with the aid of Rinn XCP (Dentsply Rinn) to
achieve parallelism. If the bone level around the
study implants was not clearly visible, a new radio-
graph was made. The distance from the implant-
abutment connection to the peri-implant marginal
bone level was measured to the nearest 0.5 mm
mesially and distally. Bone loss was calculated by
comparing the change in bone level between the
baseline and the 1-year control radiographs.
Statistical Analysis
The Fisher exact test was used to evaluate dierences
between the groups with respect to success, survival,
and complications with implants, bone grafts, and pa-
tients. To determine whether the donor site inuenced
the outcome of the graft, the statistical relationship
between donor site and graft success was analyzed.
Because of the limited sample size, the chi-squared
test could not be used, so the Fisher exact test was
used to separately compare proportions of graft suc-
cess/failure between each donor site location and
the other locations. The necessity of particulate bone
graft to cover dehiscences or fenestrations at delayed
implant insertion was considered a variable related
to block bone graft resorption. In this case, maxil-
lary donor sites (tuberosity and adjacent sites) and
mandibular donor sites (chin, mandibular ramus, and
retromolar areas) were grouped together, and the sta-
tistical relationship of this variable with the donor site
location (maxillary or mandibular) was studied using
the chi-squared test. The Mann-Whitney test was used
to compare bone loss between groups. The statistical
power for this test was 80.8% to detect an eect of 0.7
with a condence interval of 95% and alpha set at .05.
Statistical analyses were completed using SPSS 15.0
software (IBM).
RESULTS
Sixty-six patients were treated with oral implants and
block bone grafts. Twenty-one patients were excluded
because the bone grafts were used to augment both
the width and height of the alveolar bone and three
were excluded for incomplete protocols.
The nal study sample included 42 patients (28
women, 14 men) with a mean age of 48 ± 17.1 years
(range, 21 to 82). Oral hygiene was good in 29 patients
and average in 13 patients. Twenty-four patients were
nonsmokers, 12 smoked up to 10 cigarettes per day,
and 6 smoked between 11 and 20 cigarettes per day.
A total of 45 regions were augmented and 71 im-
plants were inserted (33 delayed and 38 simultane-
ously). All regions were augmented with autogenous
block bone grafts harvested from intraoral regions:
the lateral aspect of the mandibular ramus (10 regions,
22.2%), the retromolar area (10 regions, 22.2%), the
mandibular symphysis (4 regions, 8.9%), a site adjacent
to the defect (15 regions, 33.3%), and the maxillary tu-
berosity (6 regions, 13.3%) (Table 1).
Complications Related to Augmentation
Complications at the recipient site occurred in nine
patients (four in the simultaneous implantation group
and ve in the delayed implantation group). Dierenc-
es in the proportion of complications between both
groups were statistically insignicant (P = .561). Com-
plications were more frequent in men (75.0%) than in
women (25.0%), and this dierence was statistically
signicant (P = .013). No relevant dierences were de-
tected with respect to age, hygiene, or smoking habits.
No postoperative complications at donor sites were
registered.
In patients who received implants simultane-
ously with bone grafts, complications were wound
dehiscence with graft exposure (three patients) and
exposure of the osteosynthesis screw without graft
exposure (one patient). Patients with exposed grafts
were told to rinse with chlorhexidine 0.2% three times/
day for 3 to 4 weeks; one site re-epithelialized, and two
grafts were lost.
In the delayed implant placement group, tempo-
rary hypoesthesia of the chin occurred in one patient
after the graft procedure; the block bone graft had
been obtained from the mandibular symphysis. Vita-
min B complex (30 mg/day for 2 months) was adminis-
tered, and the symptoms had completely disappeared
Table 1 Description of Patients, Implants, and
Bone Grafting Procedures
Time of implant placement
Tot alSimultaneous Delayed
No. of patient s 20 22 42
No. of augmented sites 20 25 45
No. of implant s 38 33 71
Donor site
Chin 2 2 4
Mandibular ramus 6 4 10
Retromolar area 7 3 10
Adjacent site 411 15
Maxillary tuberosity 1 5 6
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Peñarrocha-Diago et al
The International Journal of Oral & Maxillofacial Implants 851
after 2 months. Wound dehiscence with bone graft
exposure occurred in four patients with ve grafted
sites; after treatment with chlorhexidine, three sites re-
epithelialized with no further problems and two grafts
were lost.
Graft Success
Six bone grafts (13.3%) were not successful; four grafts
were lost and two did not create sucient bone for
ideal implant placement. The failed blocks were unsta-
ble upon retrieval. In three cases the screws were still
xed, and in one case the screws were also unstable.
Resorbed blocks were stable.
In the patients with simultaneous implant place-
ment, two grafts were lost, but neither of these bone
graft failures involved failure of the implants. In the de-
layed implantation group, two grafts were lost in one
patient, and two patients needed a new block bone
graft prior to implant placement because the bone
volume obtained was not sucient for ideal implant
placement; wound dehiscence had occurred in all four
grafts during the postoperative period.
No signicant relationships were found between
donor site location and graft success (Table 2). Despite
the successful outcome of the rest of the block bone
grafts, particulate bone graft was used on the buccal
for 22 of the 33 delayed implants during the insertion
procedure to cover dehiscences and fenestrations and
ensure a satisfactory result. More cases of maxillary
than mandibular donor sites needed particulate bone
graft at delayed implant placement; the dierence be-
tween the maxilla and the mandible was statistically
signicant (Table 3; P = .032).
According to the dened criteria, the graft success
rate was 86.7% (84.0% in the delayed group and 90.0%
in the simultaneous group); this dierence was not sta-
tistically signicant (P = .251).
Additional Outcomes
One implant failed in the delayed placement group
(before loading) and none failed in the simultaneous
placement group. However, 1 year after loading, ve
implants in two patients in the simultaneous implan-
tation group showed severe marginal bone loss (3 to
7 mm); these implants remained in situ until the end
of the follow-up period but were not considered suc-
cessful according to the criteria of Buser et al.7 The dif-
ferences in implant success and survival rates between
groups were not statistically signicant (P = .465 and
P = .135, respectively). Average marginal bone loss af-
ter 1 year of loading was 0.69 ± 0.67 mm for simultane-
ously inserted implants in those patients in whom the
bone graft was successful, and average bone loss was
0.20 ± 0.50 mm for patients with successful grafts who
received delayed implants; this dierence was statis-
tically signicant (P < .001). All prostheses could be
placed and none had to be removed, yielding a 100%
prosthetic success rate. No signicant dierences were
found in implant success and survival rates or average
marginal bone loss with respect to demographic fac-
tors (age, sex) or habits (smoking, hygiene).
DISCUSSION
This study was designed to retrospectively evaluate
after 1 year of follow-up whether implants placed si-
multaneously with intraoral bone grafts achieved
outcomes equivalent to those of implants placed af-
ter consolidation of the bone graft. The results of this
study suggest that both procedures yield high implant
survival rates, although simultaneously placed im-
plants had a slightly lower success rate than delayed
implants. Both techniques achieved the planned treat-
ment outcome, but the placement of implants simul-
taneously with block bone grafts did so more quickly.
Implant insertion simultaneous with block grafting
oers the advantages of shortened treatment time and
a reduction in the required number of surgical inter-
ventions. The most important issues to be addressed
are primary stability and optimal positioning of the im-
plants; if insucient bone remains to provide primary
stability and proper implant positioning, delayed im-
plant placement is typically the appropriate treatment.1
Table 2 Statistical Analysis of the Relationship
Between Donor Site Location and Graft Success
Donor site Success Failure P*
Chin 2 2 .080
Mandibular ramus 10 0.312
Adjacent site 14 1.647
Maxillary tuberosity 2 1 .356
Retromolar area 11 2.999
*Fisher exa ct test.
Table 3 Statistical Analysis of the Relationship
Between Donor Site Location (Maxilla/
Mandible) and the Need for Particulate Bone
Grafting at Delayed Implant Placement
Donor site
Particulate grafting needed?
P Yes No
Maxilla 13 3.032
Mandible 710
*Chi-squared test.
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Peñarrocha-Diago et al
852 Volume 28, Number 3, 2013
When a block bone graft is performed, resorption
always occurs. Although both intraoral maxillary and
mandibular bone have an intramembranous origin,
the dierent anatomies of these regions result in dif-
ferent graft morphologies and properties. Mandibular
bone grafts (ie, ramus and chin), which are primarily
corticocancellous or more cortical bone, exhibit little
volume loss and show good incorporation after short
healing times.8 In contrast, the quality of bone in the
posterior maxilla, especially in the maxillary tuberos-
ity region, consists mainly of a thin cortical layer and a
mixture of marrow spaces, adipose tissue, and a small
amount of vital osteogenic cells.9 To prevent bone re-
sorption during the healing period, the use of mem-
branes has been advocated.10,11 In the present study,
particulate alloplastic graft material and collagen
membranes were used to protect the grafts. Accord-
ing to the results of this study, more than half of the
delayed implants that needed particulate bone graft
to cover peri-implant defects at implant insertion had
been placed in sites previously regenerated with max-
illary bone grafts, and this dierence was statistically
signicant. In addition, two patients required a second
block bone graft prior to implant placement because
the bone gain obtained was not sucient for ideal
implant placement; in these cases grafts had been
obtained from the maxillary tuberosity or a maxillary
adjacent site to the bone defect. The present study did
not include a control group that did not receive syn-
thetic particulate bone in addition to the block graft,
so this study provides insucient evidence on the ef-
fectiveness of this technique to prevent resorption.
Complications at the recipient site are often caused
by problems with soft tissues, such as insucient
wound closure, ap necrosis, and dehiscence with ex-
posure of the bone graft. To minimize the risk of de-
hiscence, it is necessary to achieve tension-free wound
closure.12 The treatment of prematurely exposed bone
is complicated, since resuturing the ap may lead to
increased exposure of the graft. Von Arx and Buser10
recommended the application of chlorhexidine solu-
tion or gel several times a day to reduce the bacterial
load; if re-epithelialization does not occur, the exposed
bone is often removed with rotary instruments.13 In
the present study, eight dehiscences were found;
ve re-epithelialized without problems after applica-
tion of chlorhexidine (0.2% three times/day for 3 to 4
weeks) and three bone grafts were lost. In two cases,
the augmentation procedure was a failure because
the bone volume obtained was not sucient to allow
the planned implant therapy and a new block graft
was necessary; this was probably associated with the
wound dehiscence with membrane and graft exposure
that had occurred in both cases. Sharaf et al14 conclud-
ed that the evidence suggests that a single preopera-
tive dose of antibiotics or a single preoperative dose
and a short-term postoperative antibiotic regimen
might reduce early implant failure and that clinicians
should minimize the ubiquitous use of antibiotics in
healthy patients with a low risk of postoperative infec-
tion. However, the clinician’s own judgment of each
patient is essential in tailoring antibiotic use to prevent
implant infection and failure. In this study, 2 g amoxi-
cillin and 125 mg clavulanic acid were administered
preoperatively, and all patients received postoperative
antibiotic treatment with 500 mg amoxicillin/125 mg
clavulanic acid three times daily for 1 week.
The most common complication at graft donor
sites according to the literature is temporary mental
paresthesia, especially when the graft comes from the
chin or mandibular ramus.15–17 The use of piezoelectric
techniques minimizes the risk of complications associ-
ated with block bone graft harvesting.18 In the pres-
ent study, all grafts were obtained using piezosurgery;
despite this, one patient experienced hypoesthesia of
the alveolar inferior nerve, which had disappeared by
6 months.
Several studies report high survival and success
rates for implants placed in block bone grafts.1,19–28
However, few studies have compared the survival
rate of implants (whether placed simultaneously
or delayed) with respect to the block bone grafting
procedure.27,28 McCarthy et al28 inserted 36 implants
(33 delayed and 3 simultaneous), and one simultane-
ous implant failed, yielding an overall survival rate of
97.1%. Lekholm et al29 stated that more implants were
lost when they were inserted simultaneously (23%)
than when they were placed in a subsequent proce-
dure (10%). In the present study, a higher survival
rate was obtained for implants inserted simultane-
ously (100%) than for those placed after graft healing
(96.9%). However, marginal bone loss was signicantly
greater for implants inserted simultaneously and, ac-
cording to the criteria dened by Buser et al,7 the
success rate for simultaneously placed implants was
lower (89.5%) than that achieved for delayed implants
(96.9%).
Nevertheless, trials with larger sample sizes and lon-
ger follow-up periods are needed to conrm or reject
these ndings. On the other hand, all procedures were
performed by the same oral surgeon, who had exten-
sive clinical experience in regenerative procedures,
which might limit extrapolation of the results.
CONCLUSIONS
In lateral bone atrophy, intraoral block bone grafts ob-
tained with piezosurgery were successful in providing
sucient bone for implant therapy and were associated
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Peñarrocha-Diago et al
The International Journal of Oral & Maxillofacial Implants 853
with few complications. Both simultaneous and de-
layed implant insertion protocols yielded high implant
survival and success rates, but average marginal bone
loss was signicantly higher around simultaneously in-
serted implants.
ACKNOWLEDGMENT
The authors reported no conicts of interest related to this study.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
... The question of the appropriate surgical procedure when conducting regeneration and implantation simultaneously remains controversial, especially when block grafts are used. Some advocates have found that single-stage regeneration and implant placement concurrently does not jeopardize the treatment result (Glauser et al., 2001), while others have demonstrated better stability and success rates using a two-stage procedure (Fraguas et al., 2013), and many researchers state there is no difference in success rates between the two methods (Heinemann et al., 2015;Peñarrocha-Diago, Aloy-Prósper, Peñarrocha-Oltra, Guirado, & Peñarrocha-Diago, 2013;Ribeiro et al., 2018). A single-stage surgery involving placement of the bone substitute and implant at the same time has the benefit of a single surgical procedure for the patient. ...
... A single-stage surgery involving placement of the bone substitute and implant at the same time has the benefit of a single surgical procedure for the patient. In addition, the implant placement helps secure the bone graft to the surrounding bone, maintains space needed for regeneration, and yields high implant success rates (Peñarrocha-Diago et al., 2013). ...
... In this method, primary fixation is achieved by fixing the graft to the surrounding bone using the implant. It is still debated whether the quality of bone and healing is the same using this method (Peñarrocha-Diago et al., 2013;Tosun et al., 2018). ...
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Chapter
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Chapter
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To execute an evidence-based review answering the following question: "Among patients receiving dental implants, do those who receive perioperative antibiotic therapy, compared with those who do not, have a decreased likelihood of implant failure?" We performed a literature review. The primary predictor variable was an antibiotic regimen, which was grouped into 3 categories: a single preoperative dose, a single preoperative dose and multiday postoperative therapy, and no antibiotic therapy. The primary and secondary outcome variables were implant failure and postoperative infection, respectively. Eight studies meeting the inclusion criteria were reviewed. Two studies assessed the effect of a single preoperative antibiotic dose and reported a reduction in implant failure by 1.3% to 2% compared with no antibiotics use. Two studies compared the effect of pre- and postoperative antibiotics and no antibiotic use and found a 4.2% decrease to 1.1% increase in the failure rates when antibiotics were used. Four studies considered the effect of different antibiotic regimens. Only 2 studies found a statistically significant reduction in implant failure (2.5% to 5.4%) when a single preoperative antibiotic dose was used in conjunction with multiday treatment, compared with postoperative multiday treatment only. Four studies analyzed the rate of postoperative infection, which was 0.6% to 3% when no antibiotics were used, 0.6% when preoperative antibiotics alone were used, and 0.8% to 1% when preoperative and postoperative antibiotics were given. A single dose of preoperative antibiotic therapy may slightly decrease the failure rate of dental implants. However, the current data do not support the routine use of postoperative antibiotics, which can be tailored by the clinician to the patient's specific needs.
Article
To evaluate whether 7-mm-long implants could be an alternative to longer implants placed in vertically augmented posterior mandibles. Sixty patients with posterior mandibular edentulism with 7-8 mm bone height above the mandibular canal were randomized to either vertical augmentation with anorganic bovine bone blocks and delayed 5-month placement of ≥10 mm implants or to receive 7-mm-long implants. Four months after implant placement, provisional prostheses were delivered, replaced after 4 months, by definitive prostheses. The outcome measures were prosthesis and implant failures, any complications and peri-implant marginal bone levels. All patients were followed to 1 year after loading. One patient dropped out from the short implant group. In two augmented mandibles, there was not sufficient bone to place 10-mm-long implants possibly because the blocks had broken apart during insertion. One prosthesis could not be placed when planned in the 7 mm group vs. three prostheses in the augmented group, because of early failure of one implant in each patient. Four complications (wound dehiscence) occurred during graft healing in the augmented group vs. none in the 7 mm group. No complications occurred after implant placement. These differences were not statistically significant. One year after loading, patients of both groups lost an average of 1 mm of peri-implant bone. There no statistically significant differences in bone loss between groups. When residual bone height over the mandibular canal is between 7 and 8 mm, 7 mm short implants might be a preferable choice than vertical augmentation, reducing the chair time, expenses and morbidity. These 1-year preliminary results need to be confirmed by follow-up of at least 5 years.
Article
To assess whether augmentation in the proximity of the incisive foramen with an intraoral bone graft to allow for reliable placement of implants is achievable, not jeopardizing the nasopalatine nerve and vessels in a way causing patients' distress. Five patients who had lost a central maxillary incisor due to trauma, and in whom a deficiency of bone at the palatal side was present in the proximity of the incisal canal, were augmented with autogenous cancellous bone harvested from the retromolar region. After a healing period of 3 months, implants were inserted. Patients' acceptance, complications, and postoperative morbidity of the procedure were prospectively evaluated by standardized clinical and radiographic examinations up to 12 months after augmentation. At the time of implant surgery, in all cases there was sufficient bone for insertion of the implants with adequate primary stability. Up to now (follow-up of 12-15 months) no fixtures have been lost and all peri-implant tissues have a healthy appearance. All patients were satisfied. Augmentation in the proximity of the incisive foramen to enable implant placement appears to be feasible, both from the perspective of the patient and the professional.
Article
The aim of this study was to evaluate the 1-year success rate and marginal bone loss for dental implants placed simultaneously with bone grafts. The study sample comprised 37 patients treated with dental implants placed simultaneous with intraoral block bone grafts. The block grafts were harvested from the chin, retromolar area, or maxillary tuberosity. Complications with the bone grafts were categorized as minor or major and, for the graft success rate, the Barone and Covani criteria were used. The definition of implant success was based on the clinical and radiographic criteria of Albrektsson et al. Peri-implant bone loss was measured after 1 year of prosthetic loading. The study involved 39 bone grafts (17 maxillary and 22 mandibular) and 129 implants (73 implants in grafted areas) in 37 patients. No complications were observed at the donor sites. A part of the onlay bone graft was exposed in eight sites; six sites showed spontaneous reepithelialization following chlorhexidine application, but two grafts became infected and had to be removed. Three implants were lost in the grafted areas; the success rate for implants with simultaneous bone grafting was therefore 95.9%. No complications were found at 12 months after prosthesis placement. The mean overall bone loss after 1 year of loading was 0.64 mm. In patients meeting the inclusion criteria, simultaneous placement of bone grafts and implants shortens treatment time without increasing complications or reducing the success rate.
Article
Hard tissue defects resulting from trauma, infection, or tooth loss often lead to an unfavorable anatomy of maxillary and mandibular alveolar processes that become not suitable for implant therapy without bone grafting. The goal of pre-implant bone augmentation of the deficient alveolar ridge is reconstruction of the proper alveolar anatomy through the techniques of socket preservation, horizontal and vertical ridge augmentation, sinus bone grafting, and others. A variety of bone grafts and bone grafting materials have been used in the last 30 years for augmentation of deficient alveolar ridge for the purpose of implant treatment of partially and completely edentulous patients. Bone grafting options include autogenous, allogeneic, xenogeneic, synthetic bone, and combination of above. Autogenous bone grafts are considered "the gold standard" due to their compatibility and osteogenic potentials to form the new bone by processes of osteogenesis, osteoinduction, and osteoconduction. A particulate and block autogenous bone has been used for correction of alveolar ridge deficiency. Extraoral sites of autogenous block grafts include: ilium, calvarium, tibia, rib, and others. Intraoral sites of autogenous block grafts include symphysis and retromolar-ramus areas. In the clinical practice, a maxillary tuberosity bone graft has often been used as a particulate graft for augmentation of deficient alveolar ridge or maxillary sinus prior to or simultaneously with implant insertion. This article presents an innovative technique and reports a case of the maxillary tuberosity block bone graft that can be used to correct moderate to severe localized defects of the alveolar process prior to implant placement.
Article
Epidermolysis bullosa (EB) represents a group of mainly hereditary skin disorders, manifested by an exceptional tendency of the skin and mucosa to form bullae and vesicles after minor friction and trauma. Oral features include repeated blistering, scar formation, elimination of buccal and vestibular sulci, and alveolar bone resorption. The use of endosseous implants in the fixed prosthetic rehabilitation of patients with recessive dystrophic EB might provide a considerably better outcome than conventional removable prosthetic methods. This clinical report describes the fixed rehabilitation with 2 implants placed simultaneously with bone graft in a partially edentulous patient diagnosed with recessive dystrophic EB. The implants, with simultaneous bone graft, were placed to decrease the number of surgical operations required, avoiding soft tissue ulcerations and discomfort in the patient. This treatment option appears to be favorable for recessive dystrophic EB patients compared with other options involving removable prostheses, which irritate the oral mucosa.