Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629

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Journal of Cranio-Maxillo-Facial Surgery

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Clinical efficacy of grafting materials in alveolar ridge augmentation:

A systematic review*
Markus Troeltzsch a, *, Matthias Troeltzsch b, Philipp Kauffmann a, Rudolph Gruber a,
Phillipp Brockmeyer a, Norman Moser a, Anna Rau c, Henning Schliephake a
a
Department of Maxillofacial Surgery (Head: Prof. Dr. Dr. H. Schliephake), University of Goettingen, Germany
b
Department of Maxillofacial Surgery, Ludwig e Maximilians e University of Munich, Germany
c
Department of Anesthesiology, University of Goettingen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To evaluate the efficacy of grafting materials in lateral and vertical ridge augmentations.
Paper received 2 March 2016 Materials and methods: A systematic review of the literature on the clinical use of grafting materials of
Accepted 29 July 2016 the years 1995 to April 2015 was conducted using electronic search of PubMed and Cochrane libraries
Available online 18 August 2016
and hand search of eight print journals. A total of 184 papers were included, comprising 6182 patients.
Parameters evaluated were observation period [months], bone formation [histologic area%], defect fill
Keywords:
[%], horizontal and vertical gain [mm], loss of augmented volume [mm], complication rate [%], and
Augmentation
implant survival rate [%]. Results are expressed as weighted means ± SD.
Bone grafting
Vertical augmentation
Results: Results were obtained after a weighted mean observation period of 27.4 months (range 3e168
Horizontal augmentation months). Bone formation in the augmented areas varied from 33.2 ± 14.9% for allogeneic grafts to
Implants 56.0 ± 25.6% for mixtures of autogenous and other grafting materials. Defect fill in dehiscence defects
ranged from 51.0 ± 13.6% (synthetic) to 85.8 ± 13.4% (xenogeneic) for the different materials, with an
overall weighted mean of 79.8 ± 18.7%. Weighted mean horizontal gain for all particulate grafting ma-
terials was 3.7 ± 1.2 mm, with variation between 2.2 ± 1.2 mm (synthetic) and 4.5 ± 1.0 mm (mixtures of
autogenous bone with allogeneic/xenogeneic grafting material) without statistical significance.
Weighted overall mean vertical gain was 3.7 ± 1.4 mm. Vertical gain was substantially higher when
space-making barrier materials such as titanium meshes were used; however this was also associated
with strong increase in complication rate. Block grafts achieved higher horizontal gain by approximately
1 mm. The use of block grafts achieved significantly increased vertical gain compared to particulate
material only when autogenous block grafts from extraoral donor sites were used.
Conclusion: Horizontal and vertical gain by 3.7 mm on average can be achieved using particulate ma-
terials. This can be increased by using titanium meshes. Substantial vertical gains beyond this dimension
require the use of extraoral bone block grafts.
© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction

Oral rehabilitation frequently requires the repair of alveolar

Dr. Dr. Markus Troeltzsch and Dr. Dr. Matthias Troeltzsch contributed equally to
this systematic review and share first authorship.
*
The publication shall be attributed to the Department for Maxillofacial Surgery,
University of Goettingen, Koch Str. 40, 37075 Goettingen, Germany.
* Corresponding author. Department of Maxillofacial Surgery, University of
Goettingen, Robert Koch Str. 40, 37075, Goettingen, Germany. Fax: þ49 551 39
12653.
E-mail address: troeltzsch@gmx.net (M. Troeltzsch).
bone defects before prosthetic restoration can be achieved with
acceptable long-term stability. The history of alveolar bone loss as
well as the location and the extent of the resulting defects
commonly determine the necessity and the strategy for defect
repair. One of the most frequent reasons for reconstruction of the
alveolar ridge is the lack of adequate bone volume for the place-
ment of dental implants. Therefore, bone grafting procedures of the
alveolar ridge are expected to provide sufficient bone height, bone
width, and ridge contour for implant placement in order to provide

http://dx.doi.org/10.1016/j.jcms.2016.07.028
1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629
favorable hygiene conditions for healthy periimplant tissues and
satisfactory esthetics.
The use of autogenous bone grafts for ridge repair has been
considered as the gold standard for obvious biological reasons
(Bauer and Muschler, 2000; Reddi et al., 1987; Spin-Neto et al.,
2013a). However, the surgical morbidity associated with graft pro-
curement procedures has triggered countless attempts to avoid a
second surgical site for graft procurement by using allografts, xe-
nografts, or synthetic material to replace the lost alveolar bone. The
market offers a confusing variety of commercially available grafting
materials with different levels of scientific proof of their efficacy.
The ultimate goal for the use of bone grafting materials is the
repair of bone to an extent that completely fills the defect and re-
stores the former shape of the ridge. The ingrowth of bone into the
grafting materials occurs through osteoconduction from the adja-
cent defect walls and follows the vascularization that invades the
graft material. Hence, the structure and size of the graft as well as
the defect geometry determine the extent of bony regeneration. As
tissue ingrowth from the overlying soft tissue does not form bone
in non-autogenous grafting materials (Bauer and Muschler, 2000;
Merten et al., 2003; Wiese and Merten, 1993; Wiltfang et al.,
1997), the use of these materials is commonly combined with the
use of barrier membranes that occlude the underlying defect from
non-osseous tissue ingrowth, following the principles of guided
bone regeneration.
The variety of grafting materials and the high number of
possible combinations with membrane materials is increased by
different preparations in terms of particle size and shape of the
grafting materials. A systematic evaluation of this large array of
variables is complicated by different defect geometries and
augmentation techniques. A randomized controlled trial that could
evaluate and compare such a matrix of variables in a comprehen-
sive and systematic manner would be impossible to perform.
However, countless reports of clinical and histological results from
case series and cohort studies provide a large body of knowledge
about the clinical performance of these materials that constitutes a
kind of “community wisdom” and, if carefully reviewed, may pro-
vide valid information from which useful conclusions for clinical
recommendations can be drawn. It is obvious that the validity of
this compilation of results is limited by the heterogeneity of the
included study designs and outcome parameters.
It was the idea of the present approach that a strict selection of
studies with respect to quality of methodology, description of
confounding parameters, and clear reporting of metric results
would create a collection of objective data that would allow also for
the application of basic statistical tests.
The aim of the present work was to assess the clinical efficacy of
grafting materials in the reconstruction of the alveolar ridge through
a systematic review with respect to clinically relevant parameters in
different augmentation techniques and grafting materials.
2. Material and methods
This review was conducted and written with respect to the
Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA) guidelines (Liberati et al., 2009). The criteria of
the Amstar and Glenny Scores were considered while conducting
the search (Pieper et al., 2015; Zeng et al., 2015).
2.1. Search strategy
An electronic search was conducted in the PubMed and Cochrane
libraries. Results from 1995 until April 2015 were included. The
following search terms resulted in the indicated number of articles:
augmentation dental (4007), augmentation bone (8398),
1619
augmentation jaw (3133), bone graft horizontal (571), bone graft
vertical (1084), horizontal defect (850), vertical defect (1295),
combined augmentation (2630), vertical sandwich (100), dehiscence
defect (891), implant dehiscence (669). Additionally, reference lists
from systematic reviews and meta-analyses were screened, leading
to a hand search of the following journals from 1995 to April 2015:
International Journal of Oral and Maxillofacial Surgery, Journal of
Oral and Maxillofacial Surgery, Journal of Craniomaxillofacial Sur-
gery, Journal of Clinical Periodontology, Journal of Periodontology,
Clinical Oral Implant Research, International Journal of Oral Maxil-
lofacial Implants, Clinical Implant Dentistry and Related Research.
The following inclusion criteria were defined: human study,
augmentation preceding implant placement, augmentation simul-
taneous to implant placement, all study population sizes including
case reports, hard tissue augmentation, and metric results stated in
the paper.
The following exclusion criteria were defined: non-human use,
soft tissue augmentation, augmentations outside the oral and
maxillofacial area such as orthopedic indications, augmentations
related to free flaps, reports of implant stability or survival without
information about the augmentation, and a lack of metric results
were defined.
This search revealed 23,638 papers. After the exclusion of du-
plicates 11,742 studies were considered and title screened. All
studies that reported non-human use (material research, experi-
mental studies, preclinical evaluation) were excluded. If there was
doubt about the relation to the search topic the abstract was
considered. This procedure generated 2361 publications.
2.2. Screening and eligibility
The remaining 2361 papers were screened by abstract. In
studies that compared the use of growth factors or other biologicals
with grafting materials, only the control group was included, if
metric results were provided. If there was doubt about the nature of
the results, full text analysis was performed. After this procedure,
463 papers remained in the investigation. The selection process is
depicted in Fig. 1.
For the present review, only studies reporting on lateral and/or
vertical ridge augmentation as well as repair of dehiscence defects in
conjunction with implant placement were considered (n ¼ 184). Due
to the huge amount of data papers on sinus lift, socket filling pro-
cedures and periimplant augmentation following periimplantitis
and/or periodontal disease (n ¼ 279) were not considered.
For the 184 studies included into the full text evaluation, the
following data were recorded: 1) the type of paper (case reports
(n  3), case series, retrospective cohort study without controls,
controlled study, randomized controlled trials), 2) defect type
(dehiscence defects inside the skeletal envelope around simulta-
neously placed implants vs. ridge defects outside the skeletal en-
velope that underwent horizontal and/or vertical augmentation as
well as sandwich osteotomies with gap grafting), 3) the type of
grafting material (autogenous extraoral and intraoral, allogeneic,
xenogeneic, synthetic), 4) the type of graft preparation (particulate
vs. block grafts), 5) the type of barrier material used (collagen based,
PTFE, polymer, titanium), and 6) the number of treated patients.
2.3. Outcome parameters
Metric data on the following outcome parameters were extrac-
ted: a) observation period [months], b) bone formation [histologic
area%], c) defect fill [%], d) horizontal gain [mm], e) vertical gain
[mm], f) loss of augmented width/height [mm], g) complication rate
[%], and h) implant survival [%]. No implant success was registered,
as the definitions used were too heterogeneous to be included
1620 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629
Exclusion of duplicates
Application of exclusion
Inclusion:
- Metric results
- Oral augmentations
- No biologicals
- No groth factors
Fig. 1. Selection process of the studies.
(Buser et al., 2013; Chen and Buser, 2014; Pelo et al., 2007; Tarnow
et al., 2014). Defect fill had been assessed metrically during abut-
ment connection surgery as vertical reduction in defect height, the
reference point for 100% fill being the shoulder of the simulta-
neously placed implant. Horizontal and vertical gains were evalu-
ated using various means: 77 studies had used radiologic
assessment, and in 49 studies the augmented area was reopened and
direct measurement was applied. A periodontal probe was used in
closed procedures in 40 investigations, whereas the methods were
mixed in 12 papers. As done in previous reviews and meta-analyses,
the measuring methods were not considered separately during
calculation of weighted means (Al-Nawas and Schiegnitz, 2014;
Carini et al., 2014; Milinkovic and Cordaro, 2014). The 6 included
reviews and meta-analyses drew the data from the literature
included. From these studies, metrical data was used only if it was
not already reflected by the included investigations.
If uncertainty occurred during full-text analysis about the pro-
cess of data evaluation and the validity of the reported metric re-
sults, the authors of the respective study were contacted. This was
the case in 20 reports. If the ambiguity was not resolved, the study
was excluded from further evaluation.
If studies had analyzed more than one graft material in more than
one defect per patient, the results were registered separately for
each application in the respective material groups. This resulted in
the fact that the number of applications available for evaluation was
larger than the number of patients in the included studies. Not all
applications provided a full set of outcome parameters. This resulted
in a varying group size of the data sets from which individual
outcome parameters were assessed for each material/application.
2.4. Statistical analysis
Weighted means and weighted standard deviations were
calculated from the data of the included studies for each material/
preparation group to account for the varying number of applica-
tions in each study. Due to the large differences in groups sizes with
respect to grafting material and preparation, the calculated statis-
tics had to be evaluated with care. All data were analyzed with
GraphPad Prism 5 (GraphPad Software, La Jolla, CA, USA). Outcome
parameters (a through h) were analyzed for the different types of
defect, graft material, preparation, and barrier material by one-way
analyses of variance or by the nonparametric KruskaleWallis test if
First search
23638 titles
11742 titles Exclusion:
- Non human
- Soft tissue augmentation
only
criteria (abstracts) - Barrier membranes only
2361 titles
Total full text articles
463 titles
Periimplantitis and
Horizontal / Vertical / Periodontal-disease
Dehiscence Defects 279 titles
184 titles
the normality test failed, respectively. Weighted means were used
where applicable. When a significant difference was detected by
analysis of variance, post hoc analysis was performed with the
Bonferroni test for pairwise comparisons to pinpoint the difference.
The significance level was set as p < 0.05.
3. Results
An overview of the 184 publications included into this review is
given in Fig. S1. To assess the value of the included reviews, the
Amstar and Glenny scores were applied. The results can be seen in
Fig. S1. The analysis considered 7473 applications of graft material in
6182 patients. The pattern of material use had changed over the
observation period, with an initial preponderance for xenogeneic
grafts that was more and more modified by the use of synthetic
material and, even more in more recent years, by the use of allo-
geneic graft material (Fig. 2). All in all, 927 applications of xenoge-
neic material, 185 applications of synthetic material, and 1377 uses
of allogeneic material were registered. Autogenous bone was used in
2356 applications. A mixture of various materials was applied in
1956 defects. The graft materials were used in various combinations,
with 2234 collagen-based membrane applications, 717 uses of non-
resorbable synthetic barriers (extended/dense polytetrafluoro-
ethylene [PTFE]), 186 applications of polymer membranes (polylactic
acid, polyglycolic acid [PLA/PGA]), 199 cases of allogeneic bone
shields, and 478 applications of titanium meshes.
3.1. Efficacy of graft materials in dehiscence defects
For this study, dehiscence defects were defined as a fenestration
or crestal bone deficit occurring during implant placement.
Data from 1877 applications of graft materials in dehiscence
defects inside the skeletal envelope could be evaluated from 37
studies. Only particulate materials had been used in these defects.
The observation period varied considerably from 7 ± 3 months
(autogenous bone) to 42 ± 27 months (autogenous/mixture grafts)
(p ¼ 0.102). The overall weighted mean of defect fill in dehiscence
defects using particulate material was 79.8 ± 18.7%. The percentage
of defect fill for the individual graft materials varied from
51.0 ± 13.6% (synthetic) to 85.8 ± 13.4% (xenogeneic) (p ¼ 0.219)
(Fig. 3). The extent of defect repair was affected by the barrier
material used. The lowest defect fill occurred if no barrier material
 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629 1621

was used (59.0 ± 22.6%), followed by the use of polymer mem-

branes (PLA/PGA: 70.2 ± 18.1%) (Fig. 4). The highest defect fill was
found in the group of titanium-based barriers (88.9 ± 5.5%). These
differences were not statistically significant when comparing all
groups (p ¼ 0.309). The complication rate was affected by the use of
the membrane material as well, with collagen-based barriers
providing the lowest (10.4 ± 16.7%) and polymer (PLA/PGA)
membrane the highest percentage (37.4 ± 26.5%) (p ¼ 0.621).
Implant survival varied between 95.8% (graft material) and 100%
(graft material) without statistical significance. The percentage of
bone that had occupied the graft volume in dehiscence defects was
not evaluated, as it had been documented in only 3 studies.

3.2. Efficacy of graft materials in horizontal/vertical augmentation

For this investigation, horizontal and vertical augmentation

were defined as those adding to the height and width of the
existing bony structure. Ridge preservation and socket augmenta-
tion procedures are not included. An overview of the overall hori-
zontal and vertical values is provided in Fig. 5.
Data on the efficacy of grafting materials in augmentations
outside the skeletal envelope were evaluated both in the horizontal
and vertical directions. Horizontal gain was assessed for horizontal
Fig. 3. Dehiscence defect fill.
and combined horizontal/vertical defects, and vertical gain was
evaluated for vertical defects and combined vertical/horizontal
3.3. Particulate grafts
defects. All in all, data from 4955 applications in 121 studies were
evaluated. The observation time varied considerably between
The overall weighted mean in horizontal gain in ridge dimension
15.9 ± 9.9 months (synthetic), 18.2 ± 20.6 months (allogeneic),
with particulate material was 3.7 ± 1.2 mm. The horizontal gain was
22.8 ± 30.7 months (autogenous), 30.0 ± 22.3 months (xenogeneic),
significantly higher for mixtures of autogenous bone with alloge-
and 54.7 ± 32.6 months (mixture of autogenous and other graft
neic/xenogeneic grafting materials (4.5 ± 1.0 mm) compared to the
materials). The degree of bone formation within the grafted volume
use of synthetic grafting materials (2.2 ± 1.2 mm) (p ¼ 0.003). There
was assessed from 593 applications and varied between
was no significant difference between the other graft material
33.2 ± 14.9% (allogeneic), 45.6 ± 21.4% (xenogeneic), 48.1 ± 6.5%
groups (Fig. 6). The vertical gain varied without significant difference
(synthetic), 51.5 ± 15.9 (autogenous) and 56.6 ± 24.0% for mixtures
from 3.6 ± 1.0 mm in mixtures of autogenous bone with allogeneic/
of autogenous and other grafting materials. These differences
xenogeneic grafting materials to 3.9 ± 1.7 mm for particulate
reached near significance (p ¼ 0.09).

Fig. 2. Material use over time in included publications.

1622 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629

Fig. 4. Overview of the overall horizontal and vertical values.

autogenous grafts derived from mandibular bone with an overall

weighted mean of 3.7 ± 1.4 mm. The horizontal loss observed after Fig. 6. Particulate material: horizontal/vertical augmentation gains.
9.1 ± 10.7 months (allogeneic), 20.4 ± 14.7 months (synthetic),
27.9 ± 30.6 months (autogenous), 48.8 ± 29.2 months (xenogeneic),
3.4. Block grafts
and 66.5 ± 37.2 months (mixtures of autogenous bone with alloge-
neic/xenogeneic) after augmentation differed between 0.7 ± 0.5 mm
The use of block grafts in horizontal and/or vertical ridge
for particulate bone from extraoral grafts and 1.2 ± 0.9 mm for
augmentation has been able to achieve higher gains in horizontal
mixtures of autogenous bone and allogeneic/xenogeneic grafts. The
dimensions than particulate materials with weighted means be-
vertical loss observed after 22.9 ± 21.1 months (allogeneic),
tween 3.7 mm for xenogeneic and 4.6 ± 1.4 mm for allogeneic
28.3 ± 32.8 months (autogenous), 43.9 ± 32.6 months (xenogeneic),
blocks, with an overall weighted mean of 4.5 ± 1.2 mm. Gains in
and 80.8 ± 42.4 months (mixtures of autogenous bone with allo-
vertical dimensions were significantly increased for autogenous
geneic/xenogeneic) after augmentation ranged between
bone blocks from the iliac crest and the calvarium (9.4 ± 3.1 mm)
1.1 ± 0.6 mm (autogenous bone) and 1.4 ± 1.0 mm (allogeneic). There
compared to autogenous bone grafts from the mandible
was no significant difference between the material groups. The use
(5.3 ± 1.6 mm) and allogeneic (2.9 ± 1.3 mm) (p < 0.0001) (Fig. 8).
of barrier material appeared to have an effect on the vertical rather
Losses of both horizontal and vertical dimension were small for
than on the horizontal gain in ridge dimension. Space-making ma-
allogeneic blocks (0.4 ± 0.5/0.6 ± 1.0 mm, respectively) and reached
terials such as titanium meshes resulted in larger vertical gains in
1.2 ± 3.4/2.9 ± 1.9 mm, respectively, for autogenous blocks of
ridge height (6.0 ± 2.3 mm) than collagen based barriers
extraoral sources. In these procedures, the standard deviation was
(3.9 ± 1.9 mm), although without a significant difference. However,
high, indicating occasionally substantially higher losses in di-
the reported complication rates were higher for the use of titanium
mensions. Complication rates associated with horizontal gains
meshes compared to collagen-based materials without significance
ranged between 13.1 ± 13.6% for allogeneic block grafts and
(p ¼ 0.194) and a very high variance between the examined studies
7.1 ± 17.0% for extraoral bone grafts. The complication rate of 75%
(Fig. 7). Implant survival ranged from 96.1% to 99.4%, with no sig-
xenogeneic blocks was derived from one study with 20 applications
nificant differences between the type of material or application.

Fig. 5. Dehiscence defect barrier material: defect fill and complication rate.
 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629
Fig. 7. Particulate material: barrier material e gain and complication rates.
Fig. 8. Block material: horizontal/vertical augmentation e gain and complication rates.
and may not be comparable to other types of grafts used in this
indication. In contrast complication rates associated with vertical
gain were clearly higher with 25.0 ± 20.3% for allogeneic block
grafts, 20.1 ± 16.8% for extraoral autogenous bone and 14.4 ± 14.5%
for intraoral bone blocks. Differences between complication rates
associated with horizontal and vertical gain were not significant in
the respective material groups. Implant survival varied between
96.1 and 98.9, without any significant difference between types of
material or application.
3.5. Sandwich augmentation
Data for sandwich osteotomies could be derived from 26 studies
with 641 applications. The vertical gains ranged from 2.2 ± 3.5 mm
for allogeneic grafts, 4.4 ± 1.9 mm for autogenous intraoral bone
1623
grafting, 6.5 ± 4.3 mm for xenogeneic grafts, to 8.6 ± 4.3 mm for
autogenous bone grafts from the iliac crest. Differences between
the types of graft were not significant (p ¼ 0.2). Loss of vertical
height ranged from 0.5 to 2.3 mm without statistical significance.
The complication rate varied between 7.8 ± 6.2% for autogenous
intraoral bone grafting to 43.5 ± 24.3% for xenogeneic grafts
(p ¼ 0.394). Implant survival varied between 92.5% and 100.0%,
with no significant difference between the types of grafts.
4. Discussion
The present review examines data from 184 studies on the use of
grafting material for alveolar ridge reconstruction in conjunction
with implant placement. The goal of this systematic review was to
assess the clinical efficacy of grafting materials in the indication of
periimplant dehiscence reconstruction on the one hand and vertical
and horizontal augmentation of the alveolar ridge on the other.
The results obtained for the issue of “reconstruction of peri
implant dehiscence defects” have shown that the use of barrier
membranes have a beneficial effect on the degree of defect fill. They
may also be interpreted to suggest that successful defect fill depends
on the barrier material, as the use of different barrier materials was
associated with different complication rates, and the degree of defect
fill appeared to be inversely related to the rate of complications.
However, these differences did not reach statistical significance.
The overall results considering horizontal and vertical augmen-
tations outside the skeletal envelope are demonstrated in Fig. 5.
Considerably higher gains could be detected only under certain
circumstances, as discussed below. On the one hand, this corre-
sponds to the fact that histologic bone formation did not differ
significantly between materials, and, on the other hand, it provides a
clinically useful “bench mark” for augmentation procedures of
alveolar crest defects outside the skeletal envelope using particulate
grafting materials. This bench mark may be considerably surpassed
if titanium meshes are used in conjunction with particulate grafting
materials that provide three-dimensional stability to the augmented
volume. The use of titanium meshes, however, appears to be tech-
nique sensitive, as it has been associated with a higher complication
rate, although the differences reached only near significance.
It is also interesting to note that the use of block graft material
has only slightly improved the horizontal gain to an overall
weighted mean of 4.5 mm. This may be accounted for by the fact
that even with a minimum residual ridge width of 1e2 mm, not
much more than additional 4.5 mm on average is required to
provide enough width for implant placement. Results for the use of
block grafts for vertical augmentation suggest that any material
other than autogenous bone blocks from extraoral donor sites will
not significantly improve the vertical gain. In particular, allogeneic
block grafts did not appear to perform in a comparable way when
vertical gain and complication rate were integrated.
Individual controlled trials have shown a low degree of graft
incorporation with a rather high rate of dehiscences and implant
losses (Felice et al., 2008).
The results thus suggest that if large-volume vertical augmen-
tations of the alveolar ridge are necessary, the use of autogenous
bone blocks from the iliac crest or the cranium is still required to
provide sufficient gain in height. For smaller volume requirements,
particulate graft material of various origin can be expected to
perform reliably well, as has been shown by the present results. This
is particularly interesting when patient recovery (Felice et al., 2008)
and comfort are included in the overall assessment. Some studies
investigated specifically patient comfort, and while no significant
difference in the clinical performance could be demonstrated for
many materials and methods, this may not be true for the patients'
postoperative discomfort. The non-autologous materials showed a
1624 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629

significantly better outcome when compared to autogenous mate-
rials, especially iliac bone, with regard to the patients well-being
and preference in the days after the surgery (Chiapasco et al.,
2004, 2007; Felice et al., 2008, 2009b, 2010). In the study of Felice
et al. (2008) with direct comparison between a bovine material
and iliac bone, the patients clearly preferred the xenogeneic mate-
rial, with equal clinical results. With respect to the incidence of
perioperative complications, allogeneic blocks showed a high rate
for vertical augmentations. This finding has been reported before
(Chiapasco et al., 2015). Furthermore, several authors asserted that
allogeneic material lacked osteoinductive capacities (Bauer and
Muschler, 2000; Brownfield and Weltman, 2012; Paul et al., 2001)
and immunogenic issues remain under discussion, despite the fact
that the actual literature shows no significant challenges to the
immune system (Spin-Neto et al., 2013a). The results of this review
support those of previous results with respect to implant survival,
showing no effect of grafting material in all evaluated applications
(Aghaloo and Moy, 2007; Al-Nawas and Schiegnitz, 2014).
Another result that is known already from preclinical studies is
the fact that the type of graft material did not affect the degree of
bone formation inside the material if the observation period was
long enough, namely, between 15 and 54 months.
Among the analyzed studies, there were 44 controlled and 23
randomized controlled trials. Six meta-analyses and systematic re-
views were included. Hence, the majority of reports (n ¼ 88) that
qualified for data extraction were case series or case reports. This
may raise concerns as to the validity of the analyzed data due to
methodological limitations. However, even the 53 included
controlled trials that evaluated 13 different materials or combina-
tions thereof have not been able to provide a comprehensive picture
of the clinical efficacy of grafting materials, by comparing either
these materials or their use in different procedures, mostly in a
pairwise fashion due to the huge variety of materials and procedures.
This may demonstrate the need for a wider approach to evaluating
existing knowledge without discarding a lot of valid information that
is available but does not fit into the strict inclusion criteria for a
meta-analysis. The present review aimed to include valid data from
reports of lower evidence levels that would otherwise have been
ignored. The authors are aware that this potentially implied a source
of considerable bias. Part of this effect was intended to be eliminated
by strict control of data quality from included case series and case
reports. Heterogeneity of the included study settings would have
provided another source of bias that had been taken into account by
performing comparisons of materials separately for procedures and
defect types. Unfortunately, statistical heterogeneity as a measure for
variation of study results beyond the variation by chance cannot be
calculated here, as case reports or small case series cannot provide
confidence intervals that form the basis for such calculations.
Nevertheless, heterogeneity as a measure of differences between
study outcomes has to be considered as high, and would be
accounted for by assuming random effects between study results,
that is, assuming that the variation of results follows a normal dis-
tribution. Finally, additional weaknesses can be introduced by the
large number of surgeons involved in the included studies. as indi-
vidual technical details may have contributed to the quality of in-
dividual results. However, following the idea of characterizing an
average result for the clinical efficacy of grafting materials that an
average practitioner may achieve when they are using these mate-
rials in the various procedures, a large number of included surgeons
may as well be considered as a strength in the sense of a represen-
tative sample that adds some “impurity of clinical reality.” The het-
erogeneity in sample size constituted another burden for the
evaluation that was accounted for by using weighted means and
weighted standard deviations, as well as applying weighting func-
tions during statistical testing. In this way, the various effects of
heterogeneity of included studies were considered to have been
appropriately addressed.
5. Conclusion
In conclusion, the present systematic review has shown that a
satisfactory degree of defect fill in dehiscence defects of approxi-
mately 80% around implants can be achieved using grafting ma-
terials without any preference for their origin. Horizontal and
vertical defects can be augmented predictably until a width/height
of approximately 3.7 mm using particulate grafting material. The
use of block-shaped grafts can improve the horizontal gain by
approximately 1 mm, whereas significant improvement in vertical
gain can be achieved only by using an autogenous bone block from
the iliac crest or the cranium.

Tables: Overview of the included studies, by indication and material

Dehiscence defects

Materials References
used

Allograft Fu et al. (2014), Le and Borzabadi-Farahani (2014), Park (2011), Park (2010), Park (2007), Park and Wang (2006), Viswambaran et al. (2014)
Xenograft Albiero et al. (2014), Canullo and Malagnino (2008), Carpio et al. (2000), Corrente et al. (1997), Hammerle and Lang (2001), Jung et al. (2015), Juodzbalys et al.
(2007), Lorenzoni et al. (1998), Nemcovsky et al. (2002), Tarnow et al. (2014), Taschieri et al. (2014), van Steenberghe et al. (2000), Zitzmann et al. (1997),
Zitzmann et al. (2001a, b), Zuffetti et al. (2013)
Synthetic Babbush and Kanawati (2015), Konstantinidis et al. (2015), Soliman et al. (2014), Viswambaran et al. (2014)
Autograft Hassan (2008), Lee et al. (2013), Llambes et al. (2007), Lorenzoni et al. (1998), Merli et al. (2007), Peleg et al. (1999), Schlegel et al. (1998), Tawil et al. (2001),
Veis et al. (2004), von Arx and Kurt (1999), Widmark and Ivanoff (2000)
Material mix Hassan (2009), Jensen et al. (2014), Jensen and Terheyden (2009), Jung et al. (2014), Ronda et al. (2014), Wiltfang et al. (2012)

Horizontal defects
Particulate

Materials References
used

Allograft Beitlitum et al. (2010), Caldwell et al. (2015), Eskan et al. (2014), Feuille et al. (2003), Fu et al. (2014), Geurs et al. (2008), Khojasteh et al. (2012a),
Vidyadharan and Ravindran (2014)
Xenograft Bazrafshan and Darby (2014), Block et al. (2012), De Angelis and Scivetti (2011), Di Stefano et al. (2009), Hammerle et al. (2008), Khojasteh et al. (2012a),
Kuchler and von Arx (2014), Zuffetti et al. (2013)
Synthetic Ella et al. (2014), Knapp et al. (2003), Shalash et al. (2013), Strietzel et al. (2007)
Autograft Al-Nawas and Schiegnitz (2014), Buser et al. (1996), Buser et al. (2002), Chiapasco et al. (1999), Corinaldesi et al. (2009), D'Amato et al. (2015), Khojasteh
et al. (2012a), Miyamoto et al. (2012), Stimmelmayr et al. (2014), Teng et al. (2014), Trombelli et al. (2008)
Material mix Al-Nawas and Schiegnitz (2014), Shalash et al. (2013), Toscano et al. (2010)
 M. Troeltzsch et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 1618e1629 1625

Vertical defects
Particulate

Materials References
used

Allograft Beitlitum et al. (2010), Fontana et al. (2008), Khojasteh et al. (2012b), Marx et al. (2013), Simion et al. (2001), Simion et al. (1998), Vidyadharan and Ravindran (2014)
Xenograft Artzi et al. (2003), Bazrafshan and Darby (2014), Cardaropoli et al. (2013), Carini et al. (2014), Cucchi and Ghensi (2014), Khojasteh et al. (2012b)
Synthetic e
Autograft Al-Nawas and Schiegnitz (2014), Anitua et al. (2015), Chiapasco et al. (2004), Corinaldesi et al. (2009), D'Amato et al. (2015), Fontana et al. (2008), Khojasteh
et al. (2012a), Merli et al. (2014), Rocchietta et al. (2016), Roccuzzo et al. (2007), Trombelli et al. (2008)
Material mix Al-Nawas and Schiegnitz (2014), Carini et al. (2014), Fontana et al. (2015), Khojasteh et al. (2012b), Margonar et al. (2010), Park (2010), Pieri et al. (2008), Poli
et al. (2014), Schwartz-Arad et al. (2016), Simion et al. (2007), Urban et al. (2014)

Horizontal defects
Block

Materials References
used

Allograft Acocella et al. (2012), Amorfini et al. (2014), Barone et al. (2009), Bianchini et al. (2009), Chaushu et al. (2010), Contar et al. (2009), Contar et al. (2011), Keith
(2004), Landi (1998), Lumetti et al. (2014), Lumetti and Galli (2014), Lyford et al. (2003), Monje et al. (2014), Morelli et al. (2009), Nissan et al. (2011a, b, c, d,
e), Nissan et al. (2012), Novell et al. (2012), Orsini et al. (2011), Peleg et al. (2010), Pendarvis and Sandifer (2008), Pereira et al. (2015), Schlee and Rothamel
(2013), Spin-Neto et al. (2014, 2015), Spin-Neto et al. (2013b), Wallace and Gellin (2010)
Xenograft Pistilli et al. (2014)
Synthetic e
Autograft Aloy-Prosper et al. (2015), Anitua et al. (2014), Cordaro et al. (2002), Cordaro et al. (2010), D'Amato et al. (2015), de Freitas et al. (2013), El-Halaby et al.
(2009), Kim et al. (2013), Lumetti et al. (2014), Maiorana et al. (2005), Matsumoto et al. (2002), Misch (2000), Pistilli et al. (2014), Schwartz-Arad and Levin
(2005), Schwartz-Arad et al. (2005), Soehardi et al. (2009), Spin-Neto et al. (2014), von Arx and Buser (2006)
Material mix Monje et al. (2014)

Vertical defects
Block

Materials References
used

Allograft Amorfini et al. (2014), Barone et al. (2009), Bianchini et al. (2009), Chaushu et al. (2010), Contar et al. (2009), Contar et al. (2011), Dahlin and Johansson
(2011), Leong et al. (2015), Macedo et al. (2012), Nissan et al. (2011a, b, c, d, e),; Nissan et al. (2012), Peleg et al. (2010), Pendarvis and Sandifer (2008),
Pimentel et al. (2014), Schlee and Rothamel (2013), Spin-Neto et al. (2013b)
Xenograft Pistilli et al. (2014)
Synthetic e
Autograft Aloy-Prosper et al. (2015), Bastos et al. (2014), Boven et al. (2014), Burger et al. (2011), Carinci et al. (2005), Castagna et al. (2013), Chiapasco et al. (2007),
Cordaro et al. (2002), Cordaro et al. (2013), Cordaro et al. (2010), Cuesta Gil et al. (2010), D'Amato et al. (2015), De Stavola and Tunkel (2013), El-Halaby et al.
(2009), Kim et al. (2013), Lenzen et al. (1999), Marx et al. (2013), Matsumoto et al. (2002), Mertens et al. (2013), Morad and Khojasteh (2013), Orsini et al.
(2003), Penarrocha-Oltra et al. (2014), Pistilli et al. (2014), Proussaefs and Lozada (2005), Rocchietta et al. (2016), Roccuzzo et al. (2007), Roccuzzo et al.
(2004), Schmitt et al. (2014), Schwartz-Arad and Levin (2005), Schwartz-Arad et al. (2005), Simion et al. (2001), Simion et al. (1998), Smolka et al. (2006),
Soehardi et al. (2009), Wiltfang et al. (2014)
Material Mix e

Sandwich augmentations

Materials References
used

Allograft Laino and Iezzi (2014), Leong et al. (2015), Sohn et al. (2010)
Xenograft Annibali et al. (2011), Choi et al. (2004), Esposito et al. (2014), Felice et al. (2014), Felice et al. (2009b), Felice et al. (2008), Felice et al. (2010), Felice et al.
(2013), Laviv et al. (2014), Scarano et al. (2011)
Synthetic Dottore et al. (2014), Kawakami et al. (2013)
Autograft Bormann et al. (2010), Bormann et al. (2011), Brandtner et al. (2014), Dottore et al. (2014), Felice et al. (2009a, b, c), Felice et al. (2008), Jensen et al. (2006),
Kawakami et al. (2013), Laino and Iezzi (2014), Pelo et al. (2010), Stellingsma et al. (2014)
Material mix e

Funding source References

No external funding such as grants were used for this study.
Acknowledgment
The authors thank Ms. Susanne Ashrafi, Ms. Patricia Mathes, and
Mr. Dietrich Meenen for their invaluable support in administrative
and organization issues.
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