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Short‐term outcomes of lateral extraction socket augmentation using autogenous tooth roots. A prospective observational study

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Objectives To assess the short‐term clinical outcomes of lateral augmentation of deficient extraction sockets and two‐stage implant placement using autogenous tooth roots (TR). Material & Methods A total of n=13 patients (13 implants) were available for the analysis. At the time of tooth extraction, each subject had received lateral augmentation using the respective non‐retainable but non‐infected tooth root where the thickness of the buccal bone was <0.5 mm or where a buccal dehiscence‐type defect was present. Titanium implants were placed after a submerged healing period of 6 months and loaded after 20±2 weeks (V8). Clinical parameters (e.g. bleeding on probing ‐ BOP, probing pocket depth – PD, mucosal recession – MR, clinical attachment level – CAL) were recorded at V8 and after 26±4 weeks (V9) of implant loading. Results At V9, all patients investigated revealed non‐significant changes in mean BOP (‐19.23±35.32%), PD (0.24±0.49 mm), MR (0.0±0.0 mm) and CAL (0.24±0.49 mm) values, respectively. There was no significant correlation between the initial gain in ridge width and changes in BOP and PD values. Conclusions The surgical procedure was associated with stable peri‐implant tissues on the short‐term.
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DR. KATHRIN BECKER (Orcid ID : 0000-0003-1936-4683)
PROF. FRANK SCHWARZ (Orcid ID : 0000-0001-5515-227X)
Article type : Original Research
Short-term outcomes of lateral extraction socket augmentation using
autogenous tooth roots. A prospective observational study.
Parvini P1, Sahin D2, Becker K1,3, Sader R4, Becker J2, Schwarz F1,2
1 Department of Oral Surgery and Implantology, Carolinum, Goethe University, Frankfurt,
Germany
2 Department of Oral Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
3 Department of Orthodontics, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
4 Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Medical Center of the
Goethe University Frankfurt, Frankfurt am Main, Germany.
Corresponding address: Frank Schwarz
Department of Oral Surgery and Implantology
Carolinum, Goethe University, Frankfurt, Germany
Tel: +49 69 6301 7924 Fax: +49 69 6301 3829
e-mail: f.schwarz@med.uni-frankfurt.de
Short Title: Extraction socket augmentation
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Key words: clinical study, alveolar ridge augmentation, tooth autotransplantation
Author Contributions
F.S., P.P., R.S. and J.B. conceived the ideas; F.S. performed the surgical procedures; P.P., D.S.,
and K.B. collected and analyzed the data; and P.P., F.S. and R.S. led the writing.
Conflict of Interests and Source of Funding
The authors declare that they have no conflict of interests related to this study.
Source of Funding
The study was funded by a grant of the Deutsche Forschungsgemeinschaft (DFG), Bonn,
Germany.
Abstract
Objectives: To assess the short-term clinical outcomes of lateral augmentation of deficient
extraction sockets and two-stage implant placement using autogenous tooth roots (TR).
Material & Methods: A total of n=13 patients (13 implants) were available for the analysis.
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At the time of tooth extraction, each subject had received lateral augmentation using the respective
non-retainable but non-infected tooth root where the thickness of the buccal bone was <0.5 mm or
where a buccal dehiscence-type defect was present. Titanium implants were placed after a
submerged healing period of 6 months and loaded after 20±2 weeks (V8). Clinical parameters
(e.g. bleeding on probing - BOP, probing pocket depth PD, mucosal recession MR, clinical
attachment level – CAL) were recorded at V8 and after 264 weeks (V9) of implant loading.
Results: At V9, all patients investigated revealed non-significant changes in mean BOP (-
19.2335.32%), PD (0.240.49 mm), MR (0.00.0 mm) and CAL (0.240.49 mm) values,
respectively. There was no significant correlation between the initial gain in ridge width and
changes in BOP and PD values.
Conclusions: The surgical procedure was associated with stable peri-implant tissues on the short-
term.
Introduction
The management of extraction sockets has become a topic of major clinical relevance in
contemporary implant dentistry (Avila-Ortiz et al. 2019). In fact, tooth extraction triggers a
cascade of biological events leading to substantial dimensional changes of the alveolar ridge
during the first 6 months of healing (Tan et al. 2012). These changes are more pronounced at the
buccal aspect (Botticelli et al. 2004; Araujo et al. 2015) and intensified in the presence of a
compromised extraction socket. In particular, the presence of a severe bone loss at the time of
extraction resulted in a slower healing and cortication (Ahn & Shin 2008; Bertl et al. 2018) as well
as a greater volume reduction when compared with intact extraction sites (Aimetti et al. 2018).
Moreover, the vertical bone loss was significantly higher at extraction sites exhibiting a thin
buccal bone thickness (< 1 mm) when compared with sites exhibiting a bone thickness of 1 mm or
more (7.5 mm (62%) vs. 1.1 mm (9%), respectively) (Chappuis et al. 2013).
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The results of a recent prospective observational study have indicated that the usage of autogenous
tooth roots (TR) may represent a feasible approach for lateral augmentation of deficient extraction
sockets and two-stage implant placement (Schwarz et al. 2019). In particular, the surgical
procedure included a simultaneous, lateral augmentation of deficient (i.e. thickness of the buccal
bone <0.5 mm or buccal dehiscence-type defects) fresh extraction sockets using the respective
non-retainable but non-infected teeth. After 26 weeks of submerged healing, the change in ridge
width amounted to 4.892.29 mm and allowed for a successful implant placement in all patients
investigated (Schwarz et al. 2019). The basic concept was based on previous findings of a series of
experimental studies indicating that TR have a biological potential to sever as alternative grafts for
localized alveolar ridge augmentation (Schwarz et al. 2016a, 2016b, 2016c).
The aim of the present study was to assess the short-term clinical outcomes of lateral
augmentation of deficient extraction sockets and two-stage implant placement using TR.
Material and Methods
Study design and participants
A total of 15 patients, each exhibiting one non-retainable but non infected tooth attended the
Department of Oral Surgery at the Heinrich Heine University Düsseldorf, Germany and had
received a lateral augmentation of a deficient fresh extraction socket (i.e. either an insufficient
thickness of the buccal bone <0.5 mm or the presence of a buccal dehiscence-type defect) using
the respective TR. After 26 weeks of submerged healing, a re-entry was performed and implants
had been placed at the respective sites. The primary outcome was defined as the crestal ridge
width (mm) (CW26) being sufficient to place an adequately dimensioned titanium implant. The
secondary outcome was the gain in ridge width (CWg), which was calculated as CW26 CW
measured immediately before augmentation. These data have been published recently (Schwarz et
al. 2019).
At 9 to 20 weeks after implant placement, implant loading was accomplished and clinical baseline
data were recorded. The present analysis focused on the changes in clinical outcomes assessed
after 264 weeks of implant loading. The study outline and the follow-up visits are summarized in
Table 2. Due to lost to follow-up, n=13 patients exhibiting a total of n=13 implants were available
for the present analysis. The patient characteristics and reasons for tooth extraction are presented
in Tables 1a and b. The study protocol was approved by the ethics committee of the Heinrich
Heine University, Düsseldorf and registered via the Internet Portal of the German Clinical Trials
Register (DRKS00009586). Each patient was given a detailed description of the study procedures
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and signed an informed consent before participation. The present reporting considered the
checklist items as proposed in the STROBE statement.
Sample size calculation
Due to the proof-of-principle character of the present observational study and a lack of similar
data in the literature, a sample size calculation was not feasible. However, the initial sample size
of n=15 was considered to be sufficient to allow for a first evaluation of the efficacy (i.e. CWg at
26 weeks) of the presented surgical procedure.
Inclusion and exclusion criteria
Patients were initially included in the study if they presented all of the following conditions: 1)
Age 18 to 60 years, 2) candidate for lateral ridge augmentation, 3) insufficient bone ridge width at
the recipient site for implant placement, 4) sufficient bone height at the recipient site for implant
placement, 5) healthy oral mucosa, at least 3 mm keratinized tissue.
The patients were not included in the study if they presented one of the following conditions: 1)
general contraindications for dental and/or surgical treatments, 2) inflammatory and autoimmune
disease of the oral cavity, 3) uncontrolled diabetes (HbA1c > 7%), 4) history of malignancy
requiring chemotherapy or radiotherapy within the past five years, 5) previous
immunosuppressant, bisphosphonate or high dose corticosteroid therapy, 6) smokers, 7) pregnant
or lactating women (Schwarz et al. 2019).
Surgical procedures
The surgical procedures have been reported in detail previously (Schwarz et al. 2019).
In brief, TR grafts were decapitated at the cemento-enamel junction and the selected root was
separated longitudinally to entirely expose the pulp chamber using a rotating carbide bur under
gentle water (i.e. sterile saline) cooling. Subsequently, all specimens were thoroughly scaled and
root planend using curets to remove all detectable deposits. In addition, any residual pulp tissue
and/ or root canal filling material was removed and the pulp chamber was widened using a round
carbide bur (i.e. sterile saline).
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TR specimens were adapted to match the height and width of the target area and fixed using one to
two titanium osteosynthesis screw (1.5 x 9 mm, Medicon, Tuttlingen, Germany). Periosteal-
releasing incisions were performed to achieve a tension-free wound closure. At 26 weeks,
commercially available titanium implants (Bone Level® Tapered SLActive®, diameter: 4.1 mm,
Institut Straumann AG, Basel, Switzerland) were inserted in an epicrestal position (Visit 6)
without the need for secondary bone grafting procedures. The sutures were removed after 104
days (Visit 7 V7). The intraoperative measurements of CW values were accomplished to the
nearest 0.25 mm at the most coronal level of the residual buccal bone plate by using a caliper and
have been reported recently.
Prosthodontic procedure
In all patients, a conventional implant loading (Visit 8 V8) was accomplished at 9 to 20 weeks
after V7 (Table 2). All implants were restored with cemented single metal-ceramic crowns and
bridges and crown margins being located in an epimucosal position. Intraoral radiographs were
taken to ensure the correct position of the respective components and detect residual cement.
Clinical measurements
The following clinical measurements were recorded at V8 and after 264 weeks (Visit 9 – V9) of
implant loading (Table 2) using a pressure-calibrated (20-25g) and colour coded plastic
periodontal probe (Click-Probe® green, Kerr GmbH, Biberach, Germany): 1) plaque index (PI)
(Loe 1967), 2) bleeding on probing (BOP), evaluated as present if bleeding was evident within 30
seconds after probing, or absent, if no bleeding was noticed within 30 seconds after probing, 3)
probing depth (PD) measured from the mucosal margin to the bottom of the probeable pocket, 4)
mucosal recession (MR) measured from the crown margin to the mucosal margin, and 5) clinical
attachment level (CAL) measured from crown margin to the bottom of the probeable pocket. All
measurements were recorded at 6 aspects per implant: mesiovestibular (mb), midvestibular (b),
distovestibular (db), mesiooral (mo), midoral (o), and distooral (do) by one calibrated investigator
masked to the specific experimental conditions (D.S.).
The presence of peri-implant diseases at each implant site was assessed as follows: peri-implant
mucositis: presence of BOP and/ or suppuration with or without increased PD (i.e. V8 to V9);
peri-implantitis: presence of BOP and/ or suppuration with increased PD and presence of bone
loss (i.e. V8 to V9) (Berglundh et al. 2018). No intraoral radiographs were taken, since clinical
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examinations during follow-up did not suggest the presence of peri-implantitis at any implant site
investigated.
Postoperative Care
Postoperative maintenance care included a supramucosal-/ gingival professional implant/tooth
cleaning and reinforcement of oral hygiene. Maintenance care was provided according to
individual needs at V8 and V9.
Statistical analysis
The statistical analysis of the pseudonymised data sets was accomplished using a commercially
available software program (IBM SPSS Statistics 24.0, IBM Corp., Armonk, NY, USA).
Mean values, standard deviations, medians, 95% confidence intervals (CI) and frequency
distributions were calculated for all clinical parameters. The changes (d) in mean values from V8
to V9 were examined with the Shapiro-Wilk test. In a next step, within group comparisons of
dBOP, dPD, dCAL and dKT values were accomplished using the Wilcoxon signed-rank test.
Subsequently, within group changes of dPD and dCAL values were further analysed using the
paired t-test. Linear regression analyses were used to depict the relationship between CWg and
changes in BOP as well as PD values. The chi-square test was employed to compare the incidence
of peri-implant disease between two subgroups. The alpha error was set at 0.05.
Results
Mean CW26 values amounted to 11.232.42 mm (median: 11.5) with a CWg of 4.732.26 mm
(median: 5.0).
Clinical measurements
At V9, all patients investigated exhibited a good level of plaque control, as indicated by mean PI
scores of 0.530.55 (Median: 0.17) at respective implant sites.
Mean and median BOP, PD, MR, CAL, and KT values measured at V8 and V9 are summarized in
Table 3. At V8, mean BOP scores were 65.3837.59% and decreased by 19.2335.32%, thus
resulting in a mean BOP value of 46.1538.01% at V9 (p=0.002, Shapiro-Wilk test; p=0.078,
Wilcoxon signed-rank test). Mean BOP changes were more pronounced at extraction sites
exhibiting a thin buccal bone plate. At V8, mean PD scores were 2.580.30 mm and slightly
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increased by 0.240.49 mm, thus resulting in a mean PD value of 2.830.39 mm at V9 (p=0.123,
Shapiro-Wilk test; p=0.045 Wilcoxon signed-rank test; p=0.094, paired t-test). These changes
were slightly higher at extraction sites exhibiting a buccal dehiscence-type defect (Tables 4 and 5).
All sites investigated did not reveal any noticeable changes in mean MR values at V9.
Accordingly, mean CAL changes amounted to 0.240.49 mm (p=0.123, Shapiro-Wilk test;
p=0.045, Wilcoxon signed-rank test; p=0.094, paired t-test), with slightly higher changes noted at
extraction sites exhibiting a buccal dehiscence-type defect (Fig. 1, Tables 4 and 5). Mean KT
values at V8 were 3.231.16 mm and mainly changed by 0.801.7 mm (p=0.001, Shapiro-Wilk
test; p=0.317, Wilcoxon signed-rank test) at extraction sites exhibiting a buccal dehiscence-type
defect (Tables 4 and 5).
Incidence of peri-implant disease
The frequency distribution of peri-implant disease at V9 is summarized in Table 6. According to
the given case definitions, the incidence of peri-implant mucositis and peri-implantitis amounted
to 76.92% and 0.0%, respectively. The chi-square test pointed to an independency between both
subgroups and the incidence of peri-implant disease (p=0.118) (Table 6).
Regression analysis
At V6, mean CWg values amounted to 4.892.29 mm (median: 5.00; 95% CI: 3.56; 6.21)
(Schwarz et al. 2019).
The linear regression analysis failed to reveal a significant correlation between CWg and changes
in BOP (Coef: 0.321, R2=0.103, p=0.285) and PD values (Coef: 0.167, R2=0.028, p=0.585,
respectively (Figs. 2a and b).
Discussion
The present study aimed at investigating the short-term clinical outcomes of lateral augmentation
of deficient extraction sockets and two-stage implant placement using TR. After a follow-up
period of 44 weeks (i.e. at 264 weeks after loading), all patients investigated revealed non-
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significant changes in mean BOP (-19.2335.32%), PD (0.240.49 mm), MR (0.00.0 mm) and
CAL (0.240.49 mm) values when compared with V8. In this context, it must be emphasized that
the present observational study had a proof-of-principle character and may therefore not have the
statistical power to rule out significant within group changes for the presented clinical outcomes.
Moreover, it must be emphasized that the relatively high BOP scores noted at V8 may mainly be
attributed to a traumatic tissue injury caused by the crown/ bridge insertion at respective implant
sites. Accordingly, the BOP changes at V9 reflect a healing of the peri-implant soft tissue
following completion of the implant supported restorations.
The remaining mean BOP scores at 44 weeks are basically within the range of the short-term data
on peri-implant health or disease noted at native (non-augmented) implant sites (Schwarz et al.
2017). In particular, in a cross-sectional analysis of 238 patients exhibiting a total of 512 two-
piece implants, the diagnosis peri-implant mucositis (case definition: BOP on at least one aspect of
the implant but no changes in the radiographic bone level) was commonly noted in all implant age
groups investigated. At the implant level, its frequency amounted to n=25 at 1-12 months of
follow-up, n=157 at 12-48 months and n=32 at >48 months, respectively (Schwarz et al. 2017). In
contrast, a meta-analysis (n= 10 studies) of short-/ mid-term (1–3 years) and long-term (>3 years)
data on the effects of various lateral ridge augmentation procedures on peri-implant health or
disease did not reveal any major changes in BOP scores over time (i.e. follow-up of 1 to 10 years).
The calculated weighted mean differences amounted to −10.02% (95% CI: −22.23; 2.21) and
failed to reach statistical significance (Sanz-Sanchez et al. 2018). Similar findings with respect to
BOP changes were also observed when different timings (i.e. simultaneous or staged) and surgical
procedures (i.e. different types of barrier membranes, growth factors, chin blocks with or without
resorbable membranes) were compared (n = 6; WMD = −3.36; 95% CI [−12.49; 5.77]; p = .471).
These procedures were also associated with stable PD scores (n = 6; WMD = −0.051; 95% CI 0.0;
0.0]; p = .726) and marginal bone levels (n = 6; WMD = 0.062; 95% CI 0.0; 0.527]; p = .284)
(Sanz-Sanchez et al. 2018), thus corroborating the findings of the present study.
At the time being, this is the first clinical study which aimed at investigating the application of TR
for a lateral augmentation of deficient extraction sockets. However, a recent prospective case
series (4 patients) reported on the clinical performance of TR grafts (derived from impacted teeth)
for lateral alveolar ridge augmentation and staged implant placement (Pohl et al. 2017). The
clinical follow-up at 2 years revealed mean PD scores of 1.7 mm (range: 0 to 3.5 mm) in the
absence of BOP (Pohl et al. 2017). This was also supported by the outcomes of an initial human
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case report, pointing to healthy and stable (PD values of 3 to 4 mm) peri-implant tissue conditions
at 8 months following lateral ridge augmentation using TR and staged implant placement
(Schwarz et al. 2016b).
When further analysing the present regression analysis, it was also noted that the initial gain in
ridge width was not significantly correlated with changes in BOP and PD values. While this
observation may support recent findings of a less pronounced resorption of TR when compared
with AB grafts (Schwarz et al. 2018), it remains unclear to what extent graft remodeling will
affect both TR groups and subsequently clinical outcomes in the mid- and long-term.
A major limitation of the present clinical analysis was the impossibility to further assess the
biological integration of the inserted implants at TR grafted sites. However, previous preclinical
animal studies provide histological evidence that a true osseointegration was established by the
interposition of woven bone between residual TR fragments and the implant surface (Schwarz et
al. 2016a, c). The resulting removal torque values were comparable to those values noted at
titanium implants that were placed following lateral ridge augmentation using autogenous bone
blocks (Becker et al. 2017).
In conclusion and within its limitations, the present clinical study revealed that the surgical
procedure was associated with stable peri-implant tissues on the short-term.
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dimensional analysis of bone remodeling following ridge augmentation of compromised
extraction sockets in periodontitis patients: A randomized controlled study. Clinical Oral
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can we learn? Periodontology 2000 68, 122-134. https://doi.org/10.1111/prd.12082.
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Ba, G., Iacono, V., Koo, K. T., Lambert, F., McCauley, L., Quirynen, M., Renvert, S.,
Salvi, G. E., Schwarz, F., Tarnow, D., Tomasi, C., Wang, H. L. & Zitzmann, N. (2018).
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Fig. 1.Representative clinical outcomes at V9.
a. Situation at re-entry in the region of former tooth 25 where TR had been
used for the augmentation of a thin buccal bone plate (Visit 6).
b. Healthy peri-implant soft tissue conditions as indicated by the absence
of BOP.
c. Situation following implant bed preparation in the region of former tooth
23, where TR had been used for the augmentation of a buccal
dehiscence-type defect (Visit 6).
d. Clinical situation immediately following gentle probing pointing to
healthy and stable peri-implant soft tissues.
Fig. 2 Linear regression plots to depict the relationship between CWg and dBOP/
dPD values.
a. dBOP
b. dPD
Figure legends
Tables
Table 1a.
Patient characteristics (refers to Visit 7).
Patient age
50.0±7.5 years; range: 34 to 58 years
female/ male
n = 7/6
subgroup - insufficient bone thickness
n = 8
subgroup - dehiscence-type defect
n = 5
Table 1b.
Reasons for tooth extraction and numbers (refers to Visit 2).
substantial loss of the clinical crown
n= 10 (6 with endodontic treatment)
fractured teeth
n = 2
advanced periodontal destruction due to
occlusal trauma
n = 1
Table 2.
Study design and follow up visits (D=day; W=week).
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Visit 6
Visit 7
Visit 8
Visit 9
Enrollment
Surgery
SR
R/ IP
SR
IL, CM
CM
D0
D10
W4
W13
W26
D104
post V6
W9-202
post V7
W264
post V8
Visit 1: patient enrollment
Visit 2: lateral ridge augmentation using TR
Visit 3: SR=suture removal
Visits 4/ 5: follow-up visits
Visit 6: R=re-entry/ IP=implant placement
Visit 7: SR
Visit 8: IL=implant loading; CM=clinical measurements of baseline data
Visit 9: CM=clinical measurements of follow-up data
Table 3.
a. Clinical parameters measured at V8 (n=13 patients).
BOP
PD
MR
CAL
KT
Mean
65.38
2.58
0.00
2.58
3.23
SD
37.59
0.30
0.00
0.30
1.16
Median
67.00
2.67
0.00
2.67
3.00
95% CI
42.6;88.1
2.40;2.76
0.00;0.00
2.40;2.76
2.52;3.93
b. Clinical parameters measured at V9 (n=13 patients).
BOP
PD
MR
CAL
KT
Mean
46.15
2.83
0.00
2.83
3.53
SD
38.01
0.39
0.00
0.39
1.33
Median
33.00
2.92
0.00
2.92
3.00
95% CI
23.18;69.13
2.59;3.07
0.00;0.00
2.59;3.07
2.73;4.34
Table 4.
Changes (d) in clinical parameters between V8 and V9 (n=13 patients).
dBOP
dPD
dMR
dCAL
dKT
TR
mean
-19.23 ± 35.32
0.24 ± 0.49
0.0 ± 0.0
0.24 ± 0.49
0.30 ± 1.1
median
0.0
0.17
0.0
0.17
0.0
95% CI
-40.57; 2.11
-0.04; 0.54
0.0; 0.0
-0.04; 0.54
-0.36; 0.97
Cohen`s d
-0.54
0.50
-
0.50
0.27
p value
0.078*
0.094**
-
0.094**
0.317*
Within group comparison V8 - V9: * Wilcoxon signed-rank test; **paired t-test
Table 5.
a. Patients exhibiting extraction sockets with a thin buccal bone plate (<0.5 mm) (n=8).
dBOP
dPD
dMR
ΔdCAL
dKT
TR
mean
-27.13 ± 39.82
0.15 ± 0.56
0.0 ± 0.0
0.15 ± 0.56
0. 0 ± 0.0
median
0.0
0.17
0.0
0.17
0.0
95% CI
-60.42; 6.17
-0.31; 0.63
0.0; 0.0
-0.31; 0.63
0.0; 0.0
b. Patients exhibiting extraction sockets with a buccal dehiscence-type defect (n=5).
dBOP
dPD
dMR
dCAL
dKT
TR
mean
-6.60 ± 25.35
0.39 ± 0.34
0.0 ± 0.0
0.39 ± 0.34
0.80 ± 1.7
median
0.0
0.50
0.0
0.50
0.0
95% CI
-38.08; 24.88
-0.03; 0.83
0.0; 0.0
-0.03; 0.83
-1.42; 3.02
Table 6.
Crosstabulation of subgroup and incidence of peri-implant disease at V9.
Diagnosis
Total
0
1
Subgroup
Thin bone
Count
3
5
8
% within Subgroup
37.5%
62.5%
100.0%
Dehiscence type defect
Count
0
5
5
% within Subgroup
0.0%
100.0%
100.0%
Total
Count
3
10
13
% within Subgroup
23.1%
76.9%
100.0%
Diagnosis: 0 = healthy; 1 = peri-implant mucositis; p=0.118, Chi-square test.
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... As a result, a total of 20 articles were included in this review. [9][10][11][12]16,17,[25][26][27][28][29][30][31][32][33][34][35][36][37][38] Fig. 1 shows the flowchart of the search process and outcome. ...
... This systematic review included five randomized controlled trials (RCT), 16,17,[25][26][27] four controlled clinical trials (CCT), 11,28-30 five prospective observational studies, [31][32][33][34][35] four case series studies, 9,12,36,37 and two retrospective studies. 10,38 All articles were published between the years 2015 and 2021. ...
... Eight studies were at a moderate risk of bias. 9,10,12,32,33,35,36,38 The study by Schwarz et al. 31 was assessed to have a low risk of bias in all domains (Supplementary Material Fig. S2). This risk of bias evaluation is summarized in Fig. 3. ...
Article
This systematic review was conducted to evaluate the available literature on the clinical outcomes of the use of autogenous tooth bone graft prepared chairside, and its current applications. A literature search was done to answer the focused questions "In partially edentulous patients, what are the alveolar ridge volumetric changes, histological findings, and implant survival rates in sites augmented with autogenous tooth bone graft prepared chairside?" Twenty articles were included at the end of the database search. Reported alveolar bone dimension changes after ridge preservation ranged between − 0.64 mm and + 2.26 mm for height, and between − 1.21 mm and + 0.41 mm for width. Augmented sites showed a significant increase in their dimensions in all investigations. The implant survival rate was 98.8% for delayed placement and 97.4% for immediate placement. Additional reports were found on the percentage bone formation following the use of this graft at different postoperative time points, which showed a higher bone volume with time. Currently available studies have included small samples, with short follow-up periods, and most have lacked a control group. Within the limitations of this review, the available evidence suggests that the autogenous tooth bone graft prepared chairside is as effective as other bone grafting materials.
... A total of 34 abstracts were reviewed and full-text analysis included 13 articles. Finally, one comparative [31], and two noncomparative studies were included [32,33]. The level of agreement between the two authors (J.V. and K.B.Ø.) in selecting abstracts and studies to be read in full text were measured at k = 0.86 and 0.96, indicating strong and almost perfect reliability of agreement. ...
... The included studies of the present systematic review consisted of one prospective, non-randomized controlled trial [31], and two prospective noncomparative observational studies [32,33]. Partial edentulous patients in need of an implant-supported fixed restoration combined with a horizontal alveolar ridge deficiency of the maxilla and mandible were enrolled. ...
... description of the used power analysis and sample size calculation, in which the clinical width of the alveolar ridge was chosen as the primary outcome variable [31,32]. Age and gender distribution as well as inclusion criteria and exclusion criteria were specified in all the included studies [31][32][33]. ...
Article
Full-text available
Objectives: The objective of the present systematic review was to evaluate the current knowledge of implant treatment outcome following lateral alveolar ridge augmentation with autogenous tooth block graft compared with autogenous bone block graft prior to implant placement. Material and Methods: MEDLINE (PubMed), Embase and Cochrane Library search in combination with hand-search of relevant journals was conducted including human studies published in English through December 20, 2021. Comparative and non-comparative studies assessing lateral alveolar ridge augmentation with autogenous tooth block graft were included. Quality and risk-of-bias assessment were evaluated by Cochrane risk of bias tool, Newcastle-Ottawa Scale and GRADE system. Results: One comparative study characterized by low grade and two non-comparative studies fulfilled the inclusion criteria. No significant difference in short-term implant survival, health status of the peri-implant tissue or frequency of complications between the two treatment modalities was observed. Postoperative dimensional changes of the alveolar ridge width were significant diminished with tooth block compared with bone block (P = 0.0029). Consequently, the gain in alveolar ridge width was significantly higher with tooth block, after 26 weeks (P = 0.014). However, a higher frequency of short-term peri-implant mucositis was observed with tooth block. Conclusions: Lateral alveolar ridge augmentation with tooth block seems to be a suitable alternative to bone block. However, results of the present systematic review are based on short-term studies involving small patient samples. Further long-term randomized controlled trials are therefore needed before definite conclusions can be provided about the beneficial use of tooth block compared with bone block.
... The results have been satisfactory, and the application of this type of graft has shown acceptable clinical outcomes. 8,[10][11][12][13][14][15] Thus, this systematic review and metaanalysis was performed to confirm whether the ADG provides comparable results to autogenous bone or to other commercially available bone grafts (i.e. Bio-Oss) and shows similar performance when used for implant placement procedures. ...
... Several studies have been conducted on this material, proving its efficacy and applicability for this procedure. 6,12,30 Therefore, the present study was performed in order to obtain an initial comparison between the ADG and other bone grafts and to establish a base for future studies and investigations. ...
Article
The aim of this study was to determine whether the autogenous dentin graft (ADG) shows comparable results and similar clinical performance to other graft materials when utilized for implant placement. Four databases were searched, and controlled human studies that applied autogenous dentin for implant surgery, comparing it with other bone grafts, were included. Nine articles met the inclusion criteria, five of which were randomized controlled trials and were included in the meta-analysis. ADG showed equivalent primary and secondary implant stability when compared to Bio-Oss (primary: mean difference −0.74, 95% confidence interval (CI) − 3.36 to 1.88, P = 0.58; secondary: mean difference − 1.29, 95% CI − 5.69 to 3.11, P = 0.57). The standardized mean difference (SMD) of marginal bone loss at 6 months and at the final follow-up (18 months) showed the two grafts to be similar (6 months: SMD −0.26, 95% CI −0.64 to 0.12, P = 0.18; final follow-up: SMD −0.12, 95% CI −0.50 to 0.26, P = 0.53), and survival after immediate implant placement was the same in the two groups: 97.37% and 97.30%, respectively. Incidences of complications with the autogenous dentin particles or blocks were in line with those of Bio-Oss or autogenous bone blocks, respectively. This meta-analysis indicates that the autogenous dentin graft is an effective option for bone augmentation around dental implants, with acceptable implant stability, marginal bone loss, and incidences of complications and failure.
... First support for this approach came from preclinical studies [2][3][4] and case reports [4] followed by radiological analysis [5,6]. Preclinical research continues to better understand the process of graft consolidation [7,8] and acellular tooth root may even be used as allografts [9]. Clinical studies were performed supporting the use of autogenous tooth roots for augmentation of the alveolar bone [10] and before placing the implant [11]. ...
... There is a growing evidence in using dentin for extraction socket augmentation and staged implant placement [2][3][4][5][6][7][8]10,11,30]. Graft consolidation is a result of both resorption and formation of the graft [31], thus the release of growth factors from dentin is expected to occur [32]. ...
Article
Full-text available
Dentin prepared from extracted teeth is used as autograft for alveolar bone augmentation. Graft consolidation involves the acid lysis of dentin thereby generating a characteristic paracrine environment. Acid lysate of dentin is mimicking this environment. Acid dentin lysate (ADL) potentially targets hematopoietic cells thereby affecting their differentiation towards macrophages and osteoclasts; however, the question remains if ADL controls macrophage polarization and osteoclastogenesis. Here, we show that ADL reduced lipopolysaccharide (LPS)-induced macrophage polarization of the pro-inflammatory (M1) phenotype, indicated by attenuated Interleukin 1 (IL1), Interleukine 6 (IL6)and cyclooxygenase 2 (COX2) expression. This decrease in M1 macrophages was confirmed by the reduced phosphorylation and nuclear translocation of p65 in the LPS-exposed RAW 264.7 macrophages. Similarly, when RAW 264.7 macrophages were incubated with other agonists of Toll-like receptor (TLR) signaling e.g., FSL1, Polyinosinic-polycytidylic acid High Molecular Weight (Poly (1:C) HMW), Pam3CSK4, and imiquimod, ADL reduced the IL6 expression. We further show herein that ADL decreased osteoclastogenesis indicated by the reduced formation of multinucleated cell expressing cathepsin K and tartrate-resistant acid phosphatase in murine bone marrow cultures. Overall, our results suggest that acid dentin lysate can affect the differentiation of hematopoietic cells to M1 macrophage polarization and a decrease in osteoclastogenesis in bone marrow cultures.
... In implant dentistry, the management of extraction sockets has become a topic of considerable clinical significance. 1 Since past few years, preservation of ridge using augmentation procedures is gaining popularity for the management of fresh extraction sockets. 2 In recent years, researchers had used separated tooth roots in their experimental studies and found that it has biological and structural potential to serve as alternative autografts for localized ridge augmentation procedure for two-stage implant placement. 3,4 In lateral extraction socket augmentation technique, the lateral augmentation of deficient socket is done, where buccal bone thickness is <0.5 mm or there is buccal dehiscence-type defects present. ...
Article
Full-text available
During initial 6 months of healing after extraction of tooth, the alveolar ridge undergoes a series of dimensional changes that are more pronounced at the buccal aspect and escalate in the presence of a compromised extraction socket. In implant dentistry, the management of extraction sockets has become a topic of considerable clinical significance. Since past few years, preservation of ridge using augmentation procedures is gaining popularity for the management of fresh extraction sockets.
Article
Full-text available
Purpose The aim of this systematic review was to critically analyze the available evidence on the effect of different modalities of alveolar ridge preservation (ARP) as compared to tooth extraction alone in function of relevant clinical, radiographic and patient‐centered outcomes. Material and Methods A comprehensive search aimed at identifying pertinent literature for the purpose of this review was conducted by two independent examiners. Only randomized clinical trials (RCTs) that met the eligibility criteria were selected. Relevant data from these RCTs were collated into evidence tables. Endpoints of interest included clinical, radiographic, and patient‐reported outcome measures (PROMs). Interventions reported in the selected studies were clustered into ARP treatment modalities. All these different ARP modalities were compared to the control therapy (i.e. spontaneous socket healing) in each individual study after a 3‐ to 6‐month healing period. Random effects meta‐analyses were conducted if at least two studies within the same ARP treatment modality reported on the same outcome of interest. Results A combined database, grey literature and hand search identified 3,003 records of which 1,789 were screened after removal of duplicates. Following the application of the eligibility criteria, 25 articles for a total of 22 RCTs were included in the final selection, from which 9 different ARP treatment modalities were identified: 1. Bovine bone particles (BBP) + Socket sealing (SS), 2. Construct made of 90% bovine bone granules and 10% porcine collagen (BBG/PC) + SS, 3. Cortico‐cancellous porcine bone particles (CPBP) + SS, 4. Allograft particles (AG) + SS, 5. Alloplastic material (AP) with or without SS, 6. Autologous blood‐derived products (ABDP), 7. Cell therapy (CTh), 8. Recombinant morphogenic protein‐2 (rh‐BMP2), and 9. SS alone. Quantitative analyses for different ARP modalities, all of which involved socket grafting with a bone substitute, were feasible for a subset of clinical and radiographic outcomes. The results of a pooled quantitative analysis revealed that ARP via socket grafting (ARP‐SG), as compared to tooth extraction alone, prevents horizontal (Mean = 1.99 mm; 95% CI 1.54 to 2.44; P < 0.00001), vertical mid‐buccal (Mean = 1.72 mm; 95% CI 0.96 to 2.48; P < 0.00001) and vertical mid‐lingual (Mean = 1.16 mm; 95% CI 0.81 to 1.52; P < 0.00001) bone resorption. Whether there is a superior ARP or SS approach could not be determined on the basis of the selected evidence. However, the application of particulate xenogenic or allogenic materials covered with an absorbable collagen membrane or a rapidly‐absorbable collagen sponge was associated with the most favorable outcomes in terms of horizontal ridge preservation. A specific quantitative analysis showed that sites presenting a buccal bone thickness > 1.0 mm exhibited more favorable ridge preservation outcomes (difference between ARP [AG+SS] and control = 3.2 mm), as compared to sites with a thinner buccal wall (difference between ARP [AG+SS] and control = 1.29 mm). The effect of other local and systemic factors could not be assessed as part of the quantitative analyses. PROMs were comparable between the experimental and the control group in two studies involving the use of ABDP. The effect of other ARP modalities on PROMs could not be investigated, as these outcomes were not reported in any other clinical trial included in this study. Conclusion ARP is an effective therapy to attenuate the dimensional reduction of the alveolar ridge that normally takes place after tooth extraction. This article is protected by copyright. All rights reserved.
Article
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A classification for peri‐implant diseases and conditions was presented. Focused questions on the characteristics of peri‐implant health, peri‐implant mucositis, peri‐implantitis, and soft‐ and hard‐tissue deficiencies were addressed. Peri‐implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration. It is not possible to define a range of probing depths compatible with health; Peri‐implant health can exist around implants with reduced bone support. The main clinical characteristic of peri‐implant mucositis is bleeding on gentle probing. Erythema, swelling, and/or suppuration may also be present. An increase in probing depth is often observed in the presence of peri‐implant mucositis due to swelling or decrease in probing resistance. There is strong evidence from animal and human experimental studies that plaque is the etiological factor for peri‐implant mucositis. Peri‐implantitis is a plaque‐associated pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri‐implant mucosa and subsequent progressive loss of supporting bone. Peri‐implantitis sites exhibit clinical signs of inflammation, bleeding on probing, and/or suppuration, increased probing depths and/or recession of the mucosal margin in addition to radiographic bone loss. The evidence is equivocal regarding the effect of keratinized mucosa on the long‐term health of the peri‐implant tissue. It appears, however, that keratinized mucosa may have advantages regarding patient comfort and ease of plaque removal. Case definitions in day‐to‐day clinical practice and in epidemiological or disease‐surveillance studies for peri‐implant health, peri‐implant mucositis, and peri‐implantitis were introduced. The proposed case definitions should be viewed within the context that there is no generic implant and that there are numerous implant designs with different surface characteristics, surgical and loading protocols. It is recommended that the clinician obtain baseline radiographic and probing measurements following the completion of the implant‐supported prosthesis.
Article
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Objectives: This systematic review evaluated the evidence on the effect of the interventions aimed for lateral ridge augmentation (both simultaneously with implant placement or as a staged procedure) on peri-implant health or disease. Methods: A protocol was developed to answer the following PICO question: "In patients with horizontal alveolar ridge deficiencies (population), what is the effect of lateral bone augmentation procedures (intervention and comparison) on peri-implant health (outcome)?" Included studies were randomised controlled trials or controlled clinical trials with a follow-up of at least 12 months after implant loading. Meta-analyses were performed whenever possible, including subgroup analysis based on follow-up. Results: Twelve final publications from eight investigations were included. The results from the meta-analysis indicated that irrespective of the type of intervention, the inflammatory changes, based on bleeding on probing (%) were minimal, both at short- (n = 1; weighted mean difference [WMD] = -1.00; 95% CI [-14.04; 12.04]; p = .881) and long-term (n = 5; WMD = -5.63; 95% CI [-18.42; 7.16]; p = .881). When comparing different treatment modalities, no significant differences were observed (n = 6; WMD = -3.36; 95% CI [-12.49; 5.77]; p < .471). Similarly, changes in probing pocket depth and marginal bone levels were not significantly different among groups. The incidence of peri-implantitis was evaluated in three investigations and varied from 16% to 26% after a follow-up period of 6-8 years. Conclusions: The results from this systematic review and meta-analysis have shown that lateral ridge augmentation procedures can maintain peri-implant health over time with low mucosal inflammatory changes and a relatively small incidence of peri-implant bone loss.
Article
Full-text available
Purpose: To evaluate the use of chemically unchanged tooth material in lateral alveolar ridge augmentation or for the filling of jaw defects. Materials and methods: A total of 20 patients underwent either lateral augmentation of the alveolar process (11 patients) or filling of jaw defects (6 patients) with autogenous unaltered tooth material in a longitudinal 2-year study. In three patients, the jaw defect was so marked that a bone block graft had to be used for augmentation in addition to particulate dental material. In four patients, an autogenous tooth block was exclusively used; in seven, crushed tooth material was exclusively used; and in the remaining six, dystopic teeth that had been extracted were removed, crushed, and reinserted into the defect in particulate form. Fully impacted teeth served as autogenous donor teeth. Results: After a healing time of 3 to 6 months, 28 implants could be placed (10 immediate implants, 18 delayed implants). At 6, 12, and 24 months postrestoration, peri-implant bone loss as assessed by x-ray was 0 mm, 0.4 mm, and 0.6 mm, respectively. Peri-implant probing depth was 1 mm after 1 year and 2 mm after 2 years. Bleeding on probing was not seen in any of the implants after 2 years. Conclusion: Autogenous tooth material appears to be suitable for the restoration of lateral and intraosseous defects of the alveolar ridge with both complete blocks and in particulate form. However, additional long-term studies with higher case numbers will be required for substantiating these results.
Article
Objectives To assess the feasibility of using autogenous tooth roots (TR) for a lateral augmentation of deficient extraction sockets and two‐stage implant placement. Material and Methods A total of 15 patients were recruited to perform a simultaneous, lateral augmentation of deficient (i.e., thickness of the buccal bone < 0.5 mm or buccal dehiscence‐type defects) fresh extraction sockets using the respective non‐retainable but non‐infected teeth (n = 15). After 26 weeks of submerged healing, the primary endpoint was defined as the crestal ridge width (mm) (CW26) being sufficient to place an adequately dimensioned titanium implant at the respective sites. Results The surgical procedure could be accomplished in n = 14 patients. Soft tissue healing was uneventful in all patients. CW26 at visit 6 allowed for a successful implant placement in all patients (e.g., 14/14). Mean CW26 values amounted to 10.85 ± 2.71 mm (median: 8.5). The change (4.89 ± 2.29 mm) in CW compared to baseline was statistically significant (p < 0.001). Conclusions The usage of TR may represent a feasible approach for lateral augmentation of deficient extraction sockets and two‐stage implant placement.
Article
Objectives To assess and compare the efficacy and safety of autogenous tooth roots (TR) and autogenous bone blocks (AB) for lateral alveolar ridge augmentation and two‐stage implant placement. Material & Methods A total of 30 patients in need of implant therapy and lateral ridge augmentation were allocated to parallel groups receiving either 1) healthy autogenous tooth roots (e.g. retained wisdom or impacted teeth) (n=15), or 2) cortical autogenous bone blocks harvested from the retromolar area. After 26 weeks of submerged healing, the primary endpoint was defined as the crestal ridge width (mm) (CW26) being sufficient to place an adequately dimensioned titanium implant at the respective sites. Results Soft tissue healing was uneventful in both groups. CW26 at visit 6 allowed for a successful implant placement in all patients of both TR (15/15) and AB groups (15/15). Mean CW26 values amounted to 10.06±1.85 mm (median: 11.0) in the TR and 9.20±2.09 mm (median: 8.50) in the AB group, respectively. The difference between both groups did not reach statistical significance (P=0.241). Conclusions TR may serve as an alternative graft to support lateral alveolar ridge augmentation and two‐stage implant placement. This article is protected by copyright. All rights reserved.
Article
Objectives: The aim of this study was to analyze linear and volumetric hard tissue changes in severely resorbed alveolar sockets after ridge augmentation procedure and to compare them with spontaneous healing using three-dimensional cone beam computed tomography (CBCT). Material and methods: Thirty patients (mean age 53.2 ± 6.3 years) requiring tooth extraction for advanced periodontitis were randomly allocated to test and control groups. The test sites were grafted using a collagenated bovine-derived bone (DBBM-C) covered with a collagen membrane, while control sites had spontaneous healing. Both groups healed by secondary intention. Linear and volumetric measurements were taken on superimposed CBCT images obtained after tooth extraction and 12 months later. Results: Greater horizontal shrinkage, localized mainly in the crestal zone, was observed in the control group (4.92 ± 2.45 mm) compared to the test group (2.60 ± 1.24 mm). While both groups presented a rebuilding of the buccal wall, it was most pronounced in the grafted sockets (2.50 ± 2.12 mm vs. 0.51 ± 1.02 mm). A significant difference was also registered in the percentage of volume loss between grafted and non-grafted sites (9.14% vs. 35.16%, p-value <.0001). Conclusion: Alveolar sockets with extensive buccal bone deficiencies undergo significant three-dimensional volumetric alterations following natural healing. The immediate application of a slow-resorbing xenograft with a covering collagen membrane seems to be effective in improving alveolar ridge shape and dimensions, thus potentially reducing the need for adjunctive regenerative procedures at the time of implant placement.
Article
Objectives: To assess the timeframe between tooth extraction and radiographically detectable socket cortication in humans. Methods: Two hundred and fifty patients with a CT scan ≤36 months after tooth extraction were included. First, three orthoradial multiplanar reconstruction slices, representing the major part of the extraction socket, were scored regarding the degree of bone healing as (i) healed, that is, complete/continuous cortication of the socket entrance, or (ii) non-healed. Thereafter, based on the results of all three slices, the stage of cortication of the extraction socket, as one unit, was classified as (i) non-corticated, that is, all three slices judged as non-healed, (ii) partially corticated, that is, 1 or 2 slices judged as non-healed, or (iii) completely corticated, that is, all three slices judged as healed. The possible effect of several independent parameters, that is, age, gender, timeframe between tooth extraction and CT scan, tooth type, extent of radiographic bone loss of the extracted tooth, tooth-gap type, smoking status, presence of any systemic disease, and medication intake, on cortication status was statistically evaluated. Results: Three to 6 months after tooth extraction, 27% of the sockets were judged as non-corticated and 53% were judged as partially corticated. After 9-12 months, >80% of the sockets were corticated, while some incompletely corticated sockets were detected up to 15 months after extraction. Each additional month after tooth extraction contributed significantly to a higher likelihood of a more advanced stage of cortication, while radiographic bone loss ≥75% significantly prolonged cortication time; no other independent variable had a significant effect. Conclusions: The results indicate a considerably long timeframe until complete cortication of an extraction socket, that is, 3-6 months after tooth extraction 3 of 4 sockets were still not completely corticated, and only after 9-12 months, complete cortication was observed in about 80% of the sockets.
Article
Objectives: Recent animal studies have indicated, that tooth roots reveal a structural and biological potential to serve as alternative autografts for localized ridge augmentation. This proof-of-concept initial report aimed at investigating, whether this new surgical concept may be applied to humans. Material & methods: In one patient, who was in need for horizontal ridge augmentation, the roots of a retained upper wisdom tooth were separated and rigidly fixed at the defect site. After 24 weeks of submerged healing, the primary endpoint was defined as gain in ridge width (mm) being sufficient to place an adequately dimensioned titanium implant at the respective site. Secondary outcomes included safety assessments. Results: Soft tissue healing was uneventful during the entire observation period. Clinical re-entry at 24 weeks revealed, that the transplanted root was homogeneously incorporated at the former defect site and mainly replaced by a newly formed hard tissue. The gain in ridge width amounted to 4.5 mm and allowed for a successful implant placement with good primary stability. The procedure was not associated with any wound infection or adverse events. Conclusions: This novel approach may be further investigated in implant site development procedures. This article is protected by copyright. All rights reserved.
Article
Objectives: To assess the efficacy of periodontally diseased tooth roots used as autografts for lateral ridge augmentation and two-stage early osseointegration of titanium implants. Material & methods: Ligature-induced periodontitis lesions were established at the maxillary premolars in n=8 foxhounds. Extracted, scaled and root planned premolar roots (PM-P) as well as retromolar cortical autogenous bone (AB) blocks were used for horizontal ridge augmentation of mandibular chronic-type defects. At 12 weeks, titanium implants were inserted and left to heal for another 3 weeks. Histological analyses included crestal ridge width - CW; augmented area - AA and bone-to-implant contact - BIC. Results: Both PM-P and AB grafts were gradually organized and replaced by newly formed bone. Median CW (PM-P: 3.83 vs. AB: 3.67 mm), AA (PM-P: 10.18 vs. AB: 9.82 mm(2) ) and BIC (PM-P: 50.00 vs. AB: 35.21%) values did not reach statistical significance between groups (p>0.05, respectively). Histologically, PM-P grafts were not associated with any inflammatory cell infiltrates. Conclusions: PM-P autografts may reveal a structural and biological potential to serve as an alternative autograft to AB. This article is protected by copyright. All rights reserved.