Chapter 15
Chapter 15
Chapter 15
BONE GRAFTING/AUGMENTATION
Vocabulary and General Considerations
Bone grafting/augmentation materials can be separated into four broad categories, as shown in
Box 15-1 .
Box 15-1
CLASSIFICATION OF BONE GRAFTING MATERIALS
Allogenic.
Also allograft or homograft. Allogenic grafting material is harvested from the same species as
the recipient, but is of a different genotype. It is a graft taken from one human and transplanted
into another.
Xenogenic.
Also xenograft, heterograft, or heterologous graft. Xenogenic grafting material is harvested
from a species different from that of the recipient.
Alloplastic.
Also alloplast. Alloplastic grafting material is synthetic or chemically derived from a nonliving
source, and is inert.
Allogenic.
The consistency of allogenic grafting material required for a specific treatment depends on first
determining the character and volume of bone required at the host site. If autogenous material is
used as the primary graft component, the requirements of the secondary allogenic components
change. If autogenous material is not employed, use of a combination of particulate sizes of the
allogenic component may be indicated. Thus, host site requirements and the use of other
augmentation components affect whether the allogenic bone should be cortical and/or cancellous,
its particulate size, and its configuration if a cortical and/or cancellous bone block is required.
Various allogenic materials of every type of bone, texture, and particulate size are available,
including bone blocks in a wide variety of shapes and volumes. In addition, each variation is
available in treated forms to further enhance effectiveness and safety.
Xenogenic.
The consistency of the xenogenic grafting material required for a specific treatment generally
depends on the same considerations as when using materials of allogenic sources. Xenogenic
materials are usually harvested from treated bovine cadaver bone, and are supplied in a similar
array of variations useful for the many requirements of host sites. [12][13]
Alloplastic.
The consistency of alloplastic grafting materials depends on whether the case permits their use
alone, or requires their use in combination with autogenous and/or allogenic and/or xenogenic
materials. The character and volume of the host site, as well as the diagnostic reason for the
graft, help determine the type of alloplastic material required, its density, porosity, texture, and
particulate size or block shape and volume. Commonly used alloplastic materials are ceramics,
composites, polymers, hydroxy-apatites, calcium phosphates and carbonates, titanium oxides,
and bioactive glass granules.[5] Alloplastic materials are dense, porous, or microporous, and
sometimes have undergone treatments to enhance effectiveness and safety.
Barrier Membranes.
Barrier membrane materials may be natural, such as the dura protecting the brain or tendons
harvested from human or bovine cadavers, or synthetic, such as expanded or high-density
polytetrafluorethylene (PTFE).[14][15] Some are resorbable,[16][17] and others are not and therefore
must be surgically removed as part of the treatment protocol. Autogenous cortical plate is also
used as a barrier.
A list of many of the physiologic considerations and processes that bear on the success of
grafting/augmentation is shown in Box 15-2 .
Box 15-2
PHYSIOLOGIC CONSIDERATIONS AND PROCESSES THAT INFLUENCE
GRAFTING/AUGMENTATION TREATMENT
Bone Graft.
A bone graft is a tissue or material used to repair a defect or deficiency. It adds bulk or volume to
existing bone to solve a diagnosed problem.
Pluripotential Cells.
A pluripotential cell can differentiate into a fibroblast, osteoblast, osteoclast, or erythro-blast.
Only the physiologically functioning osteoblast produces bone, and this is the primary
consideration in bone grafting procedures. The sources of osteoblast-producing cells at the host
site are the blood supply, in which they circulate freely; the inner layer of the periosteum; and the
endothelial lining of marrow spaces within cancellous bone. [20]
Osteogenesis.
Osteogenesis is the development and formation of bone. The only entity that is osteogenic is a
physiologically functioning osteoblast. Osteoblasts exist at the host site and in autogenous graft
material, and can differentiate from pluripotential cells from all sources.
Osteoinduction.
Osteoinduction is the induction of bone formation in the absence of a bony host site. For instance,
certain bone morphogenic proteins (BMPs) refined from treated cortical bone have induced the
formation of bone when placed in muscle or liver tissues. [21][22] The probable source of required
osteoblasts to form bone in such locations is differentiation of pluripotential stem cells freely
circulating in the blood supply. In a series of events not yet completely understood, BMPs signal
stem cells to differentiate into osteoblasts to produce bone. [23][24][25]
Osteostimulation.
Osteostimulation is a physiologic action that stimulates, enhances, or accelerates the formation of
bone at a host site or healing endosteal implant. Osteostimulation is a far broader term than
osteoinduction, in that every osteoinductive material is osteostimulatory but not every
osteostimulatory material is osteoinductive. Cellular and ground substancemediated signals of
biomechanical, biochemical, and bioelectric origin are osteostimulatory. The regional
Osteoconduction.
Osteoconduction is the process by which a synthetic and inorganic material provides a bioinert
scaffolding that conducts and is compatible with bone growth. Osteoconductive materials do not
necessarily enhance bone formation, nor do they inhibit it. Rather, they guide the path and
progress of its formation. In general, alloplastic graft materials are osteoconductive. Some are
also osteostimulatory. It is interesting to note that healing around dental implants that exhibit
areas of direct bone apposition at the light microscopic level is an essentially osteoconductive
process.[8]
Bioactivity.
In bone augmentation, the term bioactive is similar to the term osteostimulatory. Consider the
enhanced bone growth observed in response to the wetting of particulate Bioglass with body
fluids. Because this material is inorganic, the nature of the signals it sends to enhance bone
growth is not clear, although it is hypothesized that particulate Bioglass may affect covalent bonds
and alter van der Waals forces, as suggested for AW (alumina/woolsonite) Glass.[29][30]
A nonreactive material that sends no ionic signals is referred to as bioinert.
0.01mg of BMP is yielded per kilogram of treated human cadaver bone, the synthesis of P-15 [31]
irreversibly bound to ABM (PepGen, CeraMed Dental) in sufficient concentrations to be effective
in the promotion of reparative cell migration from surrounding tissues represents a seminal
advance in grafting/augmentation materials.
Platelet-Rich Plasma.
Another emerging area is the use of platelet-rich plasma (PRP) as a grafting adjunct. This
autogenous material is sequestered from the patients blood and compacted by gradient density
centrifugation. The PRP thus collected is concentrated in excess of 300%. The beneficial
ingredients of the concentrate are a platelet-based growth factor and a beta transforming growth
factor. The addition of PRP to bone grafts increases the available amounts of these bone growth
factors, resulting in a substantial increase in the rate of healing. Histologic examination reveals
that these grafts exhibit greater bone density after healing. In-office systems are available to
ensure a dependable fresh supply of PRP to use in conjunction with a variety of implant dentistry
procedures.
Soft-tissue coverage
Infection control at host site
Volume and configuration of defect
Use or absence of autogenous bone in graft
Protection of extensive grafting during healing
Adequate healing time
Graft immobilization
Host blood supply
Bone mineralization requirements
Soft-Tissue Coverage
Secure, dependable closure following grafting is essential to success. First, determine that soft
tissue is sufficient following grafting to allow for tension-free closure. In cases of extensive
grafting, carefully estimate the potential adequacy of soft tissue for closure before placing the
material. The most common postoperative complication of grafting is dehiscence at the suture
line.
If insufficient tissue is present when the soft-tissue flaps are coapted, reflect tissue a bit more
extensively, and/or carefully score the periosteal lining of the inner portion of the flap with relief
incisions, and by applying tension, expand the soft tissue. Preserve as much attached gingiva as
possible. The second important element of dependable soft-tissue closure is adequate suturing.
Try to avoid friable tissue while suturing, and when possible penetrate through tough, dense,
attached gingiva, taking a deep bite with the needle. Generally, 3-0 black silk interrupted sutures
are placed with atraumatic needles. For friable tissue, 4-0 sutures are used. Tension-free suturing
is required to avoid tearing tissue. No particulate grafting material should remain in the suture
line. If a removable prosthesis is to be replaced provisionally following grafting, relieve the tissue
surface over the grafted area.
or five-wall defect, such as an extraction socket, occurs by adhesion to existing bone. Irrigation
and aspiration complete the preparation of the socket to accept the graft material.
Placement of the hydrated grafting material is accomplished in approximately 5-mm increments to
ensure uniform density. Each layer is applied into the socket firmly but remains loose enough to
permit blood supply throughout the area. The close approximation of the grafting material to the
fresh bony socket wall optimizes the osteostimulatory potential of the site.
Primary closure over extraction sites usually is difficult. Epithelium proliferates from the margins
of the wound at a rate of approximately 0.5 mm per day, to help seal over the socket to complete
the coverage and retain the graft material. Healing immediately following the extraction and
grafting must be protected. If tissue available for closure seems inadequate, a containment
device is needed. A surface-acting hemostatic material such as Gelfoam protects closure, slows
the flow of blood, and offers a framework for the deposition of cellular elements. This is an
inexpensive way to achieve containment of the graft material.
Preservation of ridge height and width is the benefit of this procedure. This is an ideal way to
introduce bone grafting into a clinical practice.
Clinically, few cases ideal for grafting immediately following tooth extraction exist. More often,
teeth are removed precisely because of inflammation and infection. Also, tissue closure over a
fresh extraction site often creates excessive tension at the closure line, or is not possible at all.
For these reasons, approximately 4 weeks of healing should be allowed after tooth removal
before grafting is performed. This time period resolves any present infection and allows adequate
soft tissue for dependable, secure closure to mature and keratinize. Dependable, secure, tensionfree suturing is possible, and success is more predictable. The disadvantages of this delay are
the need for extended treatment time and an additional surgical intervention.
The socket can heal without grafting, but with the loss of ridge height and width. Five-wall and
four-wall sockets or defects of other etiology require only small amounts of autogenous, allogenic,
xenogenic, and/or alloplastic grafting particulate. Following grafting, allow 5 to 6 months of
healing before inserting a dental implant. An exception is when an implant inserted into a new
extraction site fits imprecisely into its extraction site/implant osteotomy.[6]
Autogenous Bone
An important component of predictable bone grafting, autogenous bone is the only material that
forms bone with the aid of transplanted osteoblasts generally sourced from cancellous bone. This
cancellous bone provides few BMPs, if any.[8] Osteoconductive human cadaver bone products are
not viable. If autogenous bone is used, a minimal time between harvesting and grafting is advised
to retain as much cell viability as possible. In all instances in which autogenous bone is used, it is
placed directly against or into the host site.[11]
Graft Immobilization
If one incorporates the graft within the anatomy of the host site, mobility may be absent. [35]
Movement reduces the value of the host blood supply, and may promote fibrous encapsulation
and sequestration of the graft. In cases of larger grafts with fewer bony host site walls, screw
fixation can promote immobilization during healing. Again, provisional dentures, if used, are
relieved over all grafts.
GRAFTING COMPLICATIONS
Complications are well documented and variable because of differences in host site location,
volume, configuration, and physiologic and functional deficiencies that, when diagnosed, led to
the need for grafting. Improper diagnosis, treatment planning, grafting materials selection, and/or
case sequencing can all cause complications. In addition, poor soft-tissue management, the
immediate placement or placement of too many implants into a graft at the time of surgery in
certain cases, inadequate planning at the time of grafting to provide for proper esthetics, the
presence of undetected sinus or periapical pathology at the time of grafting, periodontal disease,
and certain adverse systemic and local conditions can compromise soft-tissue and/or bone
healing following grafting.
Biomechanically, a graft may be unable to function within physiologic limits of health if, for
example, too many or too few implants are placed into an autogenous graft. However, the greater
the number of implants placed at the time of grafting, the more one risks improper placement,
host bone fracture, or block graft cracking or fracture. Failure to institute progressive and careful
bone loading of large autogenous grafts can lead to complications.
Common postoperative complications are wound dehiscence, pain, and sinusitis. Poor flap
design can compromise blood supply. For reasons not fully understood, poor soft-tissue
management over autogenous grafts can lead to significant complications, to the extent that in
most cases it is advised that implants only be inserted into autogenous grafts following healing.
Autogenous soft-tissue grafts and gingivoplasty are often required for graft patients. Grafts are
best stabilized with fixation screws, not with implants. Stabilization wiring techniques are not as
predictable as fixation screws.
Clinical Considerations
The most common anatomic area in which ridge expansion is performed is the anterior maxilla,
followed by the posterior maxilla, and then the anterior and posterior mandible. As discussed in
Chapter 3 , the residual alveolar ridge in the maxilla is variable, and has a much higher
percentage of cancellous bone than in the mandible. Cancellous bone is pliable, and when
treated carefully, can be slowly expanded. In the case of the tapered Innova Endopore implants, a
series of graduated tapered osteotomes are available for this purpose. If exposure of the ridge
reveals inadequate width, a primary penetration is made at the crest in the planned long axis of
implant insertion with a 1-mm diameter XL carbide bur in a high-speed contra angle with copious
coolant. After penetrating 5 to 7 mm, the bur is moved mesially and distally no more than 2 mm. A
small, tapered cylindrical osteotome is introduced, aligned axially in the direction of intended
implant insertion, and tapped apically with a mallet to the correct depth for the chosen implant.
The assistant supports the ridge crest with finger pressure applied from both the labial and lingual
during malleting. A second osteotome is introduced and malleted to the appropriate depth, and
then a third graduated osteotome if required, to finally coordinate with the diameter and depth of
the selected implant. Seated round osteotomes are removed by rotating them only clockwise to
loosen their hold. Rotating both clockwise and counterclockwise can overexpand the site. The
coordinated trial fit gauge is malleted to position and twisted clockwise for removal, and the
implant is inserted. Crestal voids at the mesial and distal of the implant, if present, are grafted.
The case is sutured.
The parallel-sided Nobel Biocare/Steri-Oss RHL Immediate Insertion Implants use coordinated,
graduated, parallel-sided osteotomes in a manner similar to that described for the Innova
Endopore implants.
The Oratronics plate/blade form implants use graduated, tapered chisels inserted into preliminary
osteotomies and malleted to the desired depth to expand the ridge slowly. These are removed
through mesial and distal tilting only.
In many ridge expansion cases, implants are not immediately inserted. Rather, slow-resorbing
hydroxyapatite or another grafting material may be used to graft the internal void within the
expanded ridge. For example, ABM (OseoGraf/N-Block, CeraMed Dental) in block form can be
contoured for insertion into an expanded ridge. This type of graft benefits from excellent
protection, stability, and host blood supply. The grafted site is sufficiently rigid to maintain the
desired architecture and reduce the risk of ridge relapse during healing. The graft remodels to
vital bone through a cell-mediated resorption mechanism. After healing for 6 months, the
expanded and grafted ridge is exposed to prepare the osteotomies for implant insertion. Dense,
nonresorbable ceramic alloplastic grafting material is not used in such cases because it is difficult
to penetrate for osteotomy preparation.
Dental implant insertion in an expanded and grafted ridge is considered an intermediate or
advanced procedure.
NERVE REPOSITIONING
Cases that require nerve repositioning are rare. In implant dentistry, nerve repositioning is
performed to increase the volume of available bone for the insertion of endosteal implants, or in
the case of subperiosteal implants, to permit a superior framework design.
Clinical Indications
Nerve repositioning treatment is usually performed in the mandible. Rarely, to enable deeper
seating of an endosteal implant in an advanced case, an osteotomy is planned to pass either
lingual or buccal to the inferior alveolar nerve. In such cases, the nerve is approached from the
buccal and carefully repositioned either lingually or as close to the buccal as possible. This
creates a zone of safety either to the buccal or lingual of the repositioned nerve for the
preparation of one or more osteotomies.
In subperiosteal implantology, a mental nerve that exits the mental foramen at or near the crest of
the ridge can compromise the location and strength of the buccal main bearing struts designed to
clear the nerve at implant seating. To correct this, the position of the mental foramen can be
surgically lowered by judicious removal of bone, and the mental nerve repositioned apically as it
exits the altered area.
Other clinical conditions may indicate treatment requiring nerve repositioning. These procedures
are generally considered to be at the advanced level of practice.
DISTRACTION OSTEOGENESIS
A treatment that is currently gaining acceptance to enable predictable extension or lengthening of
bone is distraction osteogenesis.[40][41] In implant dentistry, this technique has direct applications
for patients with micrognathia and associated occlusal disharmony. As part of the preinsertion
regimen in implant dentistry, correction of an unfavorable occlusal relationship is accomplished
first to improve the prognosis of implant-supported prostheses. In addition, the esthetic
improvement can be striking.
Clinical Considerations
Distraction osteogenesis is a process by which bone is gradually lengthened by the action of an
appliance following the creation of a sectioning osteotomy at the anatomic area at which
additional bone is desired. Historically, in repositioning the mandible, such appliances have been
Figure 15-2 Distractors in position preactivation (lateral view). (Courtesy David Walker, Toronto,
Canada.)
Figure 15-4 Distractors in position postdistraction (inferior view). (Courtesy David Walker, Toronto,
Canada.)
Figure 15-5 Two months healing after distractor removal (lateral view). (Courtesy David Walker,
Toronto, Canada.)
Figure 15-5 Two months healing after distractor removal (lateral view). (Courtesy
David Walker, Toronto, Canada.)
REFERENCES
1. Boyne PJ: Induction of bone repair by various bone grafting materials, hard tissue growth,
repair and remineralization. Ciba Found Symp 1973; 11:121.
2. Becker W, Becker BE, Caffesse RA: A comparison of demineralized freeze-dried bone and
autologous bone to induce bone formation in human extraction sockets. J
Periodontol 1994; 65:1128.
3. Bowers G, et al: Histologic comparison of regeneration in human intrabony defects when
osteogenin is combined with demineralized freeze-dried bone allograft and with purified bovine
collagen. J Periodontol 1989; 62:675.
4. Becker W, et al: Human demineralized freeze-dried bone: inadequate induced bone formation
in athymic mice: a preliminary report. J Periodontol 1995; 66:822.
5. Damien CJ, Parsons JR: Bone graft and bone graft substitutes: a review of current technology
and applications. J Applied Biomat 1991; 2:187.
6. Misch CE, Dietsh F: Bone-grafting materials in implant dentistry. Implant Dent 1993; 2:158.
7. Lauer G, Schilli W: Collected implant cavity borings used as peri-implant osseous
augmentation material. Int J Oral Maxillofac Implants 1994; 9:437.
8. Gross JS: Bone grafting materials for dental applications: a practical guide. Compend Cont
Educ Dent 1997; 18:1013.
9. Tatum Jr O: Osseous grafts in intra-oral sites. J Oral Implantol 1996; 22:51.
10. Koole R, Bosker H, van der Dussen FN: Late secondary autogenous bone grafting in cleft
patients comparing mandibular (ectomesenchymal) and iliac crest (mesenchymal) grafts. J
Craniomaxillofac Surg 1989; 17:28.
11. Misch CE: Bone augmentation for implant placement: keys to bone grafting.
In: Misch C, ed. Contemporary implant dentistry, ed 2. St Louis: Mosby; 1998.
12. Hislop WS, Finlay PM, Moos KF: A preliminary study into the uses of anorganic bone in oral
and maxillofacial surgery. Br J Oral Maxillofac Surg 1993; 31:149.
13. Froum SJ, et al: Sinus floor elevation using anorganic bovine bone matrix (Osteograf/N) with
and without autogenous bone: a clinical, histologic, radiographic, and histomorphometric analysis.
Part II of an ongoing prospective study. Int J Periodont Rest Dent 1998; 18:529.
14. Dahlin C, et al: Healing of bone defects by guided tissue regeneration. Plast Reconstr
Surg 1998; 81:672.
15. Becker W, et al: Variations in bone regeneration adjacent to implants augmented with barrier
membranes alone or with demineralized freeze-dried bone or autologous grafts: a study in dogs.
Int J Oral Maxillofac Implants 1995; 10:143.
16. Sottosanti J: Calcium sulfate: a biodegradable and biocompatible barrier for guided tissue
regeneration. Compend Contin Educ Dent 1992; 13:226.
17. Polson AM: Guided tissue regeneration in human furcation defects after using a
biodegradable barrier: a multicenter feasibility study. J Periodontol 1995; 66:377.
18. Holmstrand K: Biophysical investigation of bone transplants and bone implants: an
experimental study. Acta Orthop Scand 1957; 26(suppl):
19. Pallasch TJ: The healing pattern of an experimentally induced defect in the rat femur studied
with tetracycline labeling. Calcif Tissue Res 1986; 2:334.
20. Melcher AH, Accurs GE: Osteogenic capacity of periosteal and osteoperiosteal flaps elevated
from the parietal bone of the rat. Arch Oral Biol 1971; 16:573.
21. Urist MR, DeLange RJ, Finerman GAM: Bone cell differentiation and growth factors.
Science 1983; 220:680.
22. Urist MR, Mikuiski A, Lietze A: Solubilized and insolubilized bone morphogenetic protein.
Proc Natl Acad Sci 1979; 76:1828.
23. Sampath TK, Reddi AH: Homology of bone-inductive proteins from human, monkey, bovine
and rat extra-cellular matrix. Proc Natl Acad Sci 1983; 80:6591.
24. Sampath TK, Muthukumaran N, Reddi AH: Isolation of osteogenin, an extracellular matrixassociated bone-inductive protein, by heparin affinity chromatography. Proc Natl Acad
Sci 1987; 84:7109.
25. Reddi AH, Wientroub S, Muthukumaran N: Biological principles of bone induction. Orthop
Clin North Am 1987; 18:207.
26. Shih MS, Norridin RW: Regional acceleration of remodeling during healing of bone defects in
beagles of various ages. Bone 1985; 6:377.
27. Frost H: The regional acceleratory phenomenon: a review. Henry Ford Hosp Med
J 1983; 31:3.
28. Weiss CM: Dental implants: physiologic and clinical comparisons of fibro-osteal and osteal
integration. J Gen Dent 1988; 36:243.
29. Hench LL, Wilson J: Bioactive materials. Mat Res Soc Symp Proc 1986; 55:65.
30. Kitsugi T, et al: Bonding behavior between two bioactive ceramics in vivo. J Biomed Mater
Res 1987; 21:1109.
31. Qian JJ, Bhatnagar RS: Enhanced cell attachment to anorganic bone mineral in the presence
of a synthetic peptide related to collagen. J Biomed Mater Res 1985; 76:2323.
32. Lin KY, et al: The effect of rigid fixation on the survival of onlay bone grafts: an experimental
study. Plast Reconstr Surg 1990; 86:449.
33. Jones JK, Triplett RG: The relationship of cigarette smoking to impaired intraoral wound
healing: a review of evidence and implications for patient care. J Oral Maxillofac
Surg 1992; 50:237.
34. Tofe AJ, Watson BA, Bowerman MA: Solution and cell mediated resorption of grafting
materials. J Oral Implantol 1991; 17:345.(abstract)
35. La Trenta GS, et al: The role of rigid skeletal fixation in bone graft augmentation of the
craniofacial skeleton. Plast Reconstr Surg 1989; 84:578.
36. Dequeker J, Merlevede W: Collagen content and collagen extractability pattern of adult
human bone according to age, sex and degree of porosity. Biochem Biophys
Acta 1971; 244:410.
37. Jarcho M: Calcium phosphate ceramics as hard tissue prosthetics. Clin
Orthop 1981; 157:259.
38. LeGeros RZ: Calcium phosphate materials in restorative dentistry: a review. Adv Dent
Res 1988; 2:164.
39. Tatum H: Maxillary and sinus implant reconstruction. Dent Clin North Am 1986; 30:207.
40. Altuna G, Walker DA, Freeman E: Rapid orthopedic lengthening of the mandible in primates
by sagittal split osteotomy and distraction osteogenesis: a pilot study. Int J Adult Orthodont
Orthognath 1995; 10:59.
41. Ilizarov G, Devyatov A, Kamerin V: Plastic reconstruction of longitudinal bone defects by
means of compression and subsequent distraction. Acta Chir Plast 1980; 22:32.
42. Walker DA, Nish I: Multi directional buried mandibular distraction osteogenesis appliances
and techniques. J Cranio Maxillofac Surg 1998; 56(suppl 4):49.
43. Innovative technology for the new millennium with the ACE OsteoGenic Distractor, ACE
Dental System, 1999 (brochure).