Bonegraftingforimplant Surgery: Ladi Doonquah,, Pierre-John Holmes,, Laxman Kumar Ranganathan,, Hughette Robertson

Bone Grafting for Implant
Surgery
Ladi Doonquah, MD, DDSa,b,*, Pierre-John Holmes, MD, DMD, MPHc,
Laxman Kumar Ranganathan, BDS, MDSc,d, Hughette Robertson, BSc, MBBSe
KEYWORDS
Graft biology Adjuvants Socket grafts Sinus augmentation
Vertical and horizontal augmentation Edentulous ridge
KEY POINTS
Assessment of the socket and use of graft product along with adjuvants aid in socket preservation
with potential for implant placement. No gold standard material has been identified.
Augmentation provides adequate alveolar bone essential for long-term implant survival. Options
are autogenous, onlay, guided bone regeneration, ridge splitting procedure, sandwich osteotomy,
and alveolar distraction osteogenesis.
Maxillary sinus height is improved with augmentation to allow for placement of implants as a single
or staged procedure.
Comprehensive rehabilitation for the edentulous ridge is becoming less invasive. Despite this, inter-
positional osteotomies, guided bone regeneration, and distraction osteogenesis continue to prove
effective.
Adjuvant therapy, 3-dimensional bioplotting, and tissue engineering have been effective in manage-
ment of osseous defects, and ongoing developments hold promise for the creation of the ideal
graft.
INTRODUCTION Despite this trend, there still is a significant sector

of the population that requires enhancement of
There have been tremendous advances in public the alveolar ridge to accommodate implants.
health that have greatly improved the retention This article reviews the current trends in surgical
rate of dentition. These advances in combination management of the deficient alveolus and looks
with the explosion of implant dentistry, in partic- to future methods and alternatives that show
ular, implant prosthodontics, has revolutionized promise of being incorporated in the surgical
the oral rehabilitation of patients afflicted with armamentarium.
edentulism. The ”less is more” philosophy for
bone rehabilitation of the dental alveolus has
seen a distinct rise, resulting in a decrease in HISTORY
extensive complicated reconstruction techniques
performed and more novel solutions put forward.1 Grafting of osseous material has been thought to
have occurred since antiquity, as detailed in
oralmaxsurgery.theclinics.com
a
Department of Surgery, University Hospital of the West Indies, 7 Golding Ave, Kingston 7, Jamaica; b Faculty
of Medicine, University of the West Indies, Kingston 7, Jamaica; c Department of Faciomaxillary Surgery, King-
ston Public Hospital, North Street, Kingston, Jamaica; d School of Dentistry, University of the West Indies, King-
ston, Jamaica; e Otorhinolaryngology, Department of Surgery, Faculty of Medical Sciences, University of the
West Indies, Kingston 7, Jamaica
* Corresponding author. Department of Surgery, University Hospital of the West Indies, 7 Golding Ave, King-
ston 7, Jamaica.
E-mail address: ldoonquah@hotmail.com
Oral Maxillofacial Surg Clin N Am 33 (2021) 211–229

https://doi.org/10.1016/j.coms.2021.01.006
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212 Doonquah et al
paintings depicting the replacement of a leg most common extraoral sites are the iliac crest,
afflicted with cancer, by a limb, from a recently tibia, and the calvarium. Autogenous bone has
deceased Moor. Several artists in the Renaissance osteogenic, osteoinductive, and osteoconductive
age depicted this as “the miracle of the black leg.” properties, which make it perfect for alveolar
The first actually documented account of a bone augmentation.
graft was a xenograft performed by Dr Job van
Meekeren in 16632 and published in 1668. In this Allograft
procedure, a segment of bone from a dog was
These grafts are immunogenic due to major histo-
used to reconstruct a skull defect of a soldier.
compatibility complex antigens8 and carry the risk
The first recorded autogenous bone graft was
of viral transmission. Processing, which includes
done by Dr Merrem in 1809.3 Dr William Macewan,
screening and irradiation, reduces infectious
a neurosurgeon in Scotland, performed the first
transmission to 1 in 1,600,000.7 Allografts have
allograft in 1878. Professor Vitorrio Putti4 of Italy
predominantly osteoconductive properties and
helped lay the foundation of the biology of bone
the advantage of no patient donor site morbidity
grafting, by establishing major principles detailed
(Fig. 1).
in an original article written in 1912. Putti’s article
outlined basic bone grafting principles that
continue to underpin modern-day techniques.4 In
Synthetic Bone Graft Substitute
1965, Dr Marshall Urist, an orthopedic surgeon in See Fig. 2.
California, helped identify and document the
importance of bone morphogenetic protein (BMP). ADJUVANTS
BIOLOGY OF CRANIOFACIAL BONE GRAFTS Adjuvants are biologics that are used to enhance
bone repair. These range from blood components,
Osseous defects frequently are due to congenital gene therapy, and recombinant proteins and are
malformation, trauma, loss of dentition, infections, classified broadly as cell-based therapy, growth
tumor ablation, and osteoradionecrosis. They vary factors, and anabolic therapies.5
in size and configuration. The aim of bone grafts in Biologics provide alternatives with osteoinduc-
the craniofacial region is to restore and preserve tive and osteogenic properties that spare the pa-
form and function. As such, knowledge of the mo- tient additional donor site surgery and foster graft
lecular and physiologic processes of grafting is in- incorporation.
tegral in decision making to ensure success. The prototype biologic is BMP. BMPs initially
Four elements are needed for successful bone were identified in matrix residue and collagen fi-
regeneration: osteoinduction, osteogenesis, intact bers by Urist in 1968.9 BMP is a member of the
vascular supply, and osteoconduction.5 Osteo- transforming growth factor b (TGF-b) family with
genesis relies on transplanted osteogenic cells to more than 20 members identified. They act via
retain viability and produce osteoid derived from serine threonine kinase receptors to up-regulate
periosteum, endosteum, marrow, and intracortical downstream pathways that affect osteogenic and
elements of the graft.6 nonosteogenic activity.
In creeping substitution, bone grafts undergo BMP2, BMP4, BMP6, BMP7, and BMP9 have
partial necrosis followed by an inflammatory stage, osteogenic potential. BMP2 and BMP7 are the
where the graft is replaced by new bone after most widely studied subtypes. Ayoub in 201810
vessel invasion.7 This is referred to as osteocon- revealed dose-dependent BMP2 reconstructed
duction. For osteoinduction, factors are released 50% of surgical defects with the main adverse ef-
from the graft and stimulate osteoprogenitor cells fect being localized swelling. BMP7 10-year
to differentiate to osteoblasts. The initial hema- follow-up showed similar results as autogenous
toma, inflammatory milieu, and bony remodeling bone, with good bone regeneration and shorter
provide the biologic foundation for bone grafting. hospital stay.10 Like most growth factors, there
are issues with short half-lives and rapid
Classification of Bone Grafts
clearance.11
Grafts are classified based on their areas of origin Vascular endothelial growth factor (VEGF) po-
and ultrastructure. They are autogenous or nonau- tentiates angiogenesis. In rodent studies, it in-
togenous, and cortical, cancellous or corticocan- creases vascularity and bone quality.11 Khojasteh
cellous respectively. and Hossein11 demonstrated that BMP2 with
Autogenous is obtained from regional or distal VEGF had acceptable bone regeneration. Con-
sites. Common intraoral sites are the buttress, cerns are raised with possible hemangiomas and
torus, symphysis, and the ramus, whereas the tumor recurrence with VEGF use.
Bone Grafting for Implant Surgery 213
Fig. 1. Allograft classification.
Platelet-rich plasma (PRP) is an isolate and to 12 minutes to produce upper, middle, and lower
concentrate of platelets. Platelet concentration fractions composed of acellular plasma, fibrin clot
can be greater than 2 million cells/mL and confer and red cells, respectively. Platelets trapped in
mitogenic and chemotactic growth factors, such fibrin in the middle layer (PRF) have been utilized
as platelet-derived growth factor, insulinlike with good effect to enhance bone regeneration
growth factor, fibroblast growth factor, TGF-b, during sinus and alveolar ridge augmentation,
and VEGF, leading to much interest in its use. Roffi implant surgery (Fig. 3A), postextraction socket
and colleagues in 201312 discussed PRP use for grafting, and root coverage. PRF has been used
maxillary sinus augmentation. When used with widely as membrane as well as mixed with allo-
autologous bone, PRP showed improved handling graft to form a matrix for grafting (Fig. 3B).
but demonstrated no significant difference in sta- In addition to PRF, concentrated growth factors
bility, graft resorption or healing. When used with also are isolated from a patient’s venous blood us-
freeze-dried bone allograft (FDBA) and other car- ing altered centrifugation with 2400 rpm to 2700
riers, there was increased vital tissue.12 rpm for approximately 12 minutes. It is used to
PRP served as a predecessor to second- produce a dense fibrin matrix.13 Both PRF and
generation platelet concentrate, platelet-rich fibrin concentrated growth factors are used as barrier
(PRF). PRF promotes healing with a better orga- membranes over the growth factor enriched
nized fibrin matrix that supports angiogenesis bone graft matrix in the grafting procedure
and migration of osteoprogenitor cells. PRF, unlike (Fig. 3C). Addition of autologous fibrin glue (AFG)
PRP, lacks laborious processing, requires no anti- to the PRF and particulate graft mixture forms a
coagulant and is relatively inexpensive. After stable growth factor–enriched bone matrix, known
venous blood is drawn, centrifugation is done at as sticky bone. AFG is obtained through centrifu-
3000 revolutions per minute (rpm) for 10 minutes gation of venous blood at 2400 rpm to 2700 rpm
Fig. 2. Alloplastic classification.
214 Doonquah et al
Fig. 3. (A) Implants in the anterior maxillary incisor region with bony defect on the labial aspect. (B) Rectangular
bone tray with PRF membrane and circular bone tray with particulate PRF mixed with demineralized FDBA. (C)
PRF membrane covering the grafted area.
for 2 minutes. The top layer obtained would be blood was used with centrifugation for 2 minutes
AFG with red blood cells at the bottom. The AFG at 3300 rpm. This produced a 2-layered concen-
can be extracted with a syringe and mixed with trate with an orange-colored fluid at the top consist-
the particulate graft and PRF membrane cut into ing of fibrin, platelets, growth factors, and various
small pieces and allowed to polymerize for 5 mi- cell types, including leukocytes and stem cells.15
nutes to 10 minutes. This results in a stable mold- Similar to AFG, i-PRF can be extracted with a sy-
able mass, which prevents movement of the ringe and mixed with particulate graft to form a
grafted bone and the fibrin network prevents moldable stable mass for bone grafting.
ingrowth of soft tissue into the area.14 The growth factors, alluded to previously,
An injectable form of PRF(i-PRF) has been used require biomaterial carriers to gain access to
to make stable moldable well agglutinated mixture the recipient bed. Carriers ideally are highly inter-
for bone grafting. In this technique, intravenous connected porous networks large enough to
allow cell migration, fluid exchange, tissue is determined by diagnostic imaging, cone beam
ingrowth, and vascularization. Common carriers computed tomography (CBCT) is the most ideal.
include polylactic-co-glycolic acid (PLGA), Atraumatic extraction of the indicated tooth is per-
absorbable collagen sponge (ACS), hydroxyapa- formed preserving surrounding bone that is avail-
tite, natural bone matrix (NBM), demineralized able thus ensuring the grafting procedure has an
bone matrix, b-tricalcium phosphate, and autolo- ideal housing for the graft material. The postex-
gous thrombin16 (Table 1). traction socket is assessed with regard to whether
an immediate implant placement with grafting is
possible or socket grafting alone is done. The
POSTEXTRACTION SOCKET GRAFTING
type of defect then is categorized by the number
Socket preservation procedures after dental of surrounding bony walls.21
extraction have gained popularity in recent years. Once the decision to place a graft is made, the
Bone quantity, quality, and supporting soft tissue extraction socket must be débrided of granulation
at the time of implant placement determine the tissue and irrigated with sterile saline. Presence of
longevity of implants.17 Buccal cortical bone, purulent discharge in the area could prove to be
especially in the anterior and premolar areas, has detrimental to the graft. In such instances, consid-
been shown to exhibit more resorption in compar- eration should be given to utilize hydrogen
ison with the lingual side.18 Since the increased peroxide irrigation followed by copious amounts
awareness of alveolar ridge preservation, multiple of a mixture of saline with chlorhexidine 0.12%.
studies have been conducted assessing various A 5-wall defect with thin walls is treated with the
socket filling techniques and also the use of placement of corticocancellous demineralized
various biomaterials.19 bone in combination with autogenous blood prod-
A recently published systematic review uct (PRF and PRP). The wound is covered with
concluded that with the current techniques and PRF and a collagen plug. These together are
available biomaterials, there is no gold standard held in place with a figure-of-8 suture using
material to preserve extraction sockets and none resorbable suture material. A healing time of
of the current techniques managed to completely 4 months is adequate for implant placement.22
stop alveolar resorption. It was observed, howev- Clinical measurements and CBCT scan is per-
er, that socket preservation decreased vertical formed at the end of the healing period and the
and horizontal alveolar resorption and showed available bone height and width is assessed to
better preservation of keratinized tissue. The role evaluate the outcome of the grafting procedure
of autologous platelet concentrates in accelerating (Fig. 4).
healing and soft tissue epithelialization, while also Sockets with 3 to 4 wall defects, where loss of
reducing postoperative pain, also was noted in this bone is seen over the buccal wall and with a lack
review.20 of bone in the apical area, may require the use of
Once clinical assessment of the tooth or teeth to an autogenous block along with particulate graft.
be extracted is done, the surrounding bone status The overall goal is to maintain the alveolar bone
Table 1
Carriers
Biomaterial Preparation
Carrier Technique Advantages Disadvantages
PLGA Particulate leaching Control over porosity, pore Residual solvents; limited
sizes and crystalline mechanical properties
nature; high porosity
ACS Freeze drying method Facilitates surgical Low porosity and
implantation, retention mechanical strength
of growth factor and
hemostasis
NBM Production method of High porosity and Potential host reaction,
cadavers’ bone interconnectivity limited supply, excessive
resorption, potential
disease transmission
Adapted from Khojasteh A, Esmaeelinejad M, Aghdashi F. Regenerative techniques in oral and maxillofacial bone graft-
ing. In: Motamedi MH, editor. A textbook of advanced oral and maxillofacial surgery volume 2. London: IntechOpen;
2015.
216 Doonquah et al
Fig. 4. (A) Pretreatment, (B) graft and plug placement, and (C) postgrafting radiograph. a case of postextraction
socket grafting with demineralized FDBA and PRF plug for implant placement.
width and height and limit resorption while sup- or without interpositional grafts, or onlay grafts. In
porting the soft tissue structures. the vertical dimension, onlay grafts often have sig-
nificant resorption in the vertical dimension, so for
BONE AUGMENTATION moderate defects, a sandwich osteotomy tech-
nique is used with interpositional corticocancel-
Adequate alveolar bone is essential for long-term lous grafts to achieve more predictable height.25
survival of dental implants. It generally is accepted For large defects in the horizontal direction, onlay
that there should be 1.5 mm to 2 mm of bone grafting usually is the treatment of choice, whereas
around each implant. Implant positions now are DO is beneficial for vertical defects.
commonly dictated by the restorative positions,
so the best methods to augment the deficient alve- Horizontal Defects
olar bone should allow for implant placement to Horizontal defects are common after tooth loss,
match the restorative demands. Augmentation op- especially in the anterior maxilla and posterior
tions include autogenous onlay grafting, alloplastic mandible. It is important to assess the degree of
materials, guided bone regeneration (GBR), ridge horizontal bone loss because it dictates the
splitting procedures (RSPs), sandwich osteotomy, augmentation technique (Fig. 5).
and alveolar distraction osteogenesis (DO). These
augmentation procedures have different success Hourglass Deformity (Buccal Fenestration)
rates when applied to horizontal versus vertical
deficiencies. Autogenous bone continues to be Clinically, there is coronal and apical stability for
viewed as the gold standard for alveolar augmen- the implant but with a buccal fenestration. Allo-
tation and this has to be taken into account when plastic graft material with GBR is sufficient for
planning the procedure.23 The main negative fac- augmentation (Fig. 6).
tor of autogenous grafting is donor site morbidity.
Moderate Horizontal Deficiency
With the harvesting of bone from intraoral sites, the
patient morbidity is decreased compared with If the alveolar ridge width is 3 mm to 5 mm, an RSP
extraoral sites (iliac crest, calvarium, tibia, and should be considered, which provides 1.5 mm to
fibula). 2 mm of bone on both the buccal and lingual/
The size and location of the required augmenta- palatal cortices.26 The concept of the RSP is that
tion dictate the appropriate modality.24 Alloplastic over time, an area of alveolar bone, without a
materials with GBR techniques are useful for small tooth, undergoes atrophy, which occurs more in
defects, especially in the horizontal plane but usu- the cancellous bone than the cortical. The RSP en-
ally limited in the vertical plane. Moderate horizon- tails placing an osteotomy between the cortical
tal alveolar defects may be treated with RSPs with plates in the cancellous bone and slowly
Fig. 5. (A) Horizontal bone loss. (B) Axial CBCT view demonstrating horizontal bone loss. (C) Patient defect pre–
flap elevation. (D) Defect post–flap elevation.
expanding the cancellous space to allow for either flap is elevated gently, but over the buccal cortex
implant placement or an interpositional graft. of the expanded segment, the periosteum must
be left attached in order to maintain vascularity.
Technique The 2-mm twist drill is used to make the initial
osteotomy for the implants (Fig. 7A). A saw then
The incision is placed lingually in order to help with is used to make the ridge split osteotomy along
primary closure after expansion. A mucoperiosteal
Fig. 6. Horizontal bone loss on left Implant placement, fenestration, alloplastic bone graft and membrane on
right.
218 Doonquah et al
Fig. 7. (A) Osteotomies for bone augmentation implants. (B) Shaping osteotomy bone post expansion. (C) Im-
plants and particulate graft placement post expansion.
the alveolar crest, through the previous 2-mm 2-mm pilot osteotomy (Fig. 7B). Taps now are
osteotomies, to a depth where the greenstick frac- used in the osteotomies and they give an idea of
ture of the buccal cortex is anticipated to happen. the potential implant stability. If primary implant
Vertical osteotomies may be used at the anterior or stability is questionable, then an interpositional
posterior extent of the segment. This osteotomy is graft may be placed and the treatment converted
taken to the same depth of the ridge split osteot- to a 2-stage plan. Next, the implants are placed
omy and usually is angled at 45 . and particulate graft material is used to fill the
Expanding the cancellous space is done slowly remaining cancellous spaces (Fig. 7C). A resorb-
with either sequential chisels or expanders; the au- able collagen membrane is placed over the crest
thors prefer expanders. Slightly longer segments of the ridge. Elevation of the lingual tissue allows
tend to be easier to split than the single tooth for primary closure (Fig. 8A-C).
defect. If the buccal bony segment completely
separates from the basal bone, then it should be
treated like a free bone graft and fixated with tita- Severe Horizontal Deficiency
nium screws. Once adequate expansion has been A residual ridge width of less than 4 mm should be
achieved, the shaping drill for the proposed augmented with an onlay graft. Autogenous onlay
implant is used to shape the apical aspect of the grafts commonly are harvested from the
Fig. 8. (A) Case showing a thin left mandibular ridge (3.5 mm). (B) RSP performed with placement of two 4 mm
implants. (C) Imaging post implant placement.
symphysis and the ramus. Both sites provide usually is done to plan the depth of the
mainly cortical bone, with the symphysis adding osteotomies.
a small cancellous component.
The choice of the donor site may be dictated by Preparation of the Recipient Site
the recipient site situation and other local factors.
The recipient site is prepared by making multiple
For example, if the area of the first mandibular
small corticotomies using a small round burr to
molar is being grafted, then it is easier to harvest
promote bleeding in the area and future angiogen-
the ramus graft and have just 1 surgical site to
esis. The graft then is shaped to fit the defect and
decrease the morbidity (Fig. 9).
secured with 1.5-mm titanium screws. A resorb-
Harvesting the Symphysis able collagen membrane then is placed over the
area and the mucoperiosteal flap then is closed
The authors utilize a standard genioplasty incision in a tension free manner by scoring the periosteum
with care to avoid the mental nerves while in the vestibule (Figs. 12–14).
exposing the entire symphyseal region. A recipro-
cating saw is used to make the osteotomies. A Vertical Defects
midline bone strut usually is left in place to prevent
contracture of the overlying soft tissue into the Vertical alveolar defects continue to be more diffi-
defect and causing secondary dimpling of the cult to augment than the horizontal ones.27 Onlay
chin. When making the osteotomies, care must grafting for vertical deficits has a higher rate of
be taken to avoid the roots of the teeth, especially resorption than when used for horizontal grafting
the canine, as well as to avoid the anterior loop in the posterior mandible. The sandwich osteot-
of the mental nerve. The graft should be larger omy has increased in popularity because of the
than the defect to allow for shaping of the graft higher success rates, less complication rate, and
(Fig. 10). better vascularity for the graft.24
For severe bony and soft tissue defects usually
Harvesting of the Ramus above 6 mm, alveolar DO is the preferred method
for vertical augmentation (Fig. 15).
The surgical approach is identical to that of a
sagittal split osteotomy with a sulcular incision
Sandwich Osteotomy
and exposure of the external oblique ridge extend-
ing anteriorly and inferiorly. A reciprocating saw is The sandwich osteotomy procedure is ideal for
used to make an osteotomy parallel to the external moderate sized vertical defects 4 mm to 6 mm
oblique ridge to the desired depth. The vertical and has shown good success rates.28,29 The pro-
osteotomies then are made and a cylindrical drill cedure first was described by Schettler and Hol-
with a round disc saw at the end is used to make termann25 in a publication on preprosthetic
an inferior horizontal cut through the buccal cortex surgery for dentures. This technique most
and the graft is mobilized and removed (Fig. 11). commonly is used to increase height in the poste-
When making osteotomies, care must be taken rior mandible but is also valuable in other areas
to avoid the inferior alveolar nerve. A CBCT scan (Fig. 16).
Fig. 9. Horizontal alveolar atrophy with residual bone unable to fit a 4 mm implant. Onlay bone grafting is rec-
ommended in this case. (A) Axial view. (B) Coronal view.
220 Doonquah et al
Fig. 10. (A) Osteotomy outline of symphyseal graft. (B) Defect post–block removal. (C) Block graft post inset
occlusal/caudal view. (D) Post inset anterior view.
An incision is placed lateral to the crest, so as to of the adjacent teeth and 5 mm above the inferior
maintain the soft tissue on the transport segment. alveolar bone if applicable. When separating the
A full-thickness mucoperiosteal flap is elevated transport segment from the basal bone, it is imper-
with releasing incisions away from the osteoto- ative that the lingual or palatal tissue is not
mies. Ideally, a segment with a height of 5 mm is damaged, because it is the source of vascularity.
exposed. It is essential that the mucosa remains Careful elevation of this lingual or palatal tissue
attached to the transport segment. A saw is used over the basal and adjacent bone allows for
to create osteotomies at least 2 mm from the roots more freedom in moving the transport segment
Fig. 11. Clinical picture demonstrating the harvesting of a ramus graft. (A) Harvesting ramus graft. (B) Removed
graft.
the crest of the transport segment. A full-

thickness mucoperiosteal flap is elevated on the
buccal to visualize the areas for the osteotomies.
The osteotomies are marked lightly with a drill.
The distraction device then is placed to ensure
the correct vector for distraction; then, the screw
holes are drilled in each segment; this allows for
easy placement when the transport segment is
free. The vertical osteotomies are made divergent
from each other from the base to the crest. A hor-
izontal osteotomy connects these 2 divergent
osteotomies to make a trapezoid segment.
Extreme care is taken to not damage the lingual
or palatal soft tissue because these tissues are
Fig. 12. Onlay grafting from the symphysis. the major source of vascularity to the segment.
coronally. Once the segment is elevated, it then is The transport segment now is separated gently
fixated with a 1.5-mm titanium plate and screws. from the basal bone and the distractor attached
The gap then is filled with a corticocancellous by screws in the predrilled holes. The distractor
autogenous bone block mixed with particulate arm then is attached and the segment is distracted
allograft. A resorbable collagen membrane is to make sure that there is no interference and then
then placed over the area and the wound is closed. returned to the base. The wound then is closed
After 4 months the plate and screws are removed with the distractor arm protruding. There is a la-
and the implants placed (Fig. 17). tency period of 5 days to 7 days during which a
callus forms. The distractor is activated using a
Distraction Osteogenesis frequency of 0.5 mm twice daily. Once the move-
ment is complete, the distractor stays in place to
DO first was described by Ilizarov30 as a method to allow for consolidation of the augmented area,
lengthen long bones under the tension-stress prin- which takes 12 weeks to 16 weeks. After the
ciple. DO allows for the augmentation of both hard consolidation is complete, the distractor is
and soft tissues simultaneously. DO of the mandible removed and the implants placed (Fig. 18).
first was performed by McCarthy and colleagues31
on hypoplastic mandibles of syndromic children.
With this experience and the fabrication of smaller
distractors, the technique was performed on SINUS AUGMENTATION
smaller areas, such as the alveolar bone. At the au- Maxillary sinus is the largest of the 4 pairs of para-
thors center, extraosseous distractors are used nasal sinuses and, in an adult, it has a volume of
with 1 section attached to the buccal of the basal approximately 15 mL.32 The sinus drains into the
bone and the other section fixated to the buccal superior aspect of middle meatus in the medial
aspect of the transport segment. wall of nasal cavity.33 Because the ostium is posi-
tioned on the superior aspect of the medial wall,
Technique
the likelihood of blockage during augmentation is
The procedure is started with a paracrestal inci- negligible. In the average adult, the floor of the si-
sion with preservation of the attached tissue on nus is at the same level as the nasal floor, but, in
edentulous patients, the floor level is lower.
The bone resorption associated with pneumati-
zation of the maxillary sinus causes loss of height
and width of the alveolar bone. Various solutions
have been described to overcome this problem.
Based on the available height of bone between
the floor of sinus and the crest of the residual ridge,
a classification was developed by Misch and col-
leagues,34 termed subantral (Fig. 19). The avail-
able height of bone determines whether an open
or closed approach to the sinus was needed.
This also dictated if concomitant implant place-
ment was possible at the time of sinus augmenta-
Fig. 13. Thirteen-year clinical follow-up. tion or to be done in a staged manner. The
222 Doonquah et al
conservative, predictable, and fast41 (Fig. 21).

The technique was changed further by doing the
elevation of the sinus floor by hydraulic pressure42
using sterile saline as well as the use of specific
drills43 to prevent membrane perforation. Sinus
membrane elevation without the use of graft mate-
rial also has been discussed by Chen and col-
leagues.44,45 The periosteum and the spongy
bone in the maxilla is responsible for the deposi-
Fig. 14. Panorex at the13-year follow-up visit shows tion of bone-forming cells, invariably leading to for-
stability of the graft and implants. mation of osseous tissue. There also is a process
of tenting of the membrane by the implant and
an associated clot formation in the enclosed
classification of available bone later was modified chamber. This blood clot releases several growth
to address the width of the bone.34 factors and these factors in combination with cyto-
The increasing use of short implants35 and their kines stimulate osteoinductive activity in the clot.
comparable clinical outcomes to longer implants
have questioned the need for extensive sinus
enhancement procedures.36 There are issues, THE EDENTULOUS JAWS
however, that arise with ultrashort implants. Long-term complete edentulism, compounded by
Reduced bone-to-implant contact and crown-to- prosthetic devices, dramatically changes the
implant ratio, marginal bone loss, screw loosening, morphology and function of the alveolus. The un-
abutment fracture, and crown debonding are a few derlying anatomy of the ridge and the bio-
of the complications reported in the literature.37 physiology of the person, along with endogenous
Lateral window and crestal techniques are the and exogenous mechanical forces applied to the
most common methods that have shown favor- ridge, were thought by Atwood45 to be the major
able results with regard to implant survival.38 The determinants of the long-term form of the residual
lateral window technique was described in detail ridge.44 Cawood and Howell46 have detailed the
by Boyne and James,39 who osteotomized the progressive effects on bone morphology in a clas-
lateral wall of sinus in order to elevate the schnei- sification system they outlined in 1973. Dissimilar
derian membrane for bone grafting (Fig. 20). The compressive forces on the superior anterior-
closed osteotome crestal approach first described buccal aspect of the ridge in both jaws, effectuates
by Tatum40 is utilized for smaller grafts with a sinus a knife-edge appearance to the superior anterior
elevation of 3 mm to 5 mm with simultaneous aspect and an accentuated concavity in the
placement of implants. In comparison to the lateral buccal surface and posterior superior surface of
open technique, this method was less invasive. the mandible. In the maxilla, a similar knife-edge
Uncertainty of membrane perforation, especially contour is seen in the anterior aspect with sym-
in the oblique sinus floor, ridge fracture, and pa- metric flattening across the buccal-lingual aspect
tient discomfort caused by malleting, were some of the posterior alveolus, accompanied by exces-
of the unwanted sequelae. In a modified osteo- sive sinus pneumatization. This poses significant
tome technique, a drill was used to reach 1 mm challenges to the reconstruction of the atrophic
below the sinus, before utilization of the osteo- ridge. The goal in rehabilitation of these ridges is
tomes. This modification was found to be more to recreate sufficient height and width, that resists
the long-term resorptive effects of the overlying
soft tissue drape. Another overlooked aim is to
have an orthoalveolar form aspect to the ridges,
such that utilizing a cantilevered maxillary pros-
thesis to counteract class 3 ridge relations is not
necessary. Therefore, comprehensive rehabilita-
tion of these patients requires treatment plans
that are tailored to the specific situation of the
patient.
There are several methods, discussed previ-
ously, that can be utilized to address ridge deficits
Fig. 15. A case of vertical deficiency in the posterior in completely edentulous ridges. The ones that are
mandible (residual heights of 7 mm and 8 mm above more appropriate for complete edentulism are
the inferior alveolar nerve). listed:
Fig. 16. (A) Bilateral sandwich osteotomies were performed and allowed to consolidate for 4 months. (B) Place-
ment of five 11-mm implants.
1. Osteotomy with interpositional bone graft provides enough bone for even the most atrophic
2. GBR with a scaffold to maintain the underlying ridge; however, it has the highest rate of resorption
graft material and implant failure rate, as noted by Chiapasco
3. Onlay block bone graft and colleagues.47 For less resorbed ridges with
4. DO adequate maxillo-mandibular relationship, then
GBR or onlay grafting is appropriate.
Osteotomy with Interpositional Bone Graft Guided Bone Regeneration

The interpositional graft is a stable reliable method The GBR procedure, although less frequently
to improve bone volume in the vertical and hori- applied to large atrophic defects, still has a place
zontal dimension in the rehabilitation of severely in management of the completely edentulous
resorbed ridges. It enables reorientation of the ridge. The details of the technique are described
maxillo-mandibular relationship as is often previously, but basically it relies on an overlying
needed. A Le Fort I osteotomy and interpositional scaffold shell to maintain the contour of the
iliac graft is a surgical procedure that often is desired ridge form while allowing a variety of oste-
used in the severely atrophic maxilla. The ilium ogenic materials to regenerate bone beneath.
Fig. 17. A case of vertical deficiency secondary to trauma. The patient rejected DO, so a sandwich osteotomy was
performed and implants were placed in 4 months. (A) Sandwich osteotomy. (B) Post osteotomy xrays. (C) Post
implant placement. (D) Occlusal view post implants.
224 Doonquah et al
Fig. 18. Case showing significant vertical alveolar bone loss treated by DO. (A) DO with distractor in place. (B)
Post distraction of segment.
Tenting methods with different devices, such as use is the ability to access enough bone from the
screws or implants, have been used to effectuate traditional intraoral sites to reconstruct an entire
the scaffold.48,49 The new bone readily accommo- ridge. Autogenous membranous bone is the
dates implants which in turn helps to maintain the preferred choice for graft material because it with-
new bone. In a setting where the technique is stands resorption more than endochondral bone.
applied to large segments of the ridge, continued Allogenic block bone from tissue banks is an op-
use of an overlying prosthesis is precluded, due tion, but it is expensive and has a higher rate of
to its predisposition to causing dehiscence of the dehiscence. As in all grafting methods, however,
overlying mucoperiosteum. Implants placed in utilizing this modality for vertical augmentation is
the newly regenerated bone have comparable less reliable. A prosthesis can be tolerated during
success rates to implants placed in unrecon- reconstruction because there is less rate of dehis-
structed ridges (Fig. 22). cence when autogenous bone blocks are placed
compared with GBR procedures.
Onlay Block Grafts
Distraction Osteogenesis
The onlay block graft is a reliable and predictable
mode of reconstructing the ridge in the horizontal Distraction techniques in general require a signifi-
dimension.50 The major issue associated with its cant amount of cooperation from the patient.
Fig. 19. Misch subantral classification.
Fig. 20. Case of 5-mm residual bone below the sinus. (A) Coronal view. (B) Saggital view. (C) Open sinus lift sur-
gery with a mixed autogenous and allogenic graft and immediate implant placement. (D) Bone graft and im-
plants healed for 6 months before abutments were placed.
This, in conjunction with an inability to wear a pros- techniques to increase the vertical dimension in
thesis during the distraction period for a totally edentulous ridges.51,52 The dimensional
completely edentulous ridge, is a deterrent. criteria for its use normally invite consideration of
Despite this, it remains one of the more reliable alternative methods, such as ultrashort implants,
Fig. 21. (A) Case showing decreased bone height below the sinus; (B) closed sinus lift and placement of a 11.5-mm
implant. (C) Five-year follow-up picture also shown.
226 Doonquah et al
undifferentiated versus osteogenic differentiated

stem cells in printed scaffolds. In vitro results
have not consistently been replicated in vivo. In
Miguita and colleagues’54 2017 meta-analysis,
bone marrow and dental pulp were stem cell sour-
ces. Long observation periods showed favorable
primary outcomes with bone volume formation
assessed by histomorphometry and microtomo-
graphic evaluation. One suggestion was the use
of markers, such as CD 146, Stro-1, CD 105, CD
73, and CD 90, to allow precise characterization
of cell population and longer follow-up periods.54
Sclerostin antibody (Scl-Ab) and anti- Dickkopf
antibody (anti–DKK-1) antagonize osteoblast
Fig. 22. Case showing a Le Fort I osteotomy with an deposition55 by inhibiting BMP and WNT/b catenin
onlay graft. pathways. Scl-Ab has been used in animal studies
and improves alveolar crest height and bone den-
sity. Anti–DKK-1 also has shown efficacy with
and this also serves as a disincentive to its appli-
autogenous bone graft take in mouse studies.56
cation. Smaller distractors with the ability to
Anabolic parathyroid hormone (PTH)-derived
change the vector of the distracted segment dur-
products; 1 PTH to 34 PTH (teriparatide) and 1
ing distraction, however, allow it to be utilized in
PTH to 84 PTH (natpara) act to increase osteoblast
certain situations. Especially noteworthy is the
function and lifespan. They have been used to
change that can be made to address the interarch
manage patients with osteoradionecrosis of the
horizontal discrepancy, thus creating the ortho-
jaw but osteosarcoma development in mice has
form alveolus that leads to more long-term sus-
led to black box warnings.57 Ongoing investiga-
tainable rehabilitation.
tions in humans at lower doses have failed to
demonstrate similar untoward events.
Outcomes in Edentulism
In general, there are a lot of techniques available SUMMARY
for addressing the completely edentulous ridge in
a comprehensive manner. The treatment plan Reconstruction options for the deficient alveolus
has to be tailored to the multidimensional situation continue to be increased and refined. Several
of the residual alveolus while taking into account a methods have been reviewed, placing emphasis
patient’s general medical condition. The authors’ on the more reliable and reproducible ones.
approach is to find comprehensive solutions that Although implant prosthodontics along with CT-
can be performed in a minimally invasive way. guided navigation placement continue to improve
the ability to place implants in compromised situa-
FUTURE DEVELOPMENTS tions, the methods described will help to provide
better platforms for their placement. The present-
Bone on a shelf customized for use is the ultimate day reality is that patients afflicted with edentulism
goal. Efforts continue to ensure quality, safety, ad- are demanding comprehensive solutions,
equacy, and effectiveness of these adjuvants in completed in a reduced time frame, in the least
grafting. Much of the thrust is toward eliminating invasive way possible. Tissue engineering and
the complication rates associated particularly regenerative medicine hold significant promise in
with autogenous grafts. Multiple studies allude to this regard. Ongoing research in those areas is
issues of limited bone stock, resorption, and donor forging the way for a future where complicated
site morbidity. procurement of grafts to rebuild mutilated ridges
Three-dimensional bioplotting has the potential will be a thing of the past.58
to revolutionize grafts.53 Printed scaffolds are
customized with pore size, orientation, and tissue CLINICS CARE POINTS
engineering to influence osteoconduction,
osteoinduction, and osteogenesis. Future work Post extraction socket grafting is guided by
on geometric orientation and new printing patterns pre and post procedure diagnostic imaging
will optimize this intervention going forward. and characterization of bone walls. 5 wall de-
There have been conflicting data on tissue engi- fects are preferentially treated with particulate
neering over the past decade with the use of graft. For 3-4 wall defects, autogenous block
along with particulate graft are the preferred reconstruction of alveolar cleft: 10years follow up.
options. J Oral Maxillofac Surg 2019;77:571–81.
For vertical dimension defects, sandwich os- 11. Khojasteh A, Behnia H, Naghdi N, et al. Effects of
teotomy achieves good success rates. Over- different growth factors and carriers on bone regen-
lay grafting has good success rates for eration: a systematic review. Oral Surg Oral Med
horizontal dimension defects. Oral Path, Oral Radiol 2012;116(6):e405–23.
Distraction osteogenesis is advocated for ver- 12. Roffi A, Filando G, Kou E, et al. Does prp enhance
tical augmentation of 5mm or above. bone integration with grafts, graft substitutes on im-
A cooperative patient with awareness of delay plants: a systematic review. BMC Musculoskelet Dis-
in prosthetic placement is required prior to ord 2013;14:330.
embarking on distraction osteogenesis. 13. Sacco L. Lecture, International academy of implant
Ultrashort implants may lend to complications prosthesis and osteoconnection. Lecture 2006;12:4.
such as decreased bone to implant contact, 14. Sohn D-S, Huang B, Kim J, et al. Utilization of autol-
screw loosening, marginal bone loss and ogous concentrated growth factors (CGF) enriched
abutment fractures. bone graft matrix (Sticky bone) and CGF-enriched
Though the ilium provides enough bone for fibrin membrane in Implant Dentistry. Jr Implant
the most atrophic edentulous ridges, it has a Adv Cli Dent 2015;2015(7):11–29.
high rate of resorption. 15. Mourão CF, Valiense H, Melo ER, et al. Obtention of
Autogenous bone blocks are less likely to injectable platelets rich-fibrin (i-PRF) and its poly-
dehisce with prosthetic placement than merization with bone graft: technical note. Rev Col
guided bone regeneration. Bras Cir 2015;42:421–3.
16. Khojasteh A, Esmaeelinejad M, Aghdashi F.
Regenerative Techniques in Oral and Maxillofacial
DISCLOSURE
Bone Grafting, A Textbook of Advanced Oral and
The authors have nothing to disclose. Maxillofacial Surgery Volume 2, Mohammad Hosein
Kalantar Motamedi, IntechOpen. Available at:
https://www.intechopen.com/books/a-textbook-of-
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Bonegraftingforimplant Surgery: Ladi Doonquah,, Pierre-John Holmes,, Laxman Kumar Ranganathan,, Hughette Robertson

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Bonegraftingforimplant Surgery: Ladi Doonquah,, Pierre-John Holmes,, Laxman Kumar Ranganathan,, Hughette Robertson

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Bone Grafting for Implant

INTRODUCTION Despite this trend, there still is a significant sector

Oral Maxillofacial Surg Clin N Am 33 (2021) 211–229

Fig. 1. Allograft classification.

Fig. 2. Alloplastic classification.

the crest of the transport segment. A full-

conservative, predictable, and fast41 (Fig. 21).

Osteotomy with Interpositional Bone Graft Guided Bone Regeneration

Fig. 19. Misch subantral classification.

undifferentiated versus osteogenic differentiated

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