Success of Dental Implants Placed
in Intraoral Block Bone Grafts
and Devorah Schwartz-Arad
Background: The purpose of this study was to evaluate the
survival and success of dental implants placed in alveolar
bone following augmentation using intraoral block bone
Methods: A consecutive retrospective study was conducted
on patients who had onlay bone grafts for vertical or horizontal
augmentations followed by dental implantation from 1999 to
2001. Files of 50 healthy patients who received 129 implants
in augmented sites were reviewed. Implant survival, radiologic
implant success (marginal bone loss), and complications
Results: Follow-up from time of implantation ranged from 6
to 67 months (mean: 24.3 – 11.2 months). Ranges of implant
widths and lengths were 3.25 to 4.7 mm and 10 to 16 mm, re-
spectively. The overall survival rate was 96.9% (four implants
were removed). Marginal bone loss around implants ranged
from 0 to 3.3 mm (average: 0.22 – 0.45 mm). Only 5% of
the implants presented marginal bone loss ‡1.5 mm over the
Conclusions: Intraoral bone block graft surgery is a pre-
dictable operation for the use of dental implants. Implant place-
ment in augmented areas presents high survival and radiologic
success rates with minimal bone loss. J Periodontol 2007;78:
Bone graft; dental implant; smoking.
he use of autologous bone grafts
with dental implants is a well-
accepted procedure in oral and
ment of an endosseous implant requires
sufﬁcient bone volume for complete
bone coverage. Additionally, the pattern
of ridge resorption contributes to an
unfavorable maxillomandibular relation-
ship, requires angulations of the implants
or angled abutments, and affects the
proximity of adjacent facial concavities
(maxillary sinus and nasal cavity) and
vital structures (mandibular nerve).
Bone resorption after tooth loss is usu-
ally dramatic and irreversible and more
prominent in the ﬁrst year.
tion can be vertical or horizontal, leaving
the area without bone and making it dif-
ﬁcult to place implants.
block bone grafts from intraoral sources
have been used, especially from the
In the repair of more localized
alveolar defects, bone grafts from the
symphysis and ramus offer several bene-
conventional surgical access;
the proximity of donor and recipient sites
reduces operative and anesthesia time,
making them ideal for outpatient implant
surgery; no remaining cutaneous scar
following these operations; and minimal
discomfort and less morbidity to patients
compared to extraoral locations.
The purpose of this study was to eval-
uate the survival and radiologic success
of dental implants placed in alveolar
bone following augmentation using intra-
oral block bone grafts.
* Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger School of
Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
† Unit of Periodontology, Department of Oral and Dental Sciences, Rambam Health Care
Campus, Haifa, Israel.
‡ Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center,
Tel Hashomer, Israel.
§ Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger
School of Dental Medicine.
Volume 78 • Number 1
PARTICIPANTS AND METHODS
A consecutive retrospective study was conducted on
all patients who had undergone onlay bone grafting
from 1999 to 2001. Files of 50 healthy patients (14
males and 36 females) who received 129 screw-type
titanium dental implants placed in alveolar bone fol-
lowing augmentation using intraoral block bone grafts
were reviewed. Patients ranged in age from 17 to 71
years (average: 45.4 years). Medical history and
smoking habits were recorded. Recipient sites for in-
traoral block bone grafts included the mandibular
symphysis, retromolar area, and mandibular ramus.
All onlay bone grafts were performed 5.2 – 1.1
months before implant placement. One oral and max-
illofacial surgeon (DSA) performed all grafting proce-
dures and dental implantations using the operational
protocol described previously.
All implants were
Data collected from the ﬁles of patients included the
area of surgery, bone origin, implant location, implant
survival, and complications. Postoperative panoramic
radiographs that were taken following implant place-
ment and yearly thereafter were analyzed by two ex-
aminers (LL and DN) for marginal bone loss around
dental implants. Examiners had no information re-
garding any clinical parameters.
The marginal bone level was measured on ortho-
pantographs using the implant threads as an internal
standard, a technique formerly suggested by Haas
The bone level at the time of implant place-
ment was compared to that of the most recent fol-
low-up, and the number was subtracted. The number
of threads unsupported with bone in both the mesial
and distal sides of each implant was counted and av-
eraged for marginal bone loss calculations. The ac-
curacy level of this method is half a pitch of the
implant’s thread. The number of threads was con-
verted to millimeters using the given millimeter-per-
thread for that particular implant. The manufacturers
supplied the information concerning pitch of different
implant systems. Data were collected and analyzed
using a statistical program.
The main source for onlay bone augmentation was the
mandibular ramus (40%) followed by the symphysis
(36%). Figure 1 shows implant distribution according
to the anatomic zone. Follow-up from dental implant
placement ranged from 6 to 67 months (mean: 24.3
– 11.2 months). Overall, nine (18%) patients smoked,
with an average of 22 pack-years. Implants ranged in
width from 3.25 to 4.7 mm and in length from 10 to 16
mm. Most of the implants were 13 mm or longer
(82.9%) and 3.75 mm or wider (88.4%). The overall
survival rate was 96.9% (four of 129 implants failed).
The 5-year cumulative survival rate was 88% (Table 1);
one additional implant was lost 6 years postimplanta-
tion. Marginal bone loss around implants ranged from
0 to 3.3 mm (average: 0.22 – 0.45). Only 5% of the
implants presented marginal bone loss ‡1.5 mm dur-
ing the follow-up time (Fig. 2). Smoking was not found
to be related to implant failure.
Distribution of dental implants according to the anatomic zone of
5-Year Cumulative Survival Rate
Year N Implants Failures Cumulative Survival Rate (%)
1 101 0 100
Overall survival rate = 96.9%.
Distribution of marginal bone loss around implants.
i SPSS 10.0, SPSS, Chicago, IL.
J Periodontol • January 2007 Levin, Nitzan, Schwartz-Arad
The use of a bone graft for alveolar ridge augmenta-
tion is a widely performed procedure. Intraoral block
bone graft surgery is a relatively new area in dental im-
plantology. The use of bone from the mandibular sym-
physis, retromolar area, and mandibular ramus can
serve as a good treatment alternative for alveolar ridge
augmentation. The present study showed that intraoral
bone block graft surgery is a predictable operation for
the use of dental implants.
This procedure offers additional bone for dental im-
plant placement. The high implant survival and radi-
ologic success shown can be attributed, among other
factors, to the improvement of the crown-implant
ratio (Fig. 3). The higher amount of available bone
following augmentation allows placement of longer
implants in a better trajectory. In our previous study,
the average vertical addition was 5.6 mm measured
from the bottom of the vertical lesion before bone
grafting to the top of the graft. The average facio-
lingual addition was 3.8 mm. The mesio-distal graft
length ranged from 4 to 67 mm (average: 15.2 mm).
In this study, high survival and radiologic success
rates of dental implants in augmented bone were re-
ported, which further emphasized the predictability
of intraoral onlay bone grafts. Dental implants placed
in augmented bone using intraoral bone blocks could
serve as a predictable treatment modality with high
survival rates and low levels of marginal bone loss
In our previous reports,
smoking was associ-
ated with a high rate of complications and graft failure.
However, smoking status was not associated with
higher implant failure rates.
Further follow-up is
An intraoral bone graft from the mandibular symphy-
sis, retromolar area, and mandibular ramus can serve
as a good treatment modality for ridge augmentation.
Intraoral bone block graft surgery is a predictable op-
eration for the use of dental implants. Implant place-
ment in augmented areas presents high survival and
success rates with minimal marginal bone loss.
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A) Preoperative radiograph of vertical bone defect. B) Vertical and
horizontal augmentation with retromolar block bone grafts in the
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premolar. C) Panoramic view 5 years following rehabilitation.
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Correspondence: Dr. Devorah Schwartz-Arad, Department
of Oral and Maxillofacial Surgery, The Maurice and
Gabriela Goldschleger School of Dental Medicine, Tel Aviv
University, Tel Aviv, Israel. Fax: 972-3-6409250; e-mail:
Accepted for publication August 4, 2006.
J Periodontol • January 2007 Levin, Nitzan, Schwartz-Arad