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Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Clinical, Histological, and Histomorphometric Evaluation
of Demineralized Freeze-Dried Cortical Block Allografts
for Alveolar Ridge Augmentation
Elcin Aslan, DDS, PhD,
Alper Gultekin, DDS, PhD,
Cuneyt Karabuda, DDS, PhD,
Carmen Mortellaro, MD, DDS,
y
Vakur Olgac, DDS, PhD,
z
and Eitan Mijiritsky, DMD
§
Abstract: Autogenous bone-block grafts are the ‘‘gold standard’’
for block bone grafting, but have several disadvantages. Allografts
have the potential to overcome these disadvantages. The purpose of
this study was to evaluate the clinical and histomorphometric
features of demineralized freeze-dried cortical block allografts
(DCBA) used for ridge augmentation. Eleven patients who showed
bone deficiencies of <5 mm in the horizontal plane were included in
this study. The recipient sites were reconstructed with DCBA. The
primary outcomes of interest were bone-width measurements, post-
operative clinical evaluations, and histomorphometric analysis of
the biopsy samples collected during the implant surgery. Clinical
analysis showed that the mean gain in horizontal bone was
1.65 0.14 mm, and that the mean percentage of graft resorption
was 5.39 2.18%. On postoperative day 7, edema, pain, and
bruising were observed in 18.2%, 0%, and 9.1% of the patients,
respectively. In the biopsy samples, the mean percentages of newly
formed bone, residual block allograft, and marrow and connective
tissue were 40.30 24.59%, 40.39 21.36%, and 19.30 15.07%,
respectively. All of the block grafts were successfully integrated
into the recipient sites. DCBA may be a viable alternative for
treating both deficient maxillary and mandibular alveolar ridges.
Key Words: Bone augmentation, clinical evaluation,
demineralized cortical block allograft, histomorphometric analysis
(J Craniofac Surg 2016;27: 1181–1186)
High success rates in implantology are related to the presence of
sufficient alveolar bone volume for osseointegration of dental
implants over time.
1,2
In many patients, augmentation of the
implant sites is necessary because of the loss of bone volume
due to infection, neoplasms, trauma, or long-term edentulism.
3–6
Techniques such as guided bone regeneration, ridge splitting,
sandwich bone, and distraction osteogenesis are used for bone
augmentation before implant surgery.
3–8
Moreover, the block
grafting technique has been used successfully for alveolar bone
augmentation.
7,9
Autogenous bone-block grafts are considered the
‘‘gold standard’’ for block bone grafting.
10,11
The harvesting sites
may be intraoral or extraoral. However, this technique has several
disadvantages, including donor site morbidity, limited bone
quantity, unpredictable bone quality, postoperative pain, increased
blood loss, increased costs, risk of paresthesia, and infection.
11– 13
Mandibular fracture has been reported during ramus and chin block-
harvesting procedures.
14
Such factors may limit the number of
patients eligible for alveolar bone augmentation before implant
surgery, and cause clinicians to search for new materials and
techniques that show less morbidity.
7,8,15,16
Allografts are alternative bone grafts that can be used to over-
come most of these disadvantages. Allografts are used in forms such
as particulate, putty, and block forms. They can also be applied with
growth factors.
16
Recently, block allografts have been used in block
bone grafting. The advantages of allogeneic bone-block grafts
include an unlimited supply, decreased operative trauma and blood
loss, absence of donor site morbidity, and extremely low antigenic
potential.
7,12,17,18
An ideal graft material for ridge augmentation
should work as a scaffold to inhibit resorption, and allow integration
with natural bone at the cellular level.
19
It should also be easy to
graft.
19
The purpose of this study was to evaluate novel, demineralized,
freeze-dried cortical block allografts (DCBA) clinically, histologi-
cally, and histomorphometrically for augmenting insufficient
alveolar bone. To the best of our knowledge, this is the first clinical
study to evaluate DCBA histomorphometrically and clinically for
lateral alveolar ridge augmentation.
METHODS
Patient Selection
Between January 2010 and November 2011, subjects were
recruited for this study from among patients referred to the Depart-
ment of Oral Implantology, Faculty of Dentistry, Istanbul University
for the replacement of missing teeth with implants. The inclusion
criterion was a horizontal bone deficiency of 3.5 to 5 mm on cone
beam computed tomography (CBCT) para-axial reconstruction
images. Exclusion criteria were: systemic disease that would con-
traindicate oral surgery, uncontrolled periodontal disease, bruxism,
a smoking habit or alcoholism, pregnancy or plans to conceive
psychiatric problems, and/or use of medications known to alter bone
healing. The study protocol was explained to each patient, and
signed informed consent was obtained from each patient prior to the
start of the study. The patients had the right to withdraw from the
study at any time without an explanation. This study was approved
From the Department of Oral Implantology, Istanbul University Faculty
of Dentistry, Istanbul, Turkey; yDepartment of Health Sciences ‘‘A.
Avogadro,’’ University of Eastern Piedmont, Novara, Italy; zInstitute of
Oncology, Medical Faculty, Istanbul University, Istanbul, Turkey; and
§Department of Oral Rehabilitation, The Maurice and Gabriela Gold-
schleger School of Dental Medicine, Tel-Aviv University, Tel-Aviv,
Israel.
Received December 17, 2015; final revision received January 20, 2016.
Accepted for publication February 2, 2016.
Address correspondence and reprint requests to Eitan Mijiritsky, DMD,
Department of Oral Rehabilitation, The Maurice and Gabriela Gold-
schleger School of Dental Medicine, Tel-Aviv University, Tel-Aviv,
69350, Israel; E-mail: mijiritsky@bezeqint.net
The authors report no conflicts of interest.
Copyright #2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002548
CLINICAL STUDY
The Journal of Craniofacial Surgery Volume 27, Number 5, July 2016 1181
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
by the Ethical Committee at Istanbul University and was conducted
in accordance with the Declaration of Helsinki.
Surgical Procedure
The partially edentulous patients initially underwent a thorough
periodontal examination, including the assessment of plaque, gin-
givitis, and probing depth. If indicated, periodontal treatments were
completed preoperatively. Immediately before the operation, the
patients were instructed to rinse their teeth with 0.2% chlorhexidine
mouthwash (Klorhex; Drogsan Pharmaceuticals, Istanbul, Turkey)
for 1 minute. A 2-stage approach (implant placement after 5 months
of healing) was used in all patients. The surgical procedures were
performed by the same 2 experienced surgeons alternately. All
surgical procedures were performed under local anesthesia using
articaine hydrochloride with epinephrine (Ultracain DS Forte;
Sanofi-Aventis, Istanbul, Turkey). Crestal and vertical incisions
were made along the residual alveolar ridge. A mucoperiosteal
flap was gently elevated to allow complete visualization of the
defect and surrounding bone (Fig. 1). Before measuring the bone
width, an acrylic stent that had been made before the operation for
each patient was placed as a reference for bone measurement. The
initial horizontal bone width at the planned implant sites was
measured with a calibrated digital bone caliper. At each site, bone
width was measured at different points that were 1, 3, and 5 mm
away from the alveolar bone crest vertically. Any soft tissue
remnants were removed from the bone surface; the native bone
was perforated with drills under saline irrigation to ensure vascu-
larization between the block graft and the recipient site. We used 2
15 25 mm blocks of DCBA material (OsteoGraft; Argon
Medical Devices Inc, Erlangen, Germany). Before each operation,
the cortical bone blocks were hydrated by placing them into sterile
saline solution for 20 minutes (Fig. 2). DCBAs were fixated to the
host bone site using bone screws (Modus; Medartis AG, Basel,
Switzerland). Because the material softens after hydration, perfect
adaptation of DCBA to the bone surface was easily achieved; only
the edges of the graft were rounded using a scalpel blade, while
neither the block graft nor the recipient site required contouring
(Fig. 3). Flaps were repositioned with mattress and interrupted
nonresorbable sutures (Dog
˘san Medical Supplies Industry, Trabzon,
Turkey). Resorbable or nonresorbable membranes were not used.
Routine postoperative care included administration of amoxicillin
and clavulanic acid (625 mg, administered orally, twice daily for
7 days), ibuprofen (600 mg, administered orally, every 6 hours
as needed), and mouthwash (0.2% chlorhexidine, twice daily for
2 weeks). Intraoral examinations on postoperative days 3 and 7
included evaluation of the patient’s swelling (þ/), bruising (þ/),
pain (numeric verbal analog scale [VAS]), and flap exposures
(þ/), and the observations were recorded in each patient’s medical
chart. Patients rated their pain using a VAS. Specifically, each
subject was asked, ‘‘On a scale of 0 to 10, with 0 being no pain and
10 being the worst pain imaginable, how would you rate your
current pain?’’ All other parameters were visually assessed (þ/).
Sutures were removed 10 days after surgery. Patients who had
a removable prosthesis were instructed not to use it during the
5-month healing period.
The patients were recalled at 1-month intervals for a period of
5 months to detect possible complications such as infection, pain,
discomfort, graft exposure, and mobility of the graft. Graft stability
was assessed at the time of dental implant placement. A flap design
similar to the one described above was used before implant place-
ment (Fig. 4). After flap elevation, the second set of measurements
was made at the same points and recorded with the guidance of the
stent and fixation screws. Three months after placement, the
implants were restored with cement-retained fixed ceramic
prostheses.
Histomorphometric Evaluation
During implant placement, a trephine bur (Helmut Zepf Med-
izintechnik GmbH, Seitingen-Oberflacht, Germany) with an
internal diameter of 2.3 mm was used to collect 12 cylindrical
samples, 6 to 8 mm in depth, from the implant regions. Evaluations
were performed on 4 different cross-sections of each of the 12
cylindrical samples for a total of 48 cross-sections, which were
sampled at the implant stage of surgery. The specimens were stored
in formaldehyde solution and forwarded to the Pathology Institute
at the University for processing and histomorphometric analysis.
The analysis was performed by a specialist (VO) who was not
provided with any information regarding the experimental
materials. Cylindrical bone biopsy specimens were fixed in 10%
neutral buffered formalin (paraformaldehyde fixative) for 48 hours,
decalcified in a mixture of 50% formic acid and 20% sodium citrate
solution for 3 days, and embedded in paraffin according to standard
protocols. Sections were cut to a thickness of approximately 3 mm
and stained with hematoxylin and eosin. Qualitative and quantitat-
ive analyses were performed using a light microscope (Olympus
BX60; Olympus Corp, Lake Success, NY) connected to a high-
resolution video camera interfaced to a computer. This optical
system was associated with the ‘‘analySIS FIVE’’ image analysis
software package (Olympus Corp). The percentages of new bone,
residual graft particles, and fibrous or bone marrow tissue in the
regions of interest were calculated.
Statistical Analysis
Changes in data over time were analyzed statistically using
IBM SPSS Statistics 22 software (IBM SPSS, Armonk, NY).
Shapiro–Wilk test was used to test the normality of the data
distribution. Quantitative data were compared using the Mann –
Whitney Utest. Within-group comparisons were performed with
the paired-sample ttest for normally distributed data and Wilcoxon
FIGURE 1. Mid-crestal and vertical incisions were made along the residual
alveolar ridge. A full mucoperiosteal flap was elevated.
FIGURE 2. Cortical bone blocks were immersed in sterile saline solution for
hydration. The edges of the block graft were rounded using a scalpel blade after
20 minutes of hydration.
Aslan et al The Journal of Craniofacial Surgery Volume 27, Number 5, July 2016
1182 #2016 Mutaz B. Habal, MD
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
signed-rank test for nonnormally distributed data. The level of
statistical significance was set at P<0.05.
RESULTS
A total of 12 localized alveolar ridge defects in 11 consecutive
patients (7 women and 4 men) aged 24 to 56 years (mean,
39.58 10.5 years), who did not accept autogenous block grafting,
were included in the study. One patient with a bone defect in the
maxilla and another with a defect in the mandible were totally
edentulous, 5 patients with a bone defect in the maxilla were
partially edentulous, and 4 patients with a bone defect in the
mandible were partially edentulous. Of the 12 grafts placed, 7 were
placed in the maxilla and 5 were placed in the mandible.
There was no sign of infection, wound dehiscence, block graft
exposure, or other postoperative complications during the healing
period following bone augmentation. At the time of implant place-
ment, all the block grafts were successfully integrated into the
recipient site. The mean horizontal increase in the bone platform
was 1.65 0.14 mm, and the mean percentage of graft resorption
was 5.39 2.18% (Tables 1 and 2). A significant horizontal
increase in the alveolar ridge was found after 5 months of healing
(P<0.01 by paired-sample ttest; Table 1). There was no significant
difference in the resorption rate of bone grafts between men and
women or between maxilla and mandible defect locations (P>0.05
by Mann– Whitney Utest; Table 2). On postoperative day 3, edema
was observed in 63.6% of patients, and bruising was observed in
9.1%. On postoperative day 7, edema was observed in 18.2% of
patients, and bruising in 9.1% (Table 3). Pain score was signifi-
cantly higher on postoperative day 3 than on postoperative day 7
(P<0.01 by Wilcoxon signed-rank test; Table 4). Pain was reported
as 0 on the VAS on postoperative day 7 for all patients. In all
patients, the grafted bone remained stable during drilling and
implant placement, without graft separation, and all implants were
stabilized successfully and restored 3 months after implant place-
ment. Collectively, 32 implants (Medical Implant System, Shlomi,
Israel) were placed. All patients received a fixed implant-supported
prosthesis. No implant was lost after loading during the 2-year
follow-up.
Histologically, newly formed vital bone, residual cortical block
allograft bone, and connective tissue were observed in all specimens
(Fig. 5). The residual cortical block allograft bone was distinguished
by the existence of empty lacunae and separation lines. The newly
formed bone containing viable osteocytes showed close contact with
the residual cancellous block allograft. Osteoblasts were present
throughout newly formed bone around the residual cortical block
allograft. There was no sign of acute or chronic inflammatory
infiltrates. No signs of pathologic inflammation were found. The
residual graft particles appeared to be highly osteoconductive. In
some specimens, a rimof osteoblasts lined the new bone. Further, the
Haversian canals appeared to be colonized by capillaries and cells.
The residual graft particles did not seem to undergo resorption. The
soft tissue resembled bone marrow tissue and consistedof adipocytes.
Histomorphometrically, the mean proportion of newly formed bone
in the region of interest was 40.30 24.59%, that of the residual
cortical block allograft was 40.39 21.36%, and that of the marrow
and connective tissue was 19.30 15.07% (Fig. 6).
FIGURE 3. (A) Block graft was fixated to the host bone site using bone screws.
(B) Occlusal view of the block graft after fixation.
FIGURE 4. The block graft was clinically well integrated into the recipient site
after healing.
TABLE 1. Ridge Width Before the Operation and After 5 Months of Healing
According to Defect Location and Sex
Preoperative After 5 Months P
Mean SD Mean SD
Sex Female 4.56 0.20 6.20 0.24 0.001
Male 4.30 0.45 5.97 0.38 0.001
Defect location Mandible 4.74 0.15 6.34 0.11 0.001
Maxilla 4.28 0.25 5.97 0.30 0.001
Total 4.48 0.31 6.13 0.14 0.001
Paired-sample ttest. SD, standard deviation.
P<0.01.
TABLE 2. Magnitude and Percentage of Graft Resorption According to Sex and
Defect Location
Graft Resorption (mm) Graft Resorption (%)
Mean SD (Median) Mean SD (Median)
Sex Female 0.36 0.17 (0.35) 5.52 2.58 (5.4)
Male 0.33 0.10 (0.35) 5.111.31 (5.3)
P0.666 0.865
Defect location Maxilla 0.31 0.17 (0.3) 5.0 2.64 (4.8)
Mandible 0.40 0.10 (0.4) 5.92 1.4 (5.8)
P0.283 0.464
Mann– Whitney Utest, P>0.05.
TABLE 3. Incidence of Edema and Bruising on Postoperative Days 3 and 7
(þ)()
Edema Third day 63.6% 36.4%
Seventh day 18.2% 81.8%
Bruising Third day 9.1% 90.9%
Seventh day 9.1% 90.9%
Edema and bruising assessments were based on visual observation (þ/).
The Journal of Craniofacial Surgery Volume 27, Number 5, July 2016 DCBA for Alveolar Ridge Augmentation
#2016 Mutaz B. Habal, MD 1183
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
DISCUSSION
The present study evaluated horizontal bone gain and new bone
formation with the aid of histology and histomorphometry at 5
months after augmentation of the alveolar ridge with DCBA using a
2-stage protocol.
Resorption of the alveolar ridge is a multifactorial and biome-
chanical problem resulting from a combination of anatomical,
metabolic, and mechanical factors. These factors vary from person
to person, and the various contributions from multiple different
factors account for the differences in resorption between individ-
uals.
20– 22
Alveolar bone augmentation includes initiatives for
maintaining and protecting the residual crest and increasing the
height and width of the alveolar bone. In the literature, many block
bone augmentation techniques have been used for appropriate 3-
dimensional implant positioning. All of these techniques may yield
successful results; however, their technical complexity necessitates
specialized training and experience. Although autogenous bone-
block grafting yields satisfactory results, this technique is associ-
ated with disadvantages such as prolonged operation times, limited
graft acquisition, damage to adjacent teeth, neurosensory deficits,
donor area flap exposure, bleeding, and infection.
23,24
Thus, safe
autogenous block bone harvesting may necessitate a steep learning
curve. Because of these disadvantages, there is an increased need
for alternative graft materials that show lower morbidity and easy
application. Recently, allogeneic bone-block grafts have been used
in bone augmentation and have eliminated many of the disadvan-
tages of autogenous bone-block grafts, especially complications
associated with the donor site.
23,24
Nissan et al
12
reported a mean percentage of newly formed bone
of 44 28% following the use of a cancellous block allograft for
augmentation of the posterior mandible after 6 months of healing; in
addition, the mean percentage of residual graft material in that study
was 29 24%. Laino et al
7
applied corticocancellous bone block
allograft as inlay with the sandwich technique. The mean percen-
tages of the newly formed bone and residual graft material were
30.6% and 28.9%, respectively. Maiorana et al
25
observed an
average of 26.5% residual graft particles after the application of
a thin layer of particular deproteinized bovine bone particles on
corticocancellous autogenous block graft. Acocella et al
26
found
that if the healing period is increased after application of ridge
augmentation, the percentage of residual graft particles can be
reduced. However, this may cause resorption at the grafted site.
DCBA may be less prone to resorption, which may explain why the
residual graft percentages obtained in the previous studies were
lower than that obtained in our study. Bone formation occurs over
an extended period because of the cortical structure of the material.
Moreover, late bone formation of the cortical bone allograft is the
reason why we measured the bone width using bone calipers instead
of with CBCT. The DCBA was not noticeable in the CBCT
evaluations of any of the patients during healing. Because of the
demineralized property of the material, it was not possible to obtain
3-dimensional measurements using CBCT. Therefore, bone cali-
pers with a surgical stent were used to measure bone gain and
resorption manually. In a separate study by Nissan et al,
27
the mean
percentage of newly formed bone was 33 18%, and that of the
residual cancellous block allograft was 26 17% when using the
same cancellous block allografts in the anterior maxilla. The
regenerative and remodeling outcomes of block allografts may
be influenced by many factors such as origin of allograft, surgical
technique, available bone volume before operation, healing time,
and their placement in different regions.
1,3,9,25
Histological evidence of the presence of newly formed bone in
allografts, and that of blood vessels invading the grafted material
has also been provided by previous studies, consistent with the
results of the present study.
19,26
The presence of Haversian canals
indicates that a centrifugal bone remodeling process is plausible.
These remodeling areas were recognized by the presence of newly
formed primary bone. The fully completed remodeling could not be
evaluated because of the short follow-up period in the present study.
Wallace and Gellin,
3
Nissan et al,
27
and Acocella et al
26
reported
that maxillary bone allograft materials could be used successfully in
TABLE 4. Pain Scores (Visual Analog Scale [VAS]) on Postoperative Days 3 and 7
VAS
PMean SD (Median)
Third day 2.54 2.16 (2) 0.008
Seventh day 0 0 (0)
Wilcoxon signed-rank test. Pain was rated using a VAS on a scale from 0 to 10.
P<0.01.
FIGURE 5. Light micrograph of a ground section of a specimen collected
5 months after DCBA placement. The grafted DCBA particles are surrounded
by immature wovenbone (A) and thus well integrated (B). (C) A smaller area of the
specimen consists of bone marrow tissue. The marrow cavity is rich in cells and
blood vessels. Scale bar ¼200 mm. (H&E staining, 200 magnification). DCBA,
demineralized freeze-dried cortical block allografts; H&E, hematoxylin and eosin.
FIGURE 6. Percentages of new bone, residual graft particles, and fibrous or
bone marrow tissue.
Aslan et al The Journal of Craniofacial Surgery Volume 27, Number 5, July 2016
1184 #2016 Mutaz B. Habal, MD
Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
the treatment of bone defects, and that implants could be safely
placed in these regions. Wallace et al
3
found an average horizontal
bone gain of 4.56 1.95 mm after the operation in their patient
series of 12 patients. Pereira et al
28
found that the mean buccal bone
resorption during the period between corticocancellous fresh-frozen
allograft bone-block placement and the reopening stage was
approximately 7.1%. Spin-Neto et al
29
reported an average graft
resorption of 8.3% at 6 to 8 months after corticocancellous fresh-
frozen block bone allograft placement. In the present study, the
mean horizontal bone gain was 1.65 0.14 mm, and the mean
percentage of graft resorption was 5.39 2.18%. The bone gain
was lower in our study because of the initial width of the allogeneic
graft material (2 mm), but the percentage of resorption was con-
sistent with the results of other clinical studies.
28,29
If DCBA was
applied in more than 1 layer to increase thickness, more resorption
could be expected.
30
Therefore, slow-resorbable bone substitutes
and resorbable membrane can be applied on the top of the onlay
block graft to inhibit resorption.
25
Barone et al
31
evaluated morbidity associated with autogenous
iliac bone grafting in a clinical study and found that pain, bruising,
functional disorders, and hematoma can affect patient comfort and
satisfaction unfavorably. The present study showed that patient
complaints decreased significantly after postoperative day 3, and
on postoperative day 7, almost all patients were without
complaints.
The present study demonstrated the benefits of using DCBA for
performing horizontal ridge augmentation and the resulting advan-
tages of decreased operation time, absence of donor site morbidity,
and the use of local anesthesia. Keith et al
32
documented block graft
failure in approximately 10% of patients due to improper block
contouring, fracture secondary to improper placement of the fix-
ation screw, and infection. The application of block grafts with bone
substitutes of xenographic and alloplastic origins may not be easy to
adapt to the recipient site because of the high rigidity of the
material.
33
These block grafts must be contoured after hydration
to maximize the contact surface area between the block graft and
host bone to facilitate vascularization during surgery, or preshaped
using a sterelithographic model of the patient’s jaw before the
operation. The elasticity of the block graft material used in this
study was higher than the elasticity of other block grafts; thus,
neither the block graft nor the recipient site needed to be contoured
during the application of DCBA in this study. This elastic property
of DCBA facilitates its manipulation during surgery and decreases
the operation time. Barone and Covani
34
applied 129 autogenous
block grafts in 56 severely resorbed maxillas; however, 3 patients
had to be excluded from the study because of flap exposure. In our
study, we did not observe flap exposure during healing, which was
likely because of the material’s high elasticity and optimum adap-
tation. Moreover, none of the block grafts separated from the
alveolar bone during the implant surgery.
Block graft failures most often involve mandibular posterior
defects.
33
In the present study, DCBA was applied to both maxillary
and mandibular defects. In the second surgery, all block grafts were
clinically well integrated into the recipient sites. Because of the high
elasticity after hydration, the contact surface areas may increase,
resulting in increased blood circulation and better consolidation
between the graft and host bone. This may be 1 reason for the good
integration during implant placement. One of the drawbacks of the
present block graft is the width of the graft material (2 mm), which
limits the bone thickness obtained in the second surgery. In future
studies, different techniques, such as sandwich technique or com-
bination with growth factors, can be used with DCBA; however, the
vascularization and integration would need to be reevaluated after
application.
7,8,16
In conclusion, cortical bone-block allografts are biocompatible
and osteoconductive, allowing new bone formation following
augmentation of horizontally deficient mandible or maxilla with
a 2-stage implant placement procedure. These findings indicate that
allogeneic bone-block grafts are a feasible and predictable alterna-
tive to autogenous bone-block grafts in select patients. Because of
the short follow-up duration and limited number of patients in this
study, further studies are required to ensure long-term bone graft
stability and implant survival.
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