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Bone Grafts For Implant Dentistry: The Basics

36 oralhealth DECEMBER 2015
Fay Goldstep, DDS, FACD, FADFE
The implant restoration is an essential everyday
treatment to replace missing teeth, advance
function and enhance esthetics for patients in
the general dental practice. An understand-
ing of implant hardware design and place-
ment for optimum clinical results is common
knowledge for the dental practitioner. This
is not the case when it comes to the understanding of bone
grafting needs and procedures that are the foundations for
implant treatment.
This article will address the basic principles for bone grafts
in implant dentistry: the rationale, indications, locations,
requirements, types, materials, and some guiding consensus
on surgical techniques and materials. This will help clari-
fy a somewhat murky new area for the general practitioner
who needs to know more
– whether it is to provide
guidance to patients, or to
increase understanding of
the surgical protocols of
implant treatment.
The Rationale for Bone
Placement of implants re-
quires sufficient bone volume
and biologic quality. This is due to the macro design of the
implant, which demands certain dimensional properties for
long-term success.1
Other factors which make bone grafting necessary are:
Bone Grafts
For Implant
The Basics
Outline of topics
p 36-56 Goldstep R2.indd 36 15-11-24 12:07 PM 37
The resorption of the edentu-
lous ridge post extraction
Presence of bony defects due to
trauma or infection
The need to place implants in
strategic sites for functional
and esthetic success. In esthetic
areas, soft tissue requires a bony
base since “soft tissue follows
hard tissue”1
Treatment planning for bone
graft placement requires the se-
lection of an appropriate surgical
technique and graft material. Poor
planning or execution may lead to
resorption of the graft material or
its failure to integrate. In addition,
the lost tissue may be replaced by
fibrous tissue rather than functional
Grafts are suitable for a variety of
clinical situations.
Locations/Indications for
Bone Grafts in Implant
Bone graft materials are placed
in different locations for various
In alveolar sockets post
To refill a local bony defect due to trauma or infection
To refill a peri-implant defect due to peri-implantitis
• For vertical augmentation of the mandible and maxilla
For horizontal augmentation of the mandible and maxilla
Following the extraction of a tooth, 40 to 60 percent of the
original height and width of the surrounding alveolar bone is
expected to be lost; the greatest loss is in the first two years3
(Fig. 1).
With this loss of hard and soft tissue, conditions are less
favourable for the proper axial alignment of the implant for
function and esthetics. To minimize alveolar atrophy post
extraction, healing procedures termed “socket preservation” or
“ridge preservation” have been developed. These procedures
involve filling the socket with bone or bone substitute
material, with or without a membrane. The objectives of ridge
preservations are.4
Filling the socket (wound care)
Preservation of ridge volume (ridge preservation)
New bone formation (osteogenesis)
Ridge preservation procedures seem to delay bone forma-
tion in the early healing phases5; however, studies show that
procedures are effective with significantly lower ridge atrophy
reported than in non-treated groups.6
There is always some bone loss after extraction, since the
alveolar bundle bone into which the collagen fibres of the
periodontium are anchored, is dependent on the presence of
a tooth; this bone is always absorbed following tooth loss.7
The prime objective of ridge preservation is to diminish or
completely eliminate the necessity of more invasive aug-
mentation procedures in the future.
Techniques are available to effectively and predictably
increase the width of the alveolar ridge (horizontal augmenta-
tion). Vertical augmentation techniques are not as predictable
as those for horizontal augmentation and are subject to more
Bone grafts are more likely to succeed when the conditions
at the recipient site are favourable and certain requirements are
Bone graft classification by material source
p 36-56 Goldstep R2.indd 37 15-11-24 12:08 PM
38 oralhealth DECEMBER 2015
Following extraction, bone loss can be up
to 60 percent of the original height and
width of the alveolar ridge.
Poor esthetics can result from implant
placement without consideration of
post-extraction changes. Courtesy of Dr.
M. Leventis, Athens University, Greece.
Placement of an autogenous bone block
taken from the chin area. Courtesy of Dr.
M. Leventis, Athens University, Greece.
1A. 1B. 2.
Requirements for the Ideal Bone Graft
Bone healing and new bone formation after grafting occur
through osterogenesis, osteoinduction and osteoconduction:3
Osteogenic graft materials supply actual viable osteoblasts
Osteoinductive materials stimulate primitive mesenchy-
mal cells brought in via the blood supply from adjacent
bone or periosteum to differentiate into osteoblasts
Osteoconductive materials merely act as a lattice or
framework for cell growth, allowing osteoblasts from the
wound margin to infiltrate the defect and to migrate across
the graft. This brings a population of osteoblasts into the
graft site
For the bone graft to be successful:2
1. Osteoblasts must be present at the site
2. Blood supply must be sufficient for nourishment
3. The graft must be stabilized during healing
4. The soft tissue must not be under tension
Bone is in a constant process of renewal with formation and
resorption. During the first year of life almost 100 percent of
the skeleton is replaced, while in adulthood the rate is closer
to 10 percent per year.9 Remodeling enables bone to adapt
functionally to changes in loading.
Osteoblasts – Only osteoblasts create new bone. For a graft
to be successful, the graft matrix must contain or encourage
population by osteoblasts. If there is an insufficient number of
osteoblasts the graft will fail.2
Blood supply – Bone grafting is regeneration not repair. The
term “repair” implies the regaining of lost tissue; regeneration
is a biologic process where not only is the tissue regained, but
also its form and function. This requires a good blood supply
to the graft and surrounding tissue. Blood is needed for cell
viability and clot formation. The clot serves as the initial
matrix where cells migrate and then serves as anchorage for
the osteoblasts.2
Graft stabilization – Mechanical stresses on the graft
during healing can lead to disruption of the fibrin clot. Move-
ment will cause fibrous tissue to fill the defect instead of bone.
This is a form of repair and is not true regeneration. Fixation
devices like GBR (guided bone regeneration) collagen mem-
branes, titanium mesh and bone screws may be used.2
No tension on the soft tissue – Bone is the slowest growing
tissue. Guided bone regeneration is based on the separation
of the grafted site from the surrounding soft tissue. The GBR
membrane keeps the faster growing tissues like epithelium,
fibrous tissue or gingival connective tissue out of the defect
allowing controlled regeneration to occur with vital bone for-
mation.2 The application of bone graft material into the defect
prevents the collapse of the collagen membrane and it acts as a
place holder for new regenerating bone and an osteoconductive
scaffold for the in growth of blood vessels and osteoblasts.10
There are different types of bone grafts available, typically
classified by the source of the material used.
Bone Graft Classification by Material Source
The autogenous graft (where tissue is transferred from one
location to another in the same individual) is considered to be
the gold standard. It is osteogenic, osteoinductive and osteo-
conductive.3 There is biological activity due to vital cells and
growth factors. There is also no risk of disease transmission.
However there is an increased risk of pain, infection, donor
site morbidity, complexity in the surgical procedure, and a
limited supply of bone3 (Fig. 2).
Bone substitute materials (BSM) were developed to coun-
teract the difficulties of autogenous grafts. They can either
replace autogenous bone entirely or expand the autogenous
graft. Materials need to be effective for procedures both before
insertion of the implants (time-delayed procedures) and for
on page 40
p 36-56 Goldstep R2.indd 38 15-11-24 12:10 PM
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40 oralhealth DECEMBER 2015
from page 38
optimization of the recipient site at the time of implant place-
ment (simultaneous procedures).1
Grafts are classified as:11
Autograft (autogenous graft):
Tissue transferred from one location to another within the
same individual
A graft between genetically dissimilar members of the same
species i.e. human tissue
A graft taken from a donor of another species i.e. bovine,
porcine etc
Periapical radiograph showing pathology
associated with central and lateral
incisors (#11 & #12).
CBCT 3D reconstruction showing
pathology in the same case.
Elevation of flap, extraction of teeth,
curettage of granulation tissue and
maintenance of remaining alveolar bone.
3A. 3B. 3C.
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Inorganic, synthetic or inert foreign material implanted into
The autograft is the patient’s own bone. It is chiefly har-
vested intraorally or from the iliac crest. It is the ideal bone
substitute since in contains living cells and human growth
factors. It has greater osteogenic potential than any other bone
substitute as well as inherent biocompatibility.12
The allograft can be derived from cadavers or living donors
(tissue harvested from hip replacement surgery). It has natural
bone composition and structure. This tissue is osteoinductive
as well as osteoconductive but lacks osteogenic properties
Placement of particulate xenograft (MIS
4BONE™ XBM) to fill bone defect with par-
tial denture in-situ to retain the material.
Tension free suturing with 4-0 black silk
Labial view at two weeks.
3D. 3E. 3F.
p 36-56 Goldstep R2.indd 41 15-11-24 12:24 PM
42 oralhealth DECEMBER 2015
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because of the absence of viable cells.12
A controversy exists as to the association of allogenic ma-
terial and the risk of transmission of infections such as HIV,
hepatitis B and C, prions, malignancies, systemic disorders or
toxins. Aggressive allograft processing gives it a less intense
immunologic response, but reduces the osteoinductive proper-
ties. Frozen allografts induce stronger immune responses than
freeze dried allografts, hence they are no longer used.12
The donor tissue is cleaned and then undergoes ultrasonics
to remove blood and tissue components and to eliminate fat
Incisal view at two weeks showing
presence of xenograft granules.
Incisal view at five weeks with partial
epithelialization of the extraction sockets.
One month radiograph of grafted sites
at #11 & #12 .
3G. 3H.
p 36-56 Goldstep R2.indd 42 15-11-25 1:49 PM 43
from the cancellous bone structure; this improves penetration
of the surrounding tissues into the graft material.
Then chemical treatment denatures non-collagenic proteins,
inactivates viruses and destroys bacteria. Further oxidative
treatment denatures persisting soluble proteins and eliminates
potential antigenicity. Dehydration preserves the structural in-
tegrity of the material. Final sterilization by gamma radiation
ensures sterility.
Allografts are available in different shapes from demin-
eralized bone matrix granules to complete bone segments.
Labial view at three months with excellent
soft tissue health.
Incisal view at three months with complete
epithelialization and remaining non-
absorbed particulate xenograft.
Labial view at five months.
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44 oralhealth DECEMBER 2015
Incisal view at five months.
Final periapical radiograph with implants
in place. The above case is courtesy
Dr. Ifran Ahmad, The Ridgeway Dental
Surgery, UK and MIS implants.
Labial view of implant positioning/direc-
tion indicators.
Preoperative panorex. Extraction of two
maxillary central incisors required.
Incisal view of implants with sculpted
surrounding gingiva.
After extraction implants are placed in the
proper esthetic position.
Bovine xenograft particulate material
(MIS 4BONE™ XBM) placed with a
polylactide membrane.
Resorbable collagen membrane is used to
cover the graft.
Healing abutments are used for additional
space maintenance.
Panorex after implant placement.
Polylactide membrane acts as a wall.
Resorption is 1.5 years.
Panorex with final crowns in place six
months after implant and graft surgery.
The above case is courtesy of Dr Henriette Lerner, Associate Professor University Iasi, HL-DENTCLINIC &
ACADEMY, Baden-Baden, Germany and MIS Implants. on page 46
p 36-56 Goldstep R2.indd 44 15-11-24 12:38 PM
46 oralhealth DECEMBER 2015
Granules can be used in socket preservation for future implant
placement, ridge reconstruction for prosthetic therapy, filling
osseous defects and maxillary sinus floor elevation.
Allograft bone segment blocks are a predictable and
effective alternative to traditional autogenous block grafting
and ridge augmentation.13 When very large areas need to be
grafted, a shell of autogenous bone is often used as a biologic
container; this creates the necessary space for the incorpora-
tion of the particulated bone graft material. The bone cells
in the autogenous bone die within a few days and then the
boneplate functions as a stable, avital, slowly resorbable mem-
brane.14 Allogenic bone blocks can also be used for this shell
technique as a substitute for autogenous bone. This avoids the
time consuming harvesting and splitting of the autogenous
bone blocks.
The space between the local bone and surrounding shell can
be filled with a variety of different particulated bone grafting
materials (autogenous, allogenic, xenogenic or alloplastic).
Histologic studies have shown no difference in the final
stage of incorporation between allografts and autografts.15
The xenograft is derived from other organisms, mainly
bovine. It provides long-term volume stability. Porous natural
hydroxyapatite can be obtained from animal bones.
Bovine bone has a long well-documented tradition. It is
deproteinized by heating to eliminate the risk of allergic reac-
tions and disease transmission.16 The removal of all proteins
transforms it into biologically derived hydroxyapatite ceramic.
It is characterized by well-preserved 3D natural bone struc-
ture similar to human bone. The trabecular architecture with
interconnecting pores allows for optimal in-growth of new
vascularity.12 Guided osseous integration rather than rapid
resorption leads to excellent volume stability of the graft with
the formation of new bone on the highly structured bovine
bone surface. The bovine bone xenograft is osteoconductive
and is available in a range of volumes and particle sizes
(Figs. 3 & 4).
Another option is the use of bovine collagen. Untreated
collagen (which acts as a scaffold) and heat-denatured collagen
(which stimulates growth) are mixed, freeze-dried and cross-
linked by heat. The material is then processed into a sponge
block and formed into a bullet shape for easy placement into
the extraction socket. Clinical studies show stimulation of
new bone at an accelerated pace17 (Figs. 5,6 & 7).
The alloplast is synthetically produced so there is no risk of
disease transmission. The most common alloplastic materials
are calcium phosphate based ceramics such as hydroxyapatite
(HA) and tricalcium phosphate (TCP) (Figs. 8 & 9). Cal-
cium phosphates are BIOACTIVE and RESORBABLE.
They support attachment and proliferation of bone cells and
undergo natural remodeling. There is an initial integration
of the material into the surrounding bone matrix and then a
from page 44
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gradual degradation. HA is incompletely resorbed while TCP
is completely resorbed.
HA is the inorganic base bone substance that makes up two
thirds of bone. HA ceramics are chemically nearly identical to
natural HA.12
TCP is a calcium phosphate ceramic that is used as a syn-
thetic scaffold substance in dentistry and orthopedics. Both
TCP and HA have blood biocompatibility and osteoconduc-
tivity without immunogenic or toxic effects. However, they
possess no osteogenic or osteoinductive properties and demon-
strate minimal immediate structural support.12
HA and TCP differ in the biologic response created at the
host site. TCP is removed from the implant site as bone grows
into the scaffold; HA is more permanent.
HA’s slow solubility provides long term volume stability.
It is also an excellent carrier of osteoinductive growth factors
and osteogenic cell populations, adding to its value as a bioac-
tive delivery vehicle.12
An ideal bone regeneration material should be resorbed in
pace with new bone formation. The basic principle of using
HA and TCP in combination is a balance between the stable
HA which can be found years after implantation, and the fast
resorbing TCP. The ratio between the two affects the resorp-
tive properties of the graft material. A ratio between 65:35
and 55:45 of HA to TCP has been proven particularly suitable
in many studies.18
The HA portion remains integrated in the newly formed
bone, while the TCP part of the product is resorbed; it is
replaced by new bone which imbeds itself within the remain-
ing HA component creating a stable scaffold.4 Products with
TCP alone are completely resorbed and replaced by bone
within five to 15 months.4
Bioactive glass is another alloplastic bone substitute
Clinical protocol for insertion of Foundation, a collagen-based
bovine xenograft (J MORITA).
For the monography,
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p 36-56 Goldstep R2.indd 47 15-11-24 3:40 PM
48 oralhealth DECEMBER 2015
material. It is used extensively in orthopedics and dentistry. It
is more reactive than inert materials like HA or TCP. Intrin-
sic properties of bioactive glass give it the ability to promote
natural bone regeneration by releasing mineral ions.19 After
reacting with blood it binds with bone and progressively re-
leases silica ions. This stimulates osteoblast differentiation and
proliferation.20, 21 Over time, it is fully absorbed and replaced
by bone. When mixed with autogenous bone graft material, it
doubles natural bone regeneration.22
Different types of bone substitute materials can be com-
bined and even hybridized to accommodate the needs of the
clinical situation. Adjustment of material composition and
physical characteristics allows for a wide range of resorption
rates as well as physical forms such as powders, granules,
pastes, blocks and even custom manufactured grafts. The
selection of products allows the clinician to obtain optimal
clinical outcomes.
Scientific foundations for bone grafting lead to practical
clinical considerations. These are discussed below.
Consensus on Surgical Techniques and Materials
The survival rates of implants placed into grafted areas
are comparable with survival rates of implants placed into
pristine bone.1
Bone quality at the recipient site determines the type of
graft material to be used. Cortical bone is inferior to can-
cellous bone at the recipient bed. Cells within cancellous
bone are responsible for at least 60 percent of the patient’s
bone healing capacity. The periosteum in a young, healthy
patient contributes an additional 30 percent. Cells in the
cortical bone are responsible for only 10 percent of bone
healing. After extraction, when bone resorbs, cancellous
bone shrinks relative to cortical bone. As the cancellous
compartment decreases, the reservoir for osteoblasts does
as well. Computerized tomography can reveal the ratio of
cancellous bone to cortical at the recipient site prior to sur-
gery. This ratio helps in the selection of the graft material
as follows:
Only cortical bone–autograft
Cortico-cancellous–depends on predominant type
Mostly cancellous–everything is possible2
Ridge preservation techniques are effective in limiting hor-
izontal and vertical bone loss post extraction versus healing
by blood clot alone.29
Four weeks post extraction.
Foundation placed.Pre-extraction periapical radiograph of
tooth # 15 with fractured root.
Eight weeks post extraction.
Post extraction.
Implant placed.
The above case is courtesy of Dr. Arthur Greenspoon, Montreal, Quebec and J MORITA.
on page 51
p 36-56 Goldstep R2.indd 48 15-11-24 1:00 PM 51
Strong evidence shows that ridge preservation significantly
maintains ridge width and height. Most graft materials are
effective with only slight differences between them.29
‘External’ augmentation procedures, both horizontal or
vertical, on the alveolar ridge are more difficult than ‘in-
ternal’ augmentation procedures in areas like the maxillary
Augmentation of vertical alveolar ridge defects exhibit
higher complication rates than those for horizontal
For horizontal and vertical ridge augmentation procedures
autogenous bone blocks result in higher gain than particu-
late materials. Survival rates of implants placed in horizon-
tally and vertically augmented alveolar ridges are high.8
Autogenous onlay bone grafting procedures are effective
and predicable for the correction of severely resorbed
edentulous ridges to allow implant placement. Survival
rates are slightly lower than those of implants placed in
native pristine bone.8
There is a lack of long term information on the longev-
ity of preserved ridges and the survival of the implants
And of course:
Poor blood supply, trauma or extensive surgery in the area
can worsen the prognosis.23
Complications are higher in smokers.24, 25
General diseases affecting bone metabolism like uncon-
trolled diabetes, radiation to head and neck, bisphospho-
nate therapy are at least relative contraindications for bone
augmentation.26, 27
The subject of bone grafts for implant procedures is complex
and confusing for the surgeon, let alone the restorative dentist
and patient. This article has attempted to simplify and clarify
the basics. Armed with this information, the general dentist
can be a better judge of the techniques and materials used.
This information can prepare the clinician for counseling
(SUNSTAR GUIDOR) presents a
homogenous moldable mass, which is applied directly from the
syringe. It is an alloplastIc material, which comes in TCP- only
and TCP-HA combinations.
80-year-old patient with root fracture.
Compaction of the GUIDO
causes blood to
permeate the space between the granules. The material quickly
hardens in contact with blood, forming a scaffold of intercon-
nected granules, to fit the defect morphology. In larger defects,
a second application can be applied immediately after the first.
After root resection. Six months after placement of
7B. 7C.
The above case is courtesy of Dr. Arthur Greenspoon, Montreal, Quebec and J MORITA.
Figures 8A & 8B courtesy of SUNSTAR.
p 36-56 Goldstep R2.indd 51 15-11-24 1:01 PM
52 oralhealth DECEMBER 2015
patients on the surgical procedures to be performed at the
specialist’s office or be the impetus to further exploration of
simple bone grafting procedures that can be done in the
general practice.
Dr. Fay Goldstep has been a featured speaker in the ADA Semi-
nar Series and has lectured at the American Dental Association,
Yankee, American Academy of Cosmetic Dentistry, Academy of
General Dentistry, and the Big Apple Dental conferences. She
has lectured nationally and internationally on Proactive/Mini-
mal Intervention Dentistry, Soft-Tissue Lasers, Electronic Caries
Detection, Healing Dentistry and Innovations in Hygiene. She
has served on the teaching faculties of the postgraduate pro-
grammes in Aesthetic Dentistry at SUNY Buffalo, University of
Florida, University of Minnesota and University of Missouri-Kan-
sas City. She is a Fellow of the American College of Dentists,
International Academy for Dental-Facial Esthetics, American
Society for Dental Aesthetics and the Academy of Dentistry
International. Dentistry Today has listed her as one of the lead-
ers in continuing education since 2002. She sits on the editorial
board of Oral Health. Dr. Goldstep is a consultant to a number of
dental companies and maintains a private practice in Markham,
Ontario. She can be reached at
Oral Health welcomes this original article.
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Placement of GUIDOR
In-situ hardening provides good stabilization.
Implant placed in palatal site to avoid
buccal exposure of screw. The implant was
set 1.5 mm below the crestal bone level.
Missing #12 due to accident (eight weeks
after trauma).
Radiograph after implant and graft
Flap elevation revealed a buccal
fenestration and thin buccal plate.
Flap closure.
p 36-56 Goldstep R2.indd 52 15-11-24 1:02 PM 55
from page 52
M: Surgical protocols for ridge preservation after tooth extraction.
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10. Rothamel et al. (2012). Clinical aspect s of novel types of collagen
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Remainder of references available on our website at
Incisal view seven weeks after reopening
the flap.
9 I: Closed flap around healing cap.
Labial view four months after implant and
graft placement.
Periapical radiograph at two-year
Incisal view after reopening flap (four
months after grafting). Note: good hard
tissue with well integrated visible
granules. Partial removal of hard tissue to
uncover implant screw.
The above case courtesy of Dr. Antonio Flichy, University of Valencia, Spain and SUNSTAR GUIDOR.
p 36-56 Goldstep R2.indd 55 15-11-24 1:04 PM
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Xenogeneic bone procured from the slaughterhouse waste was deproteinated by heat treatment method intended for use as a bone substitute. The effect of heat treatment was investigated by thermal analysis and by physico-chemical methods such as X-ray powder diffraction (XRD) and Fourier transformed infrared (FTIR) spectroscopy. The heat treatment temperatures for the bovine bone samples were predetermined by thermogravimetric (TG) analysis. The XRD results revealed that the process of heat treatment promoted the crystallinity of bone samples, particularly at 700 and 900†C. There was no secondary phase transformation detected for heat- deproteinated bone except the presence of the hydroxyapatite (HA) phase, which indicated its phase purity even at a higher temperature. The FTIR spectra of raw bone and bone heated at 300†C indicated the presence of organic macromolecules whereas these disappeared in the samples heated at 500, 700 and 900†C, which suggested the removal of antigenic organic matters around 500†C. The same results were also confirmed quantitatively by calculating the amount of collagen using hydroxyproline estimation. There was no significant change in the TG-thermogram of bone heated at 500, 700 and 900†C, which indicated their thermal stability. These findings implied that the heat treated bone at 500†C had properties similar to carbonated HA with low crystallinity, while 700 and 900†C samples had the same with higher crystallinity. As low temperature treatment does not alter morphological and structural properties, we propose that the 500†C heat treated xenogeneic bone may act as an excellent osteogenic bone substitute.
Full-text available
Purpose: The objective of this systematic review was to provide a basis for an expert consensus group to evaluate the influence of different particulate bone substitute materials in local bone augmentation procedures in conjunction with dental implant placement on implant survival and histology. Materials and methods: The following indications were analysed with either simultaneous or delayed dental implant placement: external or internal maxillary sinus floor elevation and vertical and/or lateral alveolar ridge augmentation. Retro- and prospective studies written in English or German including 20 or more patients (for randomised, controlled trials and prospective, split-mouth trials with 5 or more patients) were eligible for this review. The review focused on (1) performance of the augmentation procedures (total augmentation loss, gain of vertical and horizontal alveolar ridge dimensions, histomorphometric data of the augmented areas) and (2) dental implant success criteria (survival rates of the inserted dental implants, peri-implant bone levels under functional loading). Results: From over 3800 abstracts identified, 72 full-text articles fulfilled the inclusion criteria and were further evaluated (52 studies on maxillary sinus floor elevation procedures and 21 studies on vertical and/or lateral alveolar ridge augmentation). The majority of the included studies were prospective studies including a rather limited number of patients and short observation periods. Conclusions: There is a high level of evidence that survival rates of dental implants placed into augmented areas are comparable with survival rates of implants placed into pristine bone. For maxillary sinus floor elevation, all investigated bone substitute materials performed equally well compared with bone, with high dental implant survival rates and adequate histomorphometric data. For the alveolar ridge augmentation procedures, the heterogeneity of the available data did not allow identification of a superior grafting technique.
Full-text available
The objective of this review was to evaluate the efficacy of different grafting protocols for the augmentation of localized alveolar ridge defects. A MEDLINE search and an additional hand search of selected journals were performed to identify all levels of clinical evidence except expert opinions. Any publication written in English and including 10 or more patients with at least 12 months of follow-up after loading of the implants was eligible for this review. The results were categorized according to the presenting defect type: (1) dehiscence and fenestration-type defects, (2) horizontal ridge augmentations, (3) vertical ridge augmentations, and (4) maxillary sinus floor elevations using the lateral window technique or transalveolar approach. The review focused on: (1) the outcome of the individual grafting protocols and (2) survival rates of implants placed in the augmented bone. Based on 2,006 abstracts, 424 full-text articles were evaluated, of which 108 were included. Eleven studies were randomized controlled clinical trials. The majority were prospective or retrospective studies including a limited number of patients and short observation periods. The heterogeneity of the available data did not allow identifying one superior grafting protocol for any of the osseous defect types under investigation. However, a series of grafting materials can be considered well-documented for different indications based on this review. There is a high level of evidence (level A to B) to support that survival rates of implants placed in augmented bone are comparable to rates of implants placed in pristine bone.
Full-text available
The aim of this study is to evaluate the efficacy of the application of allogenous bone at the maxillomandibular reconstructions for future rehabilitation with dental implants. The patients were submitted to reconstruction of maxilla, using allogeneic bone grafts, in 3 different techniques: onlay grafts for lateral ridge augmentation, onlay and particulate bone for sinus lift grafting, and particulate alone for sinus lift grafts. Clinical and radiographic control was done at the postoperative phase for at least 8 months, until the patient could be submitted to the installation of dental implants. The results showed success in the majority of the cases, and dental implants could be installed. This can be considered an excellent alternative when compared with the use of autogenous grafts; because handling is easier, there is a great amount of material available and a possibility of using local anesthesia, and consequently there is a reduction of patient morbidity.
An autologous bone graft is still the ideal material for the repair of craniofacial defects, but its availability is limited and harvesting can be associated with complications. Bone replacement materials as an alternative have a long history of success. With increasing technological advances the spectrum of grafting materials has broadened to allografts, xenografts, and synthetic materials, providing material specific advantages. A large number of bone-graft substitutes are available including allograft bone preparations such as demineralized bone matrix and calcium-based materials. More and more replacement materials consist of one or more components: an osteoconductive matrix, which supports the ingrowth of new bone; and osteoinductive proteins, which sustain mitogenesis of undifferentiated cells; and osteogenic cells (osteoblasts or osteoblast precursors), which are capable of forming bone in the proper environment. All substitutes can either replace autologous bone or expand an existing amount of autologous bone graft. Because an understanding of the properties of each material enables individual treatment concepts this review presents an overview of the principles of bone replacement, the types of graft materials available, and considers future perspectives. Bone substitutes are undergoing a change from a simple replacement material to an individually created composite biomaterial with osteoinductive properties to enable enhanced defect bridging.
This systematic review aims to evaluate the scientific evidence on the efficacy in the surgical protocols designed for preserving the alveolar ridge after tooth extraction and to evaluate how these techniques affect the placement of dental implants and the final implant supported restoration. A thorough search in MEDLINE-PubMed, Embase and the Cochrane Central Register of controlled trials (CENTRAL) was conducted up to February 2011. Randomized clinical trials and prospective cohort studies with a follow-up of at least 3 months reporting changes on both the hard and soft tissues (height and/or width) of the alveolar process (mm or %) after tooth extraction were considered for inclusion. The screening of titles and abstracts resulted in 14 publications meeting the eligibility criteria. Data from nine of these 14 studies could be grouped in the meta-analyses. Results from the meta-analyses showed a statistically significant greater ridge reduction in bone height for control groups as compared to test groups (weighted mean differences, WMD = -1.47 mm; 95% CI [-1.982, -0.953]; P < 0.001; heterogeneity: I(2) = 13.1%; χ(2) P-value = 0.314) and a significant greater reduction in bone width for control groups compared to the test groups (WMD = -1.830 mm; 95% CI [-2.947, -0.732]; P = 0.001; heterogeneity: I(2) = 0%; χ(2) P-value = 0.837). Subgroup analysis was based on the surgical protocol used for the socket preservation (flapless/flapped, barrier membrane/no membrane, primary intention healing/no primary healing) and on the measurement method utilized to evaluate morphological changes. Meta-regression analyses demonstrated a statistically significant difference favoring the flapped subgroup in terms of bone width (meta-regression; slope = 2.26; 95% IC [1.01; 3.51]; P = 0.003). The potential benefit of socket preservation therapies was demonstrated resulting in significantly less vertical and horizontal contraction of the alveolar bone crest. The scientific evidence does not provide clear guidelines in regards to the type of biomaterial, or surgical procedure, although a significant positive effect of the flapped surgery was observed. There are no data available to draw conclusions on the consequences of such benefits on the long-term outcomes of implant therapy.
The aim of this experiment was to analyze processes involved in the incorporation of beta-tricalcium phospate (TCP) particles in host tissue during healing following tooth extraction and grafting. Five beagle dogs were used. Four premolars in the maxilla ((3)P(3), (2)P(2)) were hemi-sected, the distal roots were removed and the fresh extraction socket filled with TCP. The tooth extraction and grafting procedures were scheduled in such a way that biopsies representing 1 and 3 days, as well as 1, 2, and 4 weeks of healing could be obtained. Tissue elements such as cells, fibers, vessels, leukocytes and mineralized bone were determined. In deparaffinized sections structures and cells that expressed Tratarate resistant acid phosphate, alkaline phosphatase, and osteopontin were identified by the use of markers. The porosities of the TCP particles were initially filled with erythrocytes that subsequently were replaced with mineralized bone. Some of the graft material was invaded by mesenchymal and inflammatory cells and disintegrated. Thus, small membrane bound granules appeared in the granulation tissue and the provisional matrix. In the process of hard tissue formation, partly mineralized (modified) TCP particles became surrounded by ridges of woven bone. It was demonstrated that the early healing of an extraction socket that had been grafted with beta-TCP involved (i) the formation of a coagulum that was (ii) replaced with granulation tissue and a provisional matrix in which (iii) woven bone could form. In this process the biomaterial was apparently involved.
The consequences of exodontia include alveolar bone resorption and ultimately atrophy to basal bone of the edentulous site/ridges. Ridge resorption proceeds quickly after tooth extraction and significantly reduces the possibility of placing implants without grafting procedures. The aims of this article are to describe the rationale behind alveolar ridge augmentation procedures aimed at preserving or minimizing the edentulous ridge volume loss. Because the goal of these approaches is to preserve bone, exodontia should be performed to preserve as much of the alveolar process as possible. After severance of the supra- and subcrestal fibrous attachment using scalpels and periotomes, elevation of the tooth frequently allows extraction with minimal socket wall damage. Extraction sockets should not be acutely infected and be completely free of any soft tissue fragments before any grafting or augmentation is attempted. Socket bleeding that mixes with the grafting material seems essential for success of this procedure. Various types of bone grafting materials have been suggested for this purpose, and some have shown promising results. Coverage of the grafted extraction site with wound dressing materials, coronal flap advancement, or even barrier membranes may enhance wound stability and an undisturbed healing process. Future controlled clinical trials are necessary to determine the ideal regimen for socket augmentation.