Maxilla reconstruction with 100% BioOss: A clinical and tomographic follow-up study

Abstract

Background
Tooth loss and use of a complete denture is still a reality and results in bone loss. Adequate reconstruction of an extremely atrophic edentulous maxilla is a challenge, and different treatment methods have been described for its resolution.

Material and Methods
Patients seeking implant placement in edentulous upper jaw with atrophic maxilla were selected in a private clinic in Porto Alegre, Brazil. The bone graft was performed with bilateral sinus lift and horizontal bone graft in anterior region with 0,25-1mm particles of Bio-Oss (Geistlich) covered with a collagen membrane (Bio-Gide, Geistlich). CBCTs were evaluated to verify the need for bone graft, and 6-8 months after bone graft follow-up, to plan implant placement and assess horizontal bone gain.

Results
124 implants were placed in 19 patients, 76 of those in the sinus region. The survival rate was 95.2%, with six implants lost over a mean implants follow-up time of 47.68 months. The horizontal bone gain ranged from 0.00 to 6.86 mm, a mean gain of 2.85mm. An average of 5.5g of Bio-Oss was used per patient, and in 73.7 % of the cases, a flapless surgery was possible for implant placement, and in 92 implants an immediate loading was possible. Final rehabilitation was accomplished with fixed prosthodontics in 16 patients with a mean follow-up of 38.4 months.

Conclusions
Within the limitations of this study, it is possible to affirm that bone graft with 100% Bio-Oss in atrophic maxilla is a reliable treatment and allow rehabilitation with implants with a high survival rate and the higher the initial bone height, the greater the gain in bone width.
Key words:Bone Regeneration, Dental Implants, Prosthodontics, Dentistry.

Full text

J Clin Exp Dent. 2024;16(9):e1110-9. Maxil la reconstr uction with BioO ss
e1110
Journal section: Prosthetic Dentistry
Publication Types: Research
Maxilla reconstruction with 100% BioOss:
A clinical and tomographic follow-up study
Thiago-Revillion Dinato 1, José-Cicero Dinato 1, Fábio-Sá Carneiro Sczepanik 1, Márcio-Lima Grossi 2
1 Clínica Dinato de Odontologia
2 Professor, Post-Graduate Program in Dentistry School of Health and Life Sciences - Pontical Catholic University of Rio Grande
do Sul
Correspondence:
School of Health and Life Sciences
Pontical Catholic University of Rio Grande do Sul (PUCRS)
Av. Ipiranga, 6681, 90619-900, Porto Alegre, RS, Brazil
thiagodinato@gmail.com
Received : 10/01/2024
Accepted: 19/08/2024
Abstract
Background: Tooth loss and use of a complete denture is still a reality and results in bone loss. Adequate recons-
truction of an extremely atrophic edentulous maxilla is a challenge, and different treatment methods have been
described for its resolution.
Material and Methods: Patients seeking implant placement in edentulous upper jaw with atrophic maxilla were se-
lected in a private clinic in Porto Alegre, Brazil. The bone graft was performed with bilateral sinus lift and horizon-
tal bone graft in anterior region with 0.25-1mm particles of Bio-Oss (Geistlich) covered with a collagen membrane
(Bio-Gide, Geistlich). CBCTs were evaluated to verify the need for bone graft, and 6-8 months after bone graft
follow-up, to plan implant placement and assess horizontal bone gain.
Results: 124 implants were placed in 19 patients, 76 of those in the sinus region. The survival rate was 95.2%,
with six implants lost over a mean implants follow-up time of 47.68 months. The horizontal bone gain ranged
from 0.00 to 6.86 mm, a mean gain of 2.85mm. An average of 5.5g of Bio-Oss was used per patient, and in 73.7 %
of the cases, a apless surgery was possible for implant placement, and in 92 implants an immediate loading was
possible. Final rehabilitation was accomplished with xed prosthodontics in 16 patients with a mean follow-up of
38.4 months.
Conclusions: Within the limitations of this study, it is possible to afrm that bone graft with 100% Bio-Oss in atro-
phic maxilla is a reliable treatment and allow rehabilitation with implants with a high survival rate and the higher
the initial bone height, the greater the gain in bone width.
Key words: Bone Regeneration, Dental Implants, Prosthodontics, Dentistry.
doi :10 .4317/ jce d . 6137 2
htt ps://d oi.org/10.4317/jce d.61372
Introduction
Dental rehabilitation of partially or totally edentulous
patients with oral implants is a valid method for resto-
ring oral aesthetics and function with predictable results
(1). A minimum amount of bone width and height is es-
sential for the successful placement of implants (1,2).
Unfavorable local conditions, due to atrophy, trauma
and periodontal disease, may provide insufcient bone
volume or an unfavorable interarch relationship, which
does not allow a correct and prosthodontically guided
Dinato TR, Dinato JC, Sczepanik FC, Grossi ML. Maxilla reconstruction
with 100% BioOss: A clinical and tomographic follow-up study. J Clin Exp
Dent. 2024;16(9):e1110-9.
Article Number: 61372 http://www.medicinaoral.com/odo/indice.htm
© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.eseMail: jced@jced.es
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J Clin Exp Dent. 2024;16(9):e1110-9. Maxil la reconstr uction with BioO ss
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positioning of dental implants (2). Thus, there are mul-
tiple etiologies for a patient to have a narrow bone in
the anterior maxilla, and a successful implant therapy is
dependent upon an adequate volume of bone at the site
of implant placement (3).
Multiple restorative methods are available to restore the
missing teeth in the anterior maxilla, including: a) im-
plant-borne xed restorations with or without prosthetic
gingiva, b) xed partial dentures supported by teeth, and
c) removable options. To provide the satisfactory environ-
ment for an esthetic implant restoration, reconstruction of
the alveolar ridge width needs to be accomplished in order
to allow implant placement and to provide an ideal ridge
contour for an esthetic appearance. The goal is to provide
a reliable, minimally invasive, and long-term predictable
method to widen the narrow ridge in order to support den-
tal implants and esthetic restorations (3).
Many techniques have been developed to reconstruct de-
cient alveolar jaws for the placement of dental implants
performed either in combination or in second stage sur-
gery after a period of healing, since adequate recons-
truction of an extremely atrophic edentulous maxilla has
always been a challenge (4). The lack of bone volume in
combination with aging results in a change in facial mor-
phology, which is often treated by a sinus lift combined
with onlay bone grafting which, and for many surgeons
is considered a reliable and predictable technique.
The development of the guided bone regeneration (GBR)
technique started in the late 1980s, with a series of expe-
rimental studies trying to reduce morbidity to patients.
The GBR is based on the concept of using either a re-
sorbable or a non-resorbable barrier membrane in order
to stabilize the blood clot and to create a space in which
cells originating from bone tissue can grow without the
interference of the faster proliferating soft tissue cells
(4,5). The GBR also allows the ideal positioning of den-
tal implants in atrophic ridges.
Scientic data regarding the amount of bone gain using
biomaterials are scarce. Therefore, the aims of the study
are: a) to describe a technique using 100% Bio-Oss
(Geistlich) for maxilla reconstruction; b) to measure ho-
rizontal bone gain 6 to 8 months after bone graft in the
anterior region of the maxilla; c) to relate the horizontal
bone gain with the initial bone height; and d) to evaluate
the survival rate and variables related to bone augmenta-
tion and/or implant survival rate.
The considered hypotheses were: a) an efcient treat-
ment with DBBM and collagen membrane solely; b)
high horizontal bone gain; and c) higher bone width gain
in higher initial bone height; d) high survival rates for
the implants
Material and Methods
-Population, research design, inclusion/exclusion crite-
ria, and blinding
In this study, 18 to 85 year-old patients seeking implant
placement in edentulous upper jaws with an atrophic
maxilla in need of sinus lifting and ridge augmentation
were selected in a private clinic in the city of Porto Ale-
gre, Brazil. Both, the bone height and width of the crest
were insufcient in dimension (i.e.: <4mm width; <7mm
height) for conventional implant placement. Hence, a
GBR procedure aimed at augmentation of the ridge was
included in the treatment plan beyond the sinus lift. Pa-
tients with blood disorders, uncontrolled diabetes, smo-
king, history of previous surgery, and presence of any
pathology in the sinus were excluded. After clinical and
radiographic evaluation, the patients read and signed the
information consent form regarding the surgical proce-
dure, including its advantages and disadvantages. The
implant specialist JCD, who performed all bone grafts,
did not participate in the data analysis. The study proto-
col was reviewed and approved by the Research Ethics
Committee of the Pontical Catholic University of Rio
Grande do Sul (CEP/PUCRS, No #1.892.269), State of
Rio Grande do Sul, Brazil.
-Clinical Variables
The following data were gathered for each patient: a)
age, b) sex, c) DBBM quantity per patient, d) implant
features, e) timing of implant placement, f) ap eleva-
tion, and g) timing of prosthetic rehabilitation. The im-
plant features included both its length (i.e.: 8, 10, 11.5,
13 mm and 16mm) and diameter (i.e.: 4.3 mm). The
implants were placed either after a conventional muco-
periostal ap or a guided surgery apless technique. All
implants were installed using a precision guide for de-
termining its position and depth (i.e., 1mm subcrestal).
-Ridge Augmentation Procedures
The need for bone graft (i.e., native bone width ≤4mm)
was determined after a clinical evaluation with cone
beam computed tomography (CBCT). Before the surgi-
cal procedure for sinus lifting and ridge augmentation,
the patients were given 2g of amoxicillin (Fig. 1a). Fo-
llowing a mouth rinse with 0.12% of an aqueous solu-
tion of chlorhexidine, the area intended for surgery was
carefully anesthetized using local anesthetics (Fig. 1b).
To raise a mucoperiosteal ap, a paracrestal technique
was used placing the line of incision towards the palatal
aspect of the ridge in the maxilla. Oblique-releasing in-
cisions were used to allow for a wide ap basis and su-
fcient access to the defective ridge area (Fig. 1c). The
aps were carefully raised using tissue elevators. The
bone ridge was examined and any soft tissues remaining
on the crest were meticulously removed with a surgical
curette (Fig. 1d).
The lateral window was established in an oval shape
using a #6 round diamond bur (Fig. 1e). The sinus mem-
brane was deected (Fig. 1f), and the space created was
lled with small (0.25 – 1 mm) DBBM particles (Fig.
1g), which has been shown in the literature to have hi-

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Fig. 1: a) Intraoral aspect with prosthesis in position; b) Initial intraoral aspect; c) Line of incision towards the palatal aspect of the ridge in t he
maxilla with oblique-releasing incisions; d) Mucoperiosteal ap raised; e) Lateral window to the maxillary sinus; f ) Deection of Sch neider’s
membrane; g) Maxillary sinus lled with small particles of biomaterial; h) Horizontal increase in the anterior region with Bio-Oss (Geistlich);
i) Resorbable collagen membrane covering the grafted region; j) Hor izontal matt ress sut ures and single i nterrupted sutures; k) Intraoral aspect
after 6 months; l) Guided surgery for implants placement; m) Milled bar connecting i mplants for immediate loading with temporary overden-
ture; n) Full denture with resilient material; o) Intraoral aspect 6 months after implant installation; p) Fixed nal prosthesis over the implants
gher osteoconduction (6). If the membrane was perfora-
ted or torn, a collagen membrane was used to repair the
damage. The aim was to increase the bone height to a
sufcient size for an 8mm implant placement, or higher.
The graft particles were positioned into the sinus cavity
and in the defect area (Fig. 1h). The aim was to increase
the ridge width to a size sufcient for standard implant
placement (i.e., 4mm or more). The membrane-suppor-
ting material was partly stabilized by the morphology
of the ridge, and partly by the covering membrane. A
collagenous membrane was trimmed to cover the mem-
brane-supporting material and to extend it 2 mm on the
intact bone borders of the defect (Fig. 1i). Releasing in-
cisions were made through the periosteum at the base
of the ap in order to allow tension-free adaptation of
the wound margins. Horizontal mattress sutures as well
as single interrupted or continuous sutures were placed
to achieve healing by primary intention (Fig. 1j). The
patients received prescriptions for analgesic (500mg of
acetaminophen a day), anti-inammatory (200mg of
nimesulide a day, for 5 days), and antibiotic (1,500mg
of amoxicillin a day, for 7 days) therapies. The patients
were instructed to rinse with a 0.12% solution of chlor-
hexidine twice a day for 2 weeks, starting on the day af-
ter the surgery. Temporary dentures were not used for at
least two weeks. Ten days following augmentation sur-
gery, the interrupted sutures were removed. Follow-up
visits were scheduled every 4-6 weeks until re-entry sur-
gery with clinical and radiographic evaluation.
Six to eight months following augmentation surgery, a
clinical evaluation (Fig. 1k) with CBCT was performed
to analyze bone availability; and implantation surgery
was carried out. Patients were scheduled for implant
placement (Fig. 1l). All implants were used with a Mor-
se taper connection and were placed 1 mm subcrestally
in the previously planned position (i.e., corresponding
to the future crown center). All implants used in this
study had a full sandblasted and acid-etched (NeoPoros)
surface treatment. An immediate loading with a bar con-
necting the implants (Fig. 1m) and a provisional denture

J Clin Exp Dent. 2024;16(9):e1110-9. Maxil la reconstr uction with BioO ss
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(Fig. 1n) over it was performed when 4 or more implants
presented at least 32N, when not, patients underwent a
second stage surgery for abutment placement and oral
rehabilitation after 6 months (Fig. 1o).
-Follow-Up
After the nal prosthodontic treatment (Fig. 1p), pa-
tients were included in a maintenance program with
recall appointments every 6 months. Periapical X-rays
were taken, and clinical evaluation examined mobility,
pain and/or infection associated with the implants. Cases
were considered successful in the absence of pain or mo-
bility upon re-entry and at recall appointments.
-Measurement technique
Diagnosis and pre-implant planning involved clinical
examination and CBCT, which were taken with the IS
i-CAT (version 17- 19, Imaging Sciences International).
The following parameters were established: a) 120 kV,
b) 5 mA, c) axial slice distance 0.300 mm3, and d) 23-
cm eld of view.
Horizontal gain in bone width was calculated by com-
paring the CBCT taken before and 6 to 8 months after
surgical intervention (Fig. 2); the evaluation was made
by measuring bone width at 12 predetermined sites (i.e.:
3 on the right canine, 3 on the right central incisor, 3 on
the left central incisor and 3 on the left canine area) that
were the same in the 2 tomography taken. A digital su-
perimposition was used to conrm the evaluation of the
same sites (Figs. 3,4). All evaluations were repeated twi-
ce in 2 different days, and 12 measurements per patient
were considered (i.e.: right canine, right central incisor,
left central incisor and left canine area).
-Statistical analysis
SPSS® version 17 was used for the statistical analysis.
The Kolmogorov-Smirnov normality test and the Le-
vene’s homogeneity of variance test were used. Con-
sidering that all results had a parametric distribution,
the Student’s paired and independent t tests, and repea-
ted-measures ANOVA were used.
Fig. 2: Tomographic images to be superposed for subsequent measurements. a) CBCT before bone
graft, b) CBCT before implant placement.
Fig. 3: Measures in the CBCT before bone g raft (a) and before implant placement (b).

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Fig. 4: White line showing the measurement in the CBCT before bone graf t (a) a nd green line showing
the measurement in the CBCT before implant placement (b) superimposed on both tomographies to
facilitate visualization of the bone gain.
Results
In 19 selected patients (6 males and 13 females; age ran-
ge: 48 to 77 years; mean age: 61.4 years), 124 implants
installed; 76 implants were placed in the grafted sinus
and 48 in the anterior maxilla. Table 1 shows description
of surgical characteristics with an implant survival rate
of 95.2% with six implants lost, which occurred 7 mon-
ths after being installed, on average. Two of the lost im-
plants were placed in the sinus. The implants lost were
8mm long (n=3), 10mm long (n=1), 11.5mm long (n=1)
and 13mm long (n=1). Four out of the six implants were
replaced at the moment of its removal, while the other
two were not (Table 2). All lost implants, except one,
were installed during a apless surgery and received im-
mediate loading.
Ninety-two implants were inserted during a apless sur-
gery (74.2%), while the other 25.8% were inserted af-
ter raising a ap. Thus, in 14 patients the implants were
installed with a guided surgery (73.7%) and the other
26.3%, in a conventional open ap way.
It was used an average of 5.5 ± 1.4g of DBBM per case,
varying from 3g to 8g. Only one sinus out of 38 had a
membrane perforation (2.6%), which was covered by a
collagen membrane, and it was possible to perform the
sinus graft.
The mean time for implant placement after the bone
graft was 7.1 ± 2.1 months, while the mean time for
rehabilitation after implant placement was 9.4 ± 3.9
months. The mean follow-up time was 47.7 months (3.9
years) for implants and 38.4 months (3.2 years) for the
oral rehabilitation.
The oral rehabilitation was performed over multiple
abutments with a xed prosthesis over the implants in
16 patients (84.2%) and over a bar connecting the multi-
ple abutments with an overdenture in the other 3 patients
(15.8%).
All implants had 4.3 mm diameter and 71 were 13 mm
long (57%), 60 of those were placed in the grafted sinus.
In 14 patients an immediate loading with a bar connec-
ting the implants and a provisional denture over it was
possible (73.7%), while the other 5 patients underwent
a second stage surgery for abutment placement and oral
rehabilitation after 6 months. This type of immediate
loading was performed when 4 or more implants presen-
ted at least 32N.
Table 3 shows a signicant statistical difference (p va-
lue < 0.001) when comparing the bone width before and
after bone graft with DBBM. Table 4 shows the com-
parison of gain in bone width after bone graft between
different variables, the quantity of Bio-Oss used in the
graft and the age of patients did not showed signicant
statistical differences. Also, bone grafts that posterior-
ly allowed apless surgery, immediate loading, or that
resulted in implant loss, did not show any statistical di-
fference. On the other hand, patient’s gender resulted in
signicant difference (p value < 0.001), with a greater
bone width gain in men (3.71 ± 1.62mm) as compared to
women (2.38 ± 1.40mm).
Regarding the bone height prior to bone graft, it is pos-
sible to observe that the higher the bone, the more likely
is to gain in width with the bone graft. This is shown
in Table 5, where a signicant statistical difference is
observed between different initial bone heights. The
mean bone width gain was higher when the initial bone
height was higher than 8 (3.51 ± 1.36 mm), 10 (3.71 ±
1.39 mm) or 12mm (4.10 ± 1.36 mm) compared to initial

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Bio-Oss quantity (g)
Mean (±SD)5.5 (1.4)
Time of implant placement after bone graft (months)
Mean (±SD) 7.1 (2.1)
Time of prosthesis placement after implant placement (months)
Mean (±SD) 9.4 (3.9)
Maxillary sinus membrane perfuration (%)
Yes
No
(n=38)
2.6
97.4
Implant placement surgery (%)
Flapless
Open ap
(n=124)
73.7
26.3
Loss of implant(s) after placement (%)
Yes
No
(n=124)
4.8
95.2
Follow-up time after implant placement (months)
Mean (±SD) 47.7 (20.3)
Follow-up time after prosthesis placement (months)
Mean (±SD) 38.4 (22.2)
Immediate implant loading after surgery (%)
Yes
No
(n=124)
73.7
26.3
Horizontal bone gain (mm)
Mean (±SD) 2.85 (1.44)
Tab le 1: Descr iption of sur gi ca l char ac te ristics (n = 124 im pla nt s, n = 19 pat ients, n = 38 sinuses).
Number of implants per patient
Mean (±SD)6.5 (0.9)
Size of implants placed (count)
4.3 x 16.0
4.3 x 13.0
4.3 x 11.5
4.3 x 10.0
4.3 x 8.0
(n=124)
5
71
17
16
15
Size of implants lost (count)
4.3 x 16.0
4.3 x 13.0
4.3 x 11.5
4.3 x 10.0
4.3 x 8.0
(n = 6)
0
1
1
1
3
Replacement(s) of lost implants (%)
Yes
No
(n = 6)
66.7
33.3
Time until loss of implant(s) (months)
Mean (±SD)
(n = 6)
7.2 (4.8)
Tab le 2: Description of implants placed (n = 124).
bone heights lower than 8 (1.46 ± 1.15 mm), 6 (1.17 ±
0.98 mm) or 4mm (1.02 ± 0.96 mm), respectively. Con-
cerning sinus oor elevation, all of the sites had less than
4mm in height and the implants placed were 16mm long
(5), 13mm long (60), 11,5mm long (9) and 10mm long
(2).
Discussion
-Graft Material
The present study performed all bone grafts with 100%
DBBM, which is a proven evidence-based method of
treatment according to Sanz et al. (7) Alluden et al. (8),
in a systematic review comparing Bio-Oss alone and
Bio-Oss mixed with particulate autogenous bone graft in
lateral ridge augmentation, afrms that non comparative
studies seems to indicate that both treatment facilitates
formation of new bone, have postoperative dehiscence
as a common complication, and have similar bone re-
sorption and implant survival rates.
Some studies demonstrated that Bio-Oss is a non-resor-
bable or slowly resorbed bone substituten (9,10). Howe-
ver, this is not in accordance with Mordenfeld et al., who
showed a two-dimensional width reduction with different
mixtures of Bio-Oss and particulate autogenous bone var-
ying between 27% and 47% after 7.5 months, which mi-
ght be due to displacement or pressure from the soft tissue
or the removable denture during mastication (11).
Onlay grafting with a cortical block has been evaluated
over time, and the resorption of the graft cortical thick-
ness has been reported to be as little as 1.2 mm to more
than 50% of the graft thickness, which shows that volu-
me loss occurs during this process, and it is difcult to
predict (12-15).
Jemt and Lekholm (16) concluded that after 6 months,

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Independent variables: Initial bone width
Mean ±SD
Final bone width
Mean ±SD
p value
General mean bone width (n=228)
4.48 ±1.09
(n=228)
7.33 ± 2.00
<0.001*
Initial bone height greater than 12 mm (n=60)
4.76 ± 2.06
(n=60)
8.86 ± 2.96
<0.001*
Initial bone height greater than 10 mm (n=102)
4.54 ± 1.91
(n=102)
8.25 ± 2.70
<0.001*
Initial bone height greater than 8 mm (n=162)
4.58 ± 1.89
(n=162)
8.09 ± 2.65
<0.001*
Initial bone height less than 8 mm (n=66)
4.27 ± 2.00
(n=66)
5.74 ± 2.69
<0.001*
Initial bone height less than 6 mm (n=39)
3.96 ± 1.98
(n=39)
5.13 ± 2.67
<0.001*
Initial bone height less than 4 mm (n=27)
3.48 ± 1.54
(n=27)
4.50 ± 2.27
<0.001*
≤5 g BioOss (n=108)
4.49 ± 1.99
(n=108)
7.21 ± 2.81
<0.001*
> 5 g BioOss (n=120)
4.47 ± 1.87
(n=120)
7.44 ± 2.93
<0.001*
Women (n=156)
4.21 ± 1.79
(n=156)
6.59 ± 2.54
<0.001*
Men (n=72)
4.98 ± 2.08
(n=72)
8.69 ± 2.96
<0.001*
≤60 y.o. (n=96)
4.67 ± 1.85
(n=96)
7.49 ± 2.31
<0.001*
>60 y.o. (n=132)
4.37 ± 1.99
(n=132)
7.32 ± 3.28
<0.001*
Open ap surgery (n=60)
4.67 ± 2.03
(n=60)
7.63 ± 2.59
<0.001*
Flapless surgery (n=168)
4.40 ± 1.88
(n=168)
7.21 ± 2.98
<0.001*
Immediate implant loading (n=168)
4.50 ± 1.96
(n=168)
7.34 ± 3.03
<0.001*
Delayed implant loading (n=60)
4.41 ± 1.82
(n=60)
7.30 ± 2.29
<0.001*
Patients with implant loss (n=60)
4.27 ± 1.88
(n=60)
7.14 ± 2.97
<0.001*
Patients without implant loss (n=168)
4.57 ± 1.94
(n=168)
7.41 ± 2.84
<0.001*
Tab le 3: Comparison of bone width (mm) before and after bone graft between different variables.
autogenous bone grafting can create sufcient bone vo-
lume for implant placement, but the individual varia-
tion in resorption pattern makes the grafting procedure
unpredictable for the long-term prognosis.
When comparing the rate of graft resorption in autoge-
nous iliac bone graft and guided bone regeneration in
patients with atrophic maxilla in a retrospective study
with 39 patients, Gultekin et al. showed that both ma-
terials can provide adequate volume for implant place-
ment, but the autogenous bone graft results in greater
bone resorption (17). These authors state that one of the
reasons to have less bone resorption compared to other
studies (14,15,18) might be a healing period of 3 months
after bone graft as well as an additional 3 months healing
for the implant osseointegration.
Allografts were also studied when Aslan et al. evaluate
the clinical and histomorphometric features of demine-
ralized freeze-dried cortical block allografts (DCBA)
used for ridge augmentation. No membranes were used,
and all cases were performed with a 2-stage approach

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Independent variables Mean bone gain Standard deviation p value
≤ 5 g BioOss (n=108) 2.72 1.53 NS*
> 5 g BioOss (n=120) 2.96 1.68
Women (n=156) 2.38 1.40 <0.001*
Men (n=72) 3.71 1.62
≤ 60 y.o. (n=96) 2.82 1.31 NS*
> 60 y.o.(n=132) 2.94 1.87
Open ap surgery (n=60) 2.95 1.57 NS*
Flapless surgery (n=168) 2.80 1.63
Immediate implant loading (n=168) 2.83 1.66 NS*
Delayed implant loading (n=60) 2.89 1.46
Patients with implant loss (n=60) 2.87 1.68 NS*
Patients without implant loss (n=168) 2.84 1.59
Tab le 4: Comparison of gain in bone width (mm) after bone graft bet ween different variables.
Independent variables Mean bone gain Standard Deviation p value
Initial bone height >12 mm (n=60) 4.10 a1.36 <0.001*
Initial bone height >10 mm (n=102) 3.71 a1.39
Initial bone height >8 mm (n=162) 3.51 a1.36
Initial bone height <8 mm (n=66) 1.46 1.15 b
Initial bone height <6 mm (n=39) 1.17 0.98 b
Initial bone height <4 mm (n=27) 1.02 0.96 b
Tab le 5: Comparison of bone width gain (mm) among dif ferent bone heights pr ior to bone graft.
(implant placement after 5 months of healing). 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% (19). In spite of the
good results, allografts have the same problems of the
autogenous grafts, since they resorb the same way.
-Implant Stability
Al-Khaldi et al. assessed the stability of dental implants
placed in grafted versus nongrafted bone in the anterior
maxilla using resonance frequency analysis (20). The-
se authors found that implants placed in grafted bone
compared favorably with those in nongrafted bone and
showed excellent stability. This is in accordance with the
present study, which showed high primary stability and
led to an immediate loading in 14 cases. The reason to
place a bar and a provisional overdenture instead of ma-
king a xed prosthesis right after the surgery is to reduce
the load on each implant, sharing it with the mucosa.
Hernández-Alfaro et al. also showed similar results af-
ter 14 edentulous patients were treated with bilateral si-
nus oor elevation, mandibular bone block grafts and
biomaterials (21). In 81 of the 108 implants placed, it
was possible to place them in immediate loading. The
implant placement was performed 14 to 16 weeks af-
ter the bone graft surgery, with immediate loading in 10
patients.
The stability of implants placed in particulate bone,
onlay block bone, interpositional bone, and nongrafted
maxillary bone was also compared by Rasmuson et al.
(22) during the early phase of osseointegration, by means
of resonance frequency analysis and implant failure as
endpoints. Implants placed in nongrafted and grafted
maxillary bone using a two-stage protocol showed simi-
lar stability during the early phase of osseointegration.
-Survival Rate
The 95.16% implant survival rate presented in this study
is lower than showed by studies assessing implants in
sinus lift technique (23,24) and grafts with iliac crest or
DBBM mixed with autogenous bone for atrophic maxi-
lla (17), but it is in accordance Hellem et al. (25).
Jensen and Terheyden (26) concluded that a high level
of evidence has shown that the survival rates of implants
placed in augmented bone are comparable to the rates of
implants placed in native bone.
The survival rates of implants placed in augmented si-
tes with GBR are reported in many publications, several
experimental studies (27,28). Studies evaluating clinical
outcomes of lateral ridge augmentation with GBR pro-
cedures in staged implantation usually used autogenous
bone as ller materials in combination with non-resor-
bable membranes (29,30). Limited data are available
reporting on the application of bone substitutes in com-

J Clin Exp Dent. 2024;16(9):e1110-9. Maxil la reconstr uction with BioO ss
e1118
bination with resorbable membranes for ridge augmen-
tation before implant installation. However, in 2008,
Meijndart et al. (31) concluded that xenografts were
equivalent to autogenous bone grafts when evaluating
both implant survival and the peri-implant hard/soft tis-
sue reactions.
-Implant timing
Clementini et al., in a systematic review, showed that,
despite no studies presenting a control group and a
standardized success criterion are found, the delayed
positioning of implants should be considered more pre-
dictable than the immediate positioning (32). The study
assessed maxillary and mandibular bone grafts with
different types of augmentations, but their results were
in agreement with the present study, where the implant
surgery was performed in a second stage in all patients.
Aloy-Prósper et al. (33) also compared implant timing
in a 3-year retrospective study with intraoral onlay block
bone grafts. A total of 53 implants (23 delayed and 30 si-
multaneous) were included, and the cumulative implant
success rate was 83.3% for simultaneous and 96.9% for
delayed implants, which corroborates with the another
study (32)
-Bone gain
Most studies (17,21,34) showed a very pronounced bone
resorption during healing before implant placement, gi-
ving the reason why the measurements were made 6-8
months after the bone graft. Thus, the stability of the
augmented site in this period is an important factor in the
maintenance of graft sites in the following years (17).
To assess horizontal bone augmentation, Qiu and Yu
evaluated onlay bone graft with DBBM block and au-
togenous bone in the anterior maxilla in a prospective
study including 14 patients (34). The authors also used
particulate DBBM and a double layer of collagen mem-
brane; and they reported a width gain of 8.73mm, but
with a resorption rate of 7.03%. The oro-facial bone
width was measured using a calibrated caliper both at
1 mm below the highest point of the remaining crest
before graft, and in the implant placement surgery. The
present study reported a mean gain in bone width of 2.85
± 1.44mm performing the bone graft only with DBBM
particles and collagen membrane.
Hämmerle et al. reported a mean ridge width gain of
3.6mm after a bone graft with both particles or blocks of
DBBM (Bio-Oss) and a collagen membrane (Bio-Gide),
with only one failure (35). The augmented areas inclu-
ded one to multiple teeth and it was observed an integra-
tion of the DBBM particles into the newly formed bone.
The present study performed a apless surgery in most
of the cases in the second stage, but that’s what was seen
in the open ap implant placement surgeries.
Another study assessed gain in bone volume after pa-
tients underwent bone graft with autogenous bone block,
DBBM particles and collagenous membrane. The avera-
ge percentage volumetric increase between the preope-
rative condition and the situation at reentry was 71.99%
(21). Despite not evaluating the bone gain in volume,
it is possible to afrm that a horizontal bone gain of
63.62% was achieved in our study.
When comparing block grafts harvested from iliac crest
(IC) or mandibular ramus (MR), both combined with
DBBM particles and collagen membrane, for horizontal
bone augmentation, Monje et al. shows that IC leads to a
greater ridge width gain than MR (4.93mm vs 3.23mm)
(36). All cases were performed in severe maxillary ante-
rior ridge defects and the results are in accordance with
other studies (34,35).
Conclusions
Within the limitations of this study it is possible to
afrm that: 1) the bone graft with 100% DBBM in atro-
phic maxilla is a reliable treatment; 2) the 95.2% sur-
vival rate found encourages placement of implants in
reconstructed maxillae; 3) a predictable horizontal bone
gain is achievable; 4) the higher the initial bone height,
the higher the possibility in bone width gain; 5) apless
surgery for implant placement is commonly an option;
6) immediate loading is achievable in most of the cases;
and 7) the replacement of lost implants is possible. More
studies are necessary to conrm this data with randomi-
zed trials and long-term analysis.
Acknowledgement
Declared none.
Institutional Review Board Statement
The study protocol was reviewed and approved by the Research Ethics
Committee of the Pontical Catholic University of Rio Grande do Sul
(CEP/PUCRS, No #1.892.269), State of Rio Grande do Sul, Brazil.
Data Availability Statement
The datasets used and/or analyzed during the current study are availa-
ble from the corresponding author.
Author Contributions
Not specied.
Funding
This study was nanced in part by the Coordenação de Aperfeiçoa-
mento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code
001.
Conict of interest
Declared none.
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