2010 - Efficacy of Horizontal and Vertical Bone Augmentation Procedures

The Efficacy of Horizontal and Vertical
Bone Augmentation Procedures for Dental 13

Implants: A Cochrane Systematic Review1
Marco Esposito, Maria Gabriella Grusovin, Pietro Felice, Georgios

Karatzopoulos, Helen V. Worthington, and Paul Coulthard
Core Message osteogenesis allows for more vertical bone

augmentation than other techniques, which, on
›› Some patients may have insufficient bone to the other hand, can allow for horizontal aug-
place dental implants, but there are many sur mentation at the same time.
gical techniques to increase the bone volume
›› This review is based on a Cochrane systematic
making implant treatment possible. Short review entitled “Interventions for replacing miss-
implants appear to be more effective and cause ing teeth: horizontal and vertical bone
fewer complications than conventional implants augmentation techniques for dental implant treat-
placed in resorbed lower jaws augmented with ment” published in The Cochrane Library (see
autogenous bone or bone substitutes (cow bone www.cochrane.org for information). Cochrane
blocks). Bone can be regenerated in a horizon- systematic reviews are regularly updated to
tal and vertical direction using various tech- include new research and in response to com-
niques, but it is unclear which techniques are ments and criticisms from readers. If you wish to
preferable. Complications especially for aug- comment on this review, please send your
menting bone vertically are frequent. Some comments to the Cochrane website or to Marco
bone substitutes may cause less complications Esposito. The Cochrane Library should be con-
and pain than autogenous bone. Osteodistraction sulted for the most recent version of the review.
The results of a Cochrane Review can be inter-
preted differently, depending on people’s per-
spectives and circumstances. Please consider the
conclusions presented carefully. They are the
opinions of the review authors, and are not neces-
M. Esposito (*) sarily shared by the Cochrane Collaboration.
G. Karatzopoulos
Oral and Maxillofacial Surgery,
School of Dentistry, The University of Manchester,
Higher Cambridge Street, Manchester,
M15 6FH Manchester, UK
e-mail: espositomarco@hotmail.com
M.G. Grusovin
The University of Manchester, Manchester,
UK and private practice, Gorizia, Italy 1
This paper is based on a Cochrane Review published in The
P. Felice Cochrane Library 2009, Issue 4 (see www.thecochranelibrary.
Department of Oral and Dental Sciences, com for information). Cochrane Reviews are regularly updated
University of Bologna, Bologna, Italy as new evidence emerges and in response to feedback, and The
Cochrane Library should be consulted for the most recent
H.V. Worthington version of the review.
P. Coulthard Conflict-of-interest statement: Pietro Felice and Marco Esposito
Cochrane Oral Health Group, School of Dentistry, are among the authors of some of the included trials; however,
The University of Manchester, Manchester, UK they were not involved in the quality assessment of these trials.
F. Chiappelli et al. (eds.), Evidence-Based Practice: Toward Optimizing Clinical Outcomes, 195
DOI: 10.1007/978-3-642-05025-1_13,
© John Wiley & Sons Ltd. 2009. Published by Springer-Verlag Berlin Heidelberg 2010. All Rights Reserved
196 M. Esposito et al.
13.1 Background each has its own merits and disadvantages. Sometimes,

it may be possible to recycle bone taken from the site
Missing teeth and supporting oral tissues have tradi- of implant placement when preparing the hole also by
tionally been replaced with dentures or bridges per- using a special filter to collect bone particles that would
mitting restoration of chewing function, speech and otherwise be lost and use this to build up a deficient
aesthetics. Dental implants offer an alternative. area.
These implants are inserted into the jawbones to Allografts: these are bone grafts harvested from
support a dental prostheses and are retained because cadavers and processed by methods such as freezing or
of the intimacy of bone growth onto their surface. demineralising and freezing. The grafts are then steri-
This direct structural and functional connection lised and supplied by specially licenced tissue banks in
between living bone and implant surface, termed several convenient ways such as bone particles or large
osseointegration, was first described by Brånemark blocks. They are resorbable. There may be some con-
[5] and has undoubtedly been one of the most sig- cern regarding their absolute non-infectivity.
nificant scientific breakthroughs in dentistry over Xenografts: these are graft materials derived from
the past 40 years. animals such as cow or coral. Animal bone, usually
Teeth may have been lost through dental disease or bovine bone, is processed to completely remove the
trauma or may be congenitally absent. In addition, organic component.
teeth may be lost as part of a surgical procedure to Alloplastic graft materials: these synthetic bone sub-
resect part of a jaw because of pathology such as can- stitutes include calcium phosphates and bioactive glasses.
cer. Sometimes, there is a lack of supporting bone in Alloplasts provide a physical framework for bone
addition to the absent teeth due to atrophy, trauma, ingrowth. Some surgeons use these materials in combina-
failure to develop or surgical resection. Dental implants tion with autogenous bone grafts. These materials resorb
can only be placed if there is sufficient bone to ade- completely or to some degree or not at all with time.
quately stabilise them, and bone augmentation permits Barrier membranes for GBR: This technique uses
implant treatment that would otherwise not be an special barrier membranes to protect defects from the
option for some of these patients. Bone augmentation ingrowth of soft tissue cells so that bone progenitor
procedures may be carried out some time prior to cells may develop bone uninhibited. Ingrowth of soft
implant placement (two-stage procedure), or at the tissue may disturb or totally prevent osteogenesis in a
same time as implant placement (one-stage procedure), defect or wound. Examples of membrane are expanded
using various materials and techniques. When carried polytetrafluoroethylene, porcine collagen and polygla-
out prior to placement, this necessitates an additional ctin. Membranes can be resorbable or non-resorbable.
surgical episode and then the area is left to heal for a Bone promoting proteins (BMPs) and platelet rich
period of time before the implants are placed. plasma (PRP): BMPs are a family of proteins naturally
There are different indications, numerous alterna- present in bone and responsible for activation of bone
tive techniques and various “biologically active” agents development [35]. BMPs may encourage bone forma-
and biomaterials currently used to augment bone. tion. They may be incorporated into any of the above
Some materials used to augment the bone volume may graft types. Growth factors and PRP are used to pro-
be described as follows: mote bone formation.
Autogenous bone grafts: these are bone grafts taken Some surgical techniques used to augment bone
from an adjacent or remote site in the same patient and volume include:
used to build up the deficient area and are considered to Onlay grafting: the graft material is laid over the
be the material of choice, i.e. the “gold standard”. They defective area to increase width or height or both of the
are biologically compatible as they are from the same alveolar jawbone. The host bed is usually perforated
patient and provide a scaffold into which new bone with a small bur to encourage the formation of a blood
may grow. Sites from within the mouth may be used clot between the graft and recipient bed. The graft is
for relatively small graft requirements or sites such as immobilised with screws or plates or with dental
the iliac crest for larger bone volumes. All of these implants [20].
require surgery at a second site, and therefore, the mor- Inlay grafting: A section of jawbone is surgically
bidity must be considered. Of the many possible sites, separated and graft material sandwiched between two
13 The Efficacy of Horizontal and Vertical Bone Augmentation Procedures for Dental Implants 197
sections. Le Fort I osteotomy and interpositional bone 13.2 Objectives

graft procedure [25] has been used for patients requir-
ing implant treatment [21].
To test (a) whether and when horizontal and vertical
Ridge expansion: the alveolar ridge is split longitu-
bone augmentation procedures are necessary and
dinally and parted to widen it and allow placement of
(b) which are the most effective horizontal and vertical
an implant or graft material or both in the void. The
bone augmentation techniques.
longitudinal split can be limited by placing transverse
Augmentation procedures were divided into two
cuts in the bone.
broad categories:
Distraction osteogenesis: the principals of distrac-
tion osteogenesis, in which a gradual controlled dis- 1. Horizontal bone augmentation procedures: any tech-
placement of a surgically prepared fracture is used to nique aimed at making the recipient bone wider or
increase bone volume, are not new but have recently thicker in order to receive dental implants of adequate
been introduced into implant surgery to increase alve- diameter (usually of a 3.5-mm diameter or wider).
olar bone volume. The gap created during the displace- 2. Vertical bone augmentation procedures: any tech-
ment of the bone segment fills with immature nique aimed at making the recipient bone higher in a
non-calcified bone that matures during a subsequent vertical dimension in order to receive dental implants
fixation period. The associated soft tissues are also of adequate length (usually 9 mm or longer). In many
expanded as the bone segment is transported. instances, a combination of horizontal and vertical
Zygomatic implants: a long implant may be placed bone augmentation is needed and these procedures
to the upper jaw passing through the sinus into the body were included in the vertical augmentation group.
of the zygomatic bone [4]. This surgical technique is an
alternative to bone augmentation in those patients with
insufficient bone for placement of the usual type of
dental implant. This comparison is not included in this 13.3 Materials and Methods
review as the zygoma implant technique is not a tech-
nique for bone augmentation, but is evaluated in another
Cochrane review [13]. 13.3.1 Criteria for Considering Studies
Each type of augmentation material may be used in for this Review
combination with a variety of different surgical tech-
niques, so many permutations of treatment are possible All RCTs evaluating patients with missing teeth who
and the situation is rather complicated. In addition, may require horizontal and/or vertical alveolar bone
new techniques and “active agents” are continuously augmentation prior to or during dental implant place-
introduced in the clinical practise. Particular treatment ment procedures to allow the placement of osseointe-
options have strong proponents with surgeons claim- grated dental implants. Any bone augmentation
ing that a particular material or technique offers technique, active agent (such as bone morphogenetic
improved implant success. proteins, PRP) or biomaterials used in relation with
This review will focus exclusively on techniques dental implants was considered. For trials to be consid-
aimed at augmenting the bone in a horizontal or verti- ered in this review, implants have to be placed and the
cal direction. Several reviews have been published outcome of the implant therapy has to be reported at
on this topic, though their findings were not based on least at the endpoint of the abutment connection proce-
the most reliable clinical trials; therefore, the informa- dure. The following time points were considered: abut-
tion presented has to be interpreted with a great deal ment connection, 1, 3 and 5 years after loading.
of caution [12, 17, 28, 34]. The reader can find infor- Outcomes measures were:
mation on the procedures for augmenting the maxil-
lary sinus, post-extractive sites, bone fenestrations at • Prosthesis failure: planned prostheses that could not
implants in the previous version of this review [11]. be placed due to implant failure(s) and loss of the
Information about bone augmentation at implants prostheses secondary to implant failure(s).
affected by peri-implantitis can be found in another • Implant failure: implant mobility and removal of
Cochrane review [10]. stable implants dictated by progressive marginal
bone loss or infection (biological failures). Implant unpublished or ongoing RCTs. In the first version of
mobility could be assessed manually or with instru- this review, more than 55 oral implant manufacturers
ments such as Periotest (Siemens AG, Benshein, and an Internet discussion group (implantology@
Germany) or resonance frequency (Osstell, Integration yahoogroups.com) were contacted; however, this was
Diagnostics, Göteborg, Sweden). discontinued due to poor yield.
• Augmentation procedure failure: failure of the aug- Study selection and data extraction.
mentation procedure (i.e. of the bone graft or the The titles and abstracts (when available) of all
GBR procedure, etc.) not affecting the success of reports identified through the electronic searches were
the implant. scanned independently by two review authors. For
• Major complications at treated/augmented sites studies appearing to meet the inclusion criteria, or for
(e.g. infection, nerve injury, haemorrhage, etc.). which there were insufficient data in the title and
• Major complications at bone donor sites (e.g. nerve abstract to make a clear decision, the full report was
injury, gait disturbance, infection, etc.). obtained. The full reports obtained from all the elec-
• Patient satisfaction including aesthetics. tronic and other methods of searching were assessed
• Patient preference including aesthetics (only in independently by two review authors to establish
split-mouth trials). whether the studies met the inclusion criteria or not.
• Bone gain vertically or horizontally or both Disagreements were resolved by discussion. Where
expressed in mm or percentage, including bone resolution was not possible, a third review author was
level changes over time. consulted. All studies meeting the inclusion criteria
• Aesthetics evaluated by dentist. then underwent validity assessment and data extrac-
• Duration of the treatment time starting from the first tion. Studies rejected at this or subsequent stages were
intervention to the functional loading of the implants. recorded in the table of excluded studies, and reasons
• Treatment costs. for exclusion recorded.
Data were extracted by two review authors indepen-
Trials evaluating only histological outcomes were not dently using specially designed data extraction forms.
considered in this review. The data extraction forms were piloted on several papers
and modified as required before use. Any disagreement
was discussed and a third review author consulted where
13.3.2 Search Strategy for Identification necessary. All authors were contacted for clarification
of Studies or missing information. Data were excluded until fur-
ther clarification was available if agreement could not
be reached. For each trial, the following data were
For the identification of studies included or considered
recorded: year of publication, country of origin and
for this review, detailed search strategies were devel-
source of study funding; details of the participants
oped for each database searched. For more details, see
including demographic characteristics; details on the
the original Cochrane review [9]. The following data-
type of intervention; details of the outcomes reported,
bases were searched:
including method of assessment and time intervals.
• The Cochrane Oral Health Group’s Trials Register
(to 9 January 2009)
• The CENTRAL (The Cochrane Library 2008, Issue 4) 13.3.3 Quality Assessment
• MEDLINE (1966 to 21 January 2009)
• EMBASE (1980 to 12 January 2009)
Three main quality criteria were examined as follows:
The most recent electronic search was undertaken on
1. Allocation concealment, recorded as adequate,
21 January 2009. Several dental journals were hand
unclear and inadequate.
searched up to January 2009. There were no language
restrictions. All the authors of the identified RCTs Allocation concealment was considered adequate if it
were contacted, the bibliographies of all identified was centralised (e.g. allocation by a central office unaware
RCTs and relevant review articles were checked, and of subject characteristics); pharmacy-controlled ran-
personal contacts were used in an attempt to identify domisation; pre-numbered or coded identical containers
which were administered serially to participants; on-site differences and standard deviations (SDs) were used to
computer system combined with allocation kept in a summarise the data for each group together with 95%
locked unreadable computer file that can be accessed CIs. The statistical unit was the patient and not the aug-
only after the characteristics of an enrolled patient have mentation procedure or the implant. A meta-analysis
been entered; sequentially numbered, sealed, opaque was done only if there were studies of similar compari-
envelopes; and other approaches similar to those listed sons reporting the same outcome measures. Odds ratios
above, along with the reassurance that the person who were combined for dichotomous data, and mean differ-
generated the allocation scheme did not administer it. ences for continuous data, using random-effects
Some schemes may be innovative and not fit any of the models.
approaches above, but still provide adequate conceal- The significance of any discrepancies in the esti-
ment. Approaches to allocation concealment which were mates of the treatment effects from the different trials
considered clearly inadequate included any procedure was to be assessed by means of Cochran’s test for het-
that was entirely transparent before allocation, such as an erogeneity and the I2 statistic, which describes the per-
open list of random numbers. Ideally, the surgeon should centage total variation across studies that is due to
have known the group allocation just after implants were heterogeneity rather than chance. Clinical heterogene-
inserted. Those articles or authors stating that allocation ity was to be assessed by examining the types of partici-
concealment procedures were implemented, but did not pants and interventions for all outcomes in each study.
provide details on how this was accomplished, were
coded as “unclear”.
2. Treatment blind to outcome assessors, recorded as 13.4 Results
yes, no, unclear, and not possible.
3. Completeness of follow-up (is there a clear expla-
Of the 19 potentially eligible trials [1–3, 7, 8, 14–16, 18,
nation for withdrawals and drop outs in each treat-
19, 22, 23, 26, 27, 29–31, 33, 36], four were excluded
ment group?) assessed as: Yes (in the case that clear
because they reported only histological outcomes without
explanations for drop outs were given, a further
reporting any implant related outcomes, one because it
subjective evaluation of the risk of bias assessing
was just a research protocol presenting only histological
the reasons for the drop out was made) and No.
outcomes and one because it presented the data of the
After taking into account the additional information various group combined [1, 2, 19, 29, 31, 36].
provided by the authors of the trials, studies were Of the 13 included trials, eight were conducted in
grouped into the following categories: Italy and five in the Netherlands [3, 7, 8, 14–16, 18, 22,
23, 26, 27, 30, 33].
(a) Low risk of bias (plausible bias unlikely to seri-
Nine trials had a parallel group study design and
ously alter the results) if all criteria were met.
four had a split-mouth design [15, 18, 26, 27]. One
(b) High risk of bias (plausible bias that seriously
study included one patient treated bilaterally, and only
weakens confidence in the results) if one or more
data from a randomly selected side were included in
criteria were not met.
this review [3].
Further quality assessment was carried out to assess For six trials it was declared that support was
sample size calculations, definition of exclusion/inclu- received from industry directly involved in the product
sion criteria and comparability of control and test being tested also in the form of free material [14, 15,
groups at entry. The quality assessment criteria were 22, 26, 27, 33]. One trial received support from
pilot tested using several articles. the implant manufacturer; however, the trial was not
designed to test the implants, but the augmentation
techniques [23]. The authors of six trials declared that
no support was received from commercial parties
13.3.4 Data Synthesis whose products were being tested in the trials [3, 7, 8,
16, 18, 30].
For dichotomous outcomes, the estimates of effect of Eleven trials were conducted at university, hospital,
an intervention were expressed as odds ratios (OR) or specialist dental clinics and two trials in private
together with 95% CIs. For continuous outcomes, mean practices [14, 23].
13.4.1 Characteristics Geistlich Pharmaceutical, Wolhusen, Switzerland).

of the Interventions Grafts were harvested from the iliac crest and bilat-
eral sinus lifts were performed at the same time
with autogenous blocks and particulate bone. After
The following interventions were tested: 3 months, implants were inserted into the healed
Different techniques for horizontal bone augmentation. graft of each side and were left to heal for an addi-
tional 6 months. All the augmentation procedures
13.4.1.1 Is Horizontal Augmentation were performed under general anaesthesia. Surgical
Necessary? (No Trial) templates were used to optimise implant insertion.
All implants were turned titanium self-tapping
(Nobel Biocare, Göteborg, Sweden) and were reha-
13.4.1.2 Which is the most effective horizontal
bilitated with implant supported overdentures.
augmentation technique? (three trials)
• Three different techniques to horizontally augment
local ridge maxillary defects (from first to first pre-
• Two-stage sinus lift with autogenous blocks and molars) for allowing placement of single implants
particulate bone together with buccal onlays mono- were tested (25): (1) bone graft from the chin,
cortico-cancellous bone grafts, to reconstruct the (2) bone graft from the chin with a resorbable barrier
width of the maxilla, fixed with titanium screws har- (Bio-Gide, Geistlich Pharma, Wolhusen, Switserland)
vested from the iliac crest with or without PRP left and (3) 100% bovine anorganic bone (Bio-Oss,
to heal for 3 months in a split-mouth trial [27]. spongiosa granules of 0.25–1 mm, Geistlich Pharma)
Barriers were not used. PRP was made using the with a Bio-Gide resorbable barrier. The cortical bone
Platelet Concentration Collection System kit (PCCS of the recipient sites was perforated to create a bleed-
kit, 3i Implant Innovations Inc. Palm Beach Gardens, ing bone surface and to open the cancellous bone.
FL, USA). Fifty-four millilitre of blood were mixed Bone blocks from the chin were fixed with a 1.5-mm
with 6 mL of anti-coagulant (citrate dextrose) and diameter titanium screw (Martin Medizin Technik,
processed with the platelet concentration system. Tuttlingen, Germany) and particulate bone from the
To promote the release of growth factors from the chin was placed around the fixed bone grafts.
platelets, 10% calcium chloride solution and the Implants were placed 3 months after autogenous
patient’s serum, as a source of autologous thrombin, bone grafting and 6 months after augmenting sites
were added before actual reconstruction of the with Bio-Oss. Single ITI-EstheticPlus implants
defect with the bone graft. The resulting gel was (Institute Straumann AG, Waldenburg, Switserland)
mixed with the bone graft and some gel was applied were placed using templates and left healing sub-
at the closure of the wound at the side treated with merged for 6 months. On the day of uncovering, pro-
PRP. Three implants were inserted into the healed visional single crowns were screwed on the implants
graft of each side and were left to heal for additional and were replaced 1 month later by final porcelain
6 months. All the augmentation procedures were crowns with a zirconium oxide core (Procera, Nobel
performed under general anaesthesia. Surgical tem- Biocare, Göteborg, Sweden).
plates were used to optimise implant insertion. All
implants were turned titanium self-tapping (Nobel
Biocare, Göteborg, Sweden) and were rehabilitated
13.4.2 Different Techniques for Vertical
with two implant supported prostheses.
• Two-stage buccal onlays monocortico-cancellous Bone Augmentation
bone grafts fixed with two titanium (diameter
1.5 mm, Martin Medizin Technik, Tuttlingen, 13.4.2.1 Is Vertical Augmentation
Germany) or resorbable poly (D,L-lactide) acid Necessary? (Two Trials)
(PDLLA, diameter 2.1 mm, Resorb X, Martin
Medizin Technik) screws in a split-mouth trial, to • One trial addressed the issue of which is the best
reconstruct the width of the maxilla [26]. Grafts treatment alternative to provide an overdenture to
were covered with resorbable barriers (Bio-Gide, patients with a resorbed mandible, i.e. symphyseal
height 6–12 mm measured on lateral radiographs Provisional screw-retained acrylic restorations were
[33]. Three procedures were tested: (1) installation delivered and replaced after 4 months by screw-
of four short implants (8 or 11 mm) left to heal for retained metal-ceramic restorations.
3 months; (2) mandibular augmentation with an
autologous bone graft from the iliac crest and (3)
transmandibular Bosker implants. We were only 13.4.2.2 Which is the Most Effective Vertical
interested in the former two procedures. Mandibles Augmentation Technique? (Eight Trials)
were augmented under general anaesthesia using the
interpositional technique. In brief, the mandible was • Vertical GBR with non-resorbable titanium-
sectioned in the interforaminal area, and a bone block reinforced ePTFE barriers (Gore-Tex, WL Gore
taken from the anterior ilium was positioned between and Associates, Inc., Flagstone, USA) supported by
the two segments that were stabilised with osteosyn- particulate autogenous bone harvested from the
thesis wires and left to heal for 3 months. The wires mandibular ramus and when the bone was not suf-
were then removed, and four 13–18 mm long ficient also from the chin (two patients) vs. vertical
implants were placed and left to heal for an addi- distraction osteogenesis [7]. Two different vertical
tional 3 months. Patients were not allowed to wear GBR procedures were used: six patients were
their dentures for the entire healing period (about treated with a one-stage approach (implants were
6 months). The short implants used were Twin Plus inserted protruding 2–7 mm from the bone level
IMZ implants (Friatec, Mannheim, Germany), whereas and the augmentation procedure was performed on
the augmented mandibles were treated with four spe- the same occasion; the abutment connection was
cially designed IMZ apical screw implants. No performed after 6–7 months), whereas five patients
explanation was given why two different types of were treated with a two-stage approach (first the
implants were used. Patients were rehabilitated with bone at site was augmented, and after healing of
overdentures supported by an egg-shaped triple bar 6–7 months, the implants were placed and left
with a Dolder-clip retention system. The bars did not submerged for an additional 3–5 months). The two-
have cantilever extensions. stage approach was used when the risk of insuffi-
• One trial compared the 7 mm short implants vs. cient primary implant stability of implants was
10 mm or longer implants placed in atrophic poste- subjectively expected. With the two-stage approach
rior mandibles augmented with a bone substitute one or two titanium miniscrews were used as addi-
block (Bio-Oss, Geistlch Pharma, Wolhusen, tional support for the titanium-reinforced barriers.
Switserland) placed according to an inlay technique All barriers were stabilised with titanium fixating
(32). Posterior mandibles with 7–8 mm of bone pins (Frios, Friadent GmbH, Mannheim, Germany)
height above the mandibular canal and a width of at or miniscrews (Gebrüder Martin GmbH & Co.,
least 5.5 mm as measured on CT scans were treated Tuttlingen, Germany) or both. The distraction pro-
under local anaesthesia. In brief, after a paracrestal cedure was accomplished by using osteodistractors
buccal incision, a horizontal osteotomy was made (Gebrüder Martin GmbH & Co.) fixed to the bone
2–4 mm above the mandibular canal. Two oblique segments with 1.5 mm large titanium screws. The
cuts were made, the bone segment was raised spar- distraction devices were activated after 1 week,
ing the lingual periosteum and a Bio-Oss block was twice a day (0.5 mm every 12 h) until the desired
modelled and positioned between the two segments amount of distraction was obtained (4–9 mm).
that were stabilised with osteosynthesis miniplates, The bone segments were then left to consolidate
covered with a resorbable membrane (Bio-Gide, for 2–3 months, the osteodistractors were then
Geistlch Pharma) and left to heal for 5 months. removed and dental implants placed and left sub-
Patients were not allowed to wear their removable merged for 3–6 months. The augmentation proce-
prostheses for 1 month after the augmentation pro- dures were performed under local anaesthesia,
cedure. Two to three implants (NanoTite, parallel local anaesthesia with intravenous sedation and
walled, with external connection, Biomet 3i, Palm general anaesthesia according to operator and
Beach, FL, USA) were placed 0.6 mm supracre- patient preferences. Surgical templates were used to
stally and left to heal for 4 months in both groups. optimise implant insertion. Two implant systems
were used: Brånemark Mark III implants (Nobel and fixed with miniscrews, supporting resorbable
Biocare, Göteborg, Sweden) in 19 patients and ITI collagen barriers (Bio-Gide®, Geistlich Pharma AG,
SLA implants (Institute Straumann AG, Waldenburg, Wolhusen, Switserland) [23]. The augmentation
Switzerland) in two patients. The choice of two dif- procedures were performed under local anaesthesia
ferent implant systems was dictated by the system or local anaesthesia with intravenous sedation
used by the referring dentists. All patients were according to operator and patient preferences.
rehabilitated with screw-retained metal-ceramic XiVe®S CELLplus (Friadent GmbH, Mannheim,
fixed prostheses. Germany) implants were used. All patients were
• Autogenous onlay bone grafts harvested from the rehabilitated with provisional resin fixed prostheses
mandibular ramus vs. vertical distraction osteogen- replaced then by metal-ceramic definitive prosthe-
esis to vertically augment deficient mandibles [8]. ses. One implant from each patient was used for the
Patients were grafted with a two-stage approach: statistical calculations.
first bone blocks were fixed with 1.5 mm diameter • Autogenous inlay bone grafts harvested from the
miniscrews (Gebrüder Martin GmbH & Co., iliac crest vs. distraction osteogenesis to vertically
Tuttlingen, Germany). Empty spaces were filled augment deficient posterior mandibles [3]. Patients
with cancellous bone chips. In case of severe verti- were grafted with a two-stage approach: first a
cal resorption, grafts were assembled in a multi- monocortical bone block was interposed between
layered fashion. No barriers were used. Bone grafts the basal bone and an osteotomised segment raised
were harvested from the mandibular ramus of the coronally without flap elevation at the lingual side
same side of reconstruction in six patients, while in to preserve blood supply and fixed with titanium
two patients, where larger defects were present, miniplates and miniscrews (KLS Martin, Tuttlingen,
bone was harvested bilaterally. After 4–5 months, Germany). No barriers were used. After 3–4 months,
implants were placed and left submerged for an miniplates were removed and implants were placed
additional 3–4 months. The distraction procedure and left submerged for 3–4 months. The distraction
was accomplished by using osteodistractors procedure was accomplished by using osteodistrac-
(Gebrüder Martin GmbH & Co.) fixed to the bone tors of various brands (Track by KLS Martin,
segments with 1.5 mm large titanium screws. The Al-Mar by Cizeta, LactoSorb by Wakterl Lorenz
distraction devices were activated after 1 week, Surgical, the latter being a resorbable device) fixed
twice a day (0.5 mm every 12 h) until the desired to the bone segments with various titanium or
amount of distraction was obtained (2–7 mm). The resorbable screws. The distraction devices were
bone segments were then left to consolidate for activated after 1 week, twice a day (0.5–1 mm/day
2–3 months, the osteodistractors were then removed for 5–7 days) until the desired amount of distraction
and dental implants placed and left submerged for was obtained (7–15 mm). In two cases a prosthetic
3–4 months. The augmentation procedures were device was used to avoid lingual tipping. The bone
performed under local anaesthesia, local anaesthe- segments were then left to consolidate for 3–4
sia with intravenous sedation and general anaesthe- months, the osteodistractors were removed and
sia according to operator and patient preferences. dental implants placed and left submerged for 3/4
Surgical templates were used to optimise implant months. All augmentation procedures were per-
insertion. ITI SLA implants (Institute Straumann formed under general anaesthesia. Dental implants
AG, Waldenburg, Switzerland) were used. All of several brands were used (A-Z implant,
patients were rehabilitated with screw-retained Biohorizons, Biomet 3i, Friadent, Nobel Biocare).
metal-ceramic fixed prostheses. All patients were rehabilitated with partial provi-
• One-stage vertical GBR using particulate autoge- sional prostheses for 14–16 months until definitive
nous bone harvested from intraoral locations cov- prostheses were delivered.
ered with non-resorbable titanium-reinforced ePTFE • Autogenous inlay bone grafts harvested from the
barriers (Gore-Tex, WL Gore and Associates, Inc., iliac crest vs. blocks of anorganic bovine bone (Bio-
Flagstone, USA), stabilised with miniscrews, vs. Oss®, Geistlich Pharma AG, Wolhusen, Switserland)
osteosynthesis plates (Gebrüder Martin GmbH & for vertically augmenting deficient posterior man-
Co., Tuttlingen, Germany), appropriately adapted dibles [15]. Patients were grafted with a two-stage
approach: first a monocortical bone block was inter- bone to ensure bleeding. After 6 months of sub-
posed between the basal bone and an osteotomised merged healing, the barriers and the mini-implant
segment raised coronally without flap elevation at were removed and Brånemark MK III (Nobel
the lingual side to preserve blood supply and fixed Biocare) implants with a TiUnite surface were
with titanium miniplates and miniscrews (KLS placed. After 5 month of healing, implant stability
Martin, Tuttlingen, Germany) and covered with a was tested and abutments were placed.
resorbable barrier (Bio-Gide®, Geistlich Pharma • Ultrasound or placebo were applied using a sonic-
AG). The contra-lateral side was treated with a sim- accelerated fracture-healing system (SAFHS model
ilar technique, but using a Bio-Oss bone block 2000, Smith and Nephew, Memphis, TN, USA) by
instead. The removable prostheses were allowed for patients subjected to vertical osteodistraction osteo-
1 month after the augmentation procedure. After 4 genesis in the anterior mandible when active osteo-
months, miniplates were removed and implants distraction was initiated after a latency period of
were placed and left submerged for 4 months. All about 5 days [30]. Ultrasound self-treatment
augmentation procedures were performed under involved a daily treatment of 20 min for about
general anaesthesia and patients remained hospital- 50 days on the skin of the chin covering the osteo-
ised for 3 days. Dental implants of three different distraction gap using 1.5 MHz pressure wave in
brands were used (Nanotite Biomet 3i cylindrical pulses of 200 ms. Between pulses there was an 800-
implants with external connection, Ankylos and ms pause (on:off period > 1:4). Patient compliance
XiVe Dentsply-Friadent implants). All patients was monitored by a memory chip inside the ultra-
were rehabilitated with fixed partial provisional sound equipment. Six weeks post-distraction, the
acrylic prostheses for 4 months until definitive distraction devices were removed and two 12 mm
metal-ceramic fixed prostheses were delivered. long ITI Bonefit implants (Straumann AG,
• Two-stage vertical GBR using non-resorbable tita- Waldenburg, Switserland) were inserted and left to
nium-reinforced ePTFE barriers (Gore-Tex, WL heal for 3 months before being loaded with an
Gore and Associates, Inc., Flagstone, USA), stabi- overdenture.
lised with miniscrews, comparing particulate autog- • Inlays vs. onlays autogenous bone grafts harvested
enous bone harvested from the retromolar area with from the iliac crest to vertically augment deficient
trephine drills and subsequently particulated with a posterior mandibles [16]. Patients were grafted with
bone mill vs. an allograft made of malleable allo- a two-stage approach: a monocortical bone block
genic bone matrix (Regenaform, Regeneration was either interposed between the basal bone and the
Technologies, Alachua, FL, USA) [18]. This osteotomised segment raised coronally without flap
allograft is a combination of assayed demineralized elevation at the lingual side to preserve blood supply
bone matrix (DFDBA) with cortico-cancellous or placed as an onlay. Grafts were fixed with titanium
bone chips uniformly dispersed in a termoplastic miniplates or miniscrews (Gebrüder Martin GmbH &
biological carrier which became malleable when Co, Tuttlingen, Germany). The grafted areas were
warmed between 43 and 49°. The augmentation covered with resorbable barriers (Bio-Gide®, Geis
procedures were performed under local anaesthesia tlich Pharma AG). All augmentation procedures
with sedative pre-medication half an hour prior to were performed under general anaesthesia. Patients
surgery. Two mini-implants were used as “poles” to were instructed not to wear removable prostheses for
support the barrier. They were placed to protrude 1 month after the augmentation procedure. After 3–4
for the required height. One pole was a stainless months miniplates/screws were removed and two
steel mini-screw (6–12 mm long; Ace Dental dental implants were placed and left submerged for
Implant System, Brockton, MA, USA), and the 4 months. Dental implants of several brands were
other was an immediate provisional implant (IPI, used (Biomet 3i and XiVe Dentsply-Friadent implants
Steri-Oss, Nobel Biocare, Göteborg, Sweden). This for the inlay group and Astra Tech, Biolok and Alpha
micro-implant (2 mm in diameter and 10 mm in Bio implants for the onlay group). All patients were
length) was removed at implant installation with a rehabilitated with screw-retained acrylic partial pro-
4-mm diameter trephine bur for histological exami- visional prostheses for 4–5 months until definitive
nation. Several drill holes were made on the cortical screw-retained prostheses were delivered.
13.4.3 Characteristics insertion was evaluated in one study using the oblique

of Outcome Measures lateral radiographic technique, but insufficient data
were presented to enable us to evaluate bone height
changes [33].
• Prosthesis failure [3, 7, 8, 14–16, 18, 22, 23, 26, 27, • Aesthetics assessed by dentist: one trial; however,
30, 33]. we could not use the data since they were not pre-
• Implant failure [3, 7, 8, 14–16, 18, 22, 23, 26, 27, sented by study groups [22].
30, 33]. • Duration of the treatment period starting from the
• Augmentation procedure failure [3, 7, 8, 14–16, 18, first intervention to the functional loading of the
22, 23, 26, 27, 30, 33]. implants: all trials.
• Major complications at augmented site [3, 7, 8, • Treatment costs: no trials. However, this outcome mea-
14–16, 18, 22, 23, 26, 27, 30, 33]. sure was indirectly extrapolated by us for all trials.
• Major complications at bone donor site [3, 7, 8, 15,
16, 18, 22, 23, 26, 27, 33].
• Patient satisfaction including aesthetics [22, 33]. 13.4.4 Duration of Follow-Up
We could not use the data of one trial since they
were not presented by study groups [22].
• Patient preference including aesthetics (only in • Four-month post-loading [14].
split-mouth trials) [15]. • One-year post-loading [15, 16, 18, 22].
• Bone gain vertically or horizontally or both expressed • One-year and half post-loading [3].
in mm or percentage including bone level changes • Two-year post-loading [26, 27, 30, 33].
over time: vertical bone gain was measured in mm by • Three-year post-loading [7, 8, 23].
direct measurement in seven studies [3, 7, 8, 15, 16,
18, 23]. Peri-implant marginal bone level changes
were assessed in five trials (7, 8, 15, 16, 22), but in 13.4.5 Risk of Bias in Included Studies
three trials (16, 25, 33) data were presented in a way
we could not use. One study included different types The final quality scoring after having incorporated the
of implants followed at different follow-up time [16]. additional information kindly provided by the authors
The resorption pattern of the mandible after implant of the trials is summarised in Table 13.1. For each
Table 13.1 Risk of bias assessment after having included additional explanations provided by the authors of the included trials
Study Allocation Outcome assessor blind Withdrawals Risk of bias
concealment
Stellingsma et al. [33] Unclear No Yes, reasons given High
Chiapasco et al. [7] Inadequate No None High
Raghoebar et al. [27] Unclear Yes None High
Raghoebar et al. [26] Unclear No None High
Chiapasco et al. [8] Adequate Yes, when possible None Low
Meijndert et al. [22] Unclear Yes Yes, reasons given High
Merli et al. [23] Adequate Yes, when possible None Low
Bianchi et al. [3] Adequate Yes, when possible None Low
Felice et al. [15] Inadequate Yes, when possible None High
Fontana et al. [18] Adequate Yes None Low
Schortinghuis et al. [30] Adequate Yes None Low
Felice et al. [14] Adequate Yes None Low
Felice et al. [16] Adequate Yes None Low
trial, we assessed whether it was at low or high risk of <5 mm in height of residual alveolar bone with
bias. Seven studies were judged to be at low risk of reduced stability and retention of upper dentures)
bias and the remaining at high risk of bias [3, 14, 16, [6, 26, 27].
18, 23, 25, 30]. • Severely resorbed mandibles, i.e. symphyseal
height 6–12 mm as measured on standardised lateral
radiographs of patients who have been edentulous
13.4.6 Allocation Concealment for at least 2 years and experienced severe func-
tional problems with their lower dentures [32].
• Residual bone height over the mandibular canal of
While assessing the information presented in the arti-
5–9 mm [3].
cles, allocation concealment was scored adequate for
three trials (18, 26, 32), inadequate for one trial (29)
5–7 mm and bone width of at least 5 mm [15].
and unclear for all other trials. All authors replied to
our request for clarification [7, 14, 15, 23]. While eval-
7–8 mm and bone width of at least 5.5 mm [14].
uating authors’ replies, one trial scored as being ade-
• Residual bone height over the mandibular canal
quately concealed became not concealed 18; five trials
of at least 4.5–11 mm and bone width of at least
were judged to be properly concealed (24, 28, 30, 31,
5 mm [16].
33), whereas four trials remained unclear 21, 23, 25,
• Patients with bilateral posterior mandibular partial
34 [3, 6–8, 14–16, 18, 23, 26, 27, 30].
edentulism (Applegate-Kennedy Class I) having a
defect of more than 3 mm considering the deepest
portion of the edentulous ridge in relation to the
13.4.7 Blinding bone adjacent the last tooth [18].
• Edentulous ridges requiring vertical regeneration
While assessing the information presented in the arti- [7, 8, 23].
cles for the outcome measures of interest in the present • Horizontal bone deficiency in a maxillary site (inci-
review that were possible to be masked, blinding of the sor, cuspid or first bicuspid) requiring a single
outcome assessor was scored as unclear for all trials implant [22].
with five exceptions [15, 22, 23, 27, 30]. Three trials
were scored as blinded (21, 25, 31) and two as blinded
when possible (26, 29) [15, 22, 23, 27, 30]. All authors 13.4.8.2 Main Exclusion Criteria
replied to our request for clarification. When evaluat-
ing authors’ replies, the outcome assessors of two tri- • Smoking more than 20 cigarettes per day [23].
als were considered blinded (30, 33), of three trials • Smoking more than 15 cigarettes per day [3, 7, 8, 15].
blinded when possible (24, 28, 32) since complete • Smoking more than ten cigarettes per day [18].
blinding was not possible, and those of three trials as • Smokers [22].
not blinded (18, 23, 34) [3, 7, 8, 14, 16, 18, 26, 32]. • Intravenous bisphosphonate [14–16].
• Severe knife-edge ridges [3, 7, 8].
• History of reconstructive, pre-prosthetic surgery or
13.4.8 Completeness of Follow-Up previous oral implantology [15, 16, 22, 26, 27].
• Edentulous period less than 3 months [14, 18].
• Edentulous period less than 1 year [26, 27].
When assessing the information presented in the arti-
• Mucosal disease, such as lichen planus, in the areas
cles, information on drop outs was clearly presented in
to be treated [3, 7, 8, 15, 16].
all trials, with one exception [7]. The authors con-
firmed that there were no withdrawals [7].
13.4.9 Sample Size
13.4.8.1 Main Inclusion Criteria
A priori calculation for the sample size was undertaken
• Severely resorbed maxillae (classes V–VI accord- in three trials [14, 15, 23]. The calculation of one trial
ing to Cawood with maxillary sinuses having was based on the complications that occurred in
another similar RCT [19, 23]. Twenty-one patients Five patients were treated with a split-mouth
were needed in each group to detect a difference approach with two-stage sinus lift with autogenous
between a proportion of complications from 0.27 to bone together with buccal onlays grafts, harvested
0.80. However, the trial included only 11 patients per from the iliac crest, one side with PRP and the other
group, thus the sample size requirement was not ful- without. All patients were followed for 2 years after
filled. In one trial of split-mouth design, the sample implant loading and there were no drop outs. No
size was calculated to detect patient preference of one serious complications occurred at the grafted sites:
procedure over the other against the alternative hypoth- one sinus membrane was perforated during surgery,
esis that treatments were equally preferred [15]. This but healing was uneventful. A small incision break-
reduced to a simple one sample proportion scenario. A down occurred in the first week at the non-PRP side
one group chi-square test with a 0.050 two-sided sig- of one patient. A seroma that healed uneventfully
nificance level had 80% power to detect the difference was the only complication that occurred at the donor
between the null hypothesis proportion of 0.500 and sites. During the prosthetic phase one implant failed
the alternative proportion of 0.900 when the sample in the PRP side, but no prostheses failed. There was
size is ten. The sample size was achieved. The calcula- no statistically significant difference for any of the
tions for another trial were based on implant failures outcomes considered in this review. The difference
[14]. A two group continuity corrected chi-square test in cost and treatment time was the use of PRP.
with a 0.050 two-sided significance level had 80% Prostheses were inserted about 10 months after
power to detect the difference between a proportion of augmentation. The trial was judged to be at high
0.100 and a proportion of 0.300 for patients experienc- risk of bias.
ing at least one implant failure (odds ratio of 3.857) • One split-mouth trial compared two titanium vs. two
when the sample size in each group was 72. However, resorbable screws for fixating two-stage buccal
only 30 patients were recruited in each group and the onlay grafts, harvested from the iliac crest, to
size requirement was not fulfilled. resorbed maxillae [26]. Eight patients were followed
Baseline comparability between treatment groups for 2 years after implant loading and there were no
drop outs. No serious complications occurred at the
• No apparent major baseline differences [7, 14–16,
grafted and donor sites. Two resorbable screws broke
18, 22, 23, 26, 27, 30, 33].
at insertion (one because of incorrect handling), but
• Unclear whether major baseline differences existed [8].
they could be removed and replaced. A small inci-
• The following major baseline differences existed:
sion breakdown occurred in the first week at the tita-
more bone (1.1 mm) above the mandibular canal in
nium screw side of one patient. Another patient
the inlay group [3].
developed a slight submucosal swelling with redness
of the mucosa above a resorbable screw 3 months
after the augmentation procedure, which disap-
13.4.10 Effects of Interventions peared after implant placement. No prostheses or
implant failed. There was no statistically significant
Different techniques for horizontal bone augmentation. difference for any of the outcomes considered in this
review. The difference in cost and treatment time
was the use of different screws. Prostheses were
13.4.10.1 Is the Augmentation Procedure inserted about 10 months after augmentation. The
Necessary? (No Trial) trial was judged to be at high risk of bias.
• One trial compared three two-stage techniques to
Which is the most effective augmentation technique? horizontally augment bone at maxillary sites (inci-
(3 trials with 106 patients) sor, cuspid or first bicuspid) to allow placement of
single implants [22]. Thirty-one patients were
• One trial compared two techniques for augmenting included in each group and were followed up for
resorbed maxillae including atrophic maxillary 1 year after loading. The following procedures were
sinuses [27]. Only patients with less than 5 mm of tested: (1) autogenous bone block from the chin;
alveolar bone height in the sinus floor were included. (2) autogenous bone block from the chin plus a
resorbable barrier; (3) 100% Bio-Oss plus a resorb- s tatistically significant (p > 0.08), Fisher’s exact test
able barrier. No patients dropped out. Not a single (two sided) found a significant difference (p > 0.048),
complication occurred. Two single implants failed with higher implant failure for the augmented man-
early in the group treated with Bio-Oss plus resorb- dibles, confirming the findings of the original article.
able barrier, though this difference was not statisti- Statistically significant differences were also found at
cally significant. Many other outcome measures 3 weeks after the first surgical intervention: (1) 85%
(peri-implant bone level changes, patient satisfac- of the patients in the augmentation group reported
tion, aesthetics judged by patients and by an inde- serious pain for more than 1 week vs. 20% of the
pendent dentist) could not be used in the present patients in the short implant group (OR 22.7; 95%
review because data were aggregated and not pre- confidence interval (CI) 4.4–117.5); (2) 30% of the
sented by study groups. With respect to cost and patients in the augmentation group reported no
treatment time, the additional costs for the barriers, improvement in their facial appearance vs. 80% of
and Bio-Oss should be considered. Patients had to the patients in the short implant group (in this group,
wait 9 months (bone block groups) or 1 year (Bio- 70% reported no change, and 10% reported a deterio-
Oss plus barrier group) to be rehabilitated. The trial ration of their facial appearance) (OR 0.11; 95% CI
was judged to be at high risk of bias. 0.03–0.46). The article also reported a statistically
significant difference with 50% of the patients in the
augmentation group experienced the operation more
negatively than expected vs. 25% of the patients in
13.4.11 Different Techniques for Vertical
the short implant group; however, we did not find this
Bone Augmentation difference significant. With respect to prosthetic
aftercare, four unplanned interventions were required
13.4.11.1 Augmentation Necessary? in the short implant group vs. ten interventions in the
(Two Trials with 100 Patients) graft group. Numerous aspects of patient satisfaction
including aesthetics were investigated using validated
• One trial evaluated the need to augment anterior atro- questionnaires at 1 year and no statistically signifi-
phic mandibles (residual bone height between 6 and cant differences among groups were found. With
12 mm) up to 2 years after loading (Fig. 13.1) [33]. respect to cost and treatment time, while short
Twenty patients received four short implants implants were placed under local anaesthesia, the
(8–11 mm), whereas 20 patients received interposed graft procedures required general anaesthesia, a mean
iliac bone grafts and four longer implants (13–18 mm) of 5.9 days of hospitalisation (range 3–9; SD 1.3) and
to support overdentures. Two patients dropped out, the double healing time (about three additional
one from each group about 3 months after overden- months), and patients could not wear the lower den-
ture delivery due to death and moving. In the short ture for 6 months. The trial was judged to be at high
implant group two complications occurred: bleeding risk of bias.
during surgery and permanent unilateral hypoaesthe- • One trial evaluated the need to augment posterior
sia, and no early implant failure. In the augmented atrophic mandibles (residual bone height above the
group six complications occurred: one life threaten- mandibular canal between 7 and 8 mm and width of
ing complication (post-operative sublingual oedema at least 5.5 mm) up to 4 months after loading
which left the patient in intensive care for 3 days); (Fig. 13.1) [14]. Thirty patients received 2–3 7 mm
two wound dehiscences; two unilateral dysaesthe- short implants and 30 patients received an interposed
siae, one of which completely recovered; and one anorganic bovine bone block (Bio-Oss) and, after
necrosis of the osteotomized cranial fragment of the 5 months of healing, 2 to 3 10 to 15 mm long implants
mandibles. In the augmented group four patients lost to support fixed partial restorations. No patient
one implant each and a fifth patient lost all implants dropped out. No complications occurred in the short
(possibly for necrosis of the osteotomized cranial implant group vs. four complications (wound dehis-
fragment of the mandible and had to be re-treated), cence/infections) in the augmented group: three of
before or at abutment connection. Although the these dehiscence persisted until implant placement,
RevMan P value for the odds ratio (OR) was not and in two patients, partial loss of the bone graft
Bone Short Odds Ratio Odds Ratio

Study or grafts implants
Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.1.1 Prosthetic
failure
Felice 2009a 3 30 1 30 66.1% 3.22 [0.32, 32.89]
Stellingsma 2003 1 19 0 19 33.9% 3.16 [0.12, 82.64]
Subtotal (95% CI) 49 49 100.0% 3.20 [0.48, 21.25]
Total events 4 1
Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.99); I2 = 0%
Test for overall effect: Z = 1.21 (P = 0.23)
1.1.2 Implant
failure
Felice 2009a 3 30 1 30 71.3% 3.22 [0.32, 32.89]
Stellingsma 2003 5 19 0 19 28.7% 14.79 [0.76, 289.43]
Subtotal (95% CI) 49 49 100.0% 6.54 [1.12, 38.22]
Total events 8 1
1.1.3 Major
complications
Felice 2009a 4 30 0 30 23.4% 10.36 [0.53, 201.45]
Stellingsma 2003 6 20 2 20 76.6% 3.86 [0.67, 22.11]
Subtotal (95% CI) 50 50 100.0% 5.38 [1.22, 23.64]
Total events 10 2
1.1.4 Experienced the operation negatively
Stellingsma 2003 10 20 5 20 100.0% 3.00 [0.79, 11.44]
Subtotal (95% CI) 20 20 100.0% 3.00 [0.79, 11.44]
Total events 10 5
Heterogeneity: Not applicable
1.1.5 Severe pain for > 1 week
Stellingsma 2003 17 20 4 20 100.0% 22.67 [4.37, 117.47]
Subtotal (95% CI) 20 20 100.0% 22.67 [4.37, 117.47]
Total events 17 4
1.1.6 No improvement of facial appearance (3 weeks)
Stellingsma 2003 6 20 16 20 100.0% 0.11 [0.03, 0.46]
Subtotal (95% CI) 20 20 100.0% 0.11 [0.03, 0.46]
Total events 6 16
0.001 0.1 1 10 1000

Favours bone grafts Favours short impl.
Fig. 13.1 Forest plots illustrating the meta-analysis of two trials comparing short implants vs. augmentation of the mandible. Shot
implants had statistically less implant failures and complications than longer implants placed in augmented mandibles
occurred. Two augmentation procedures were consid- which was associated with an infection, and two
ered a complete failure because the planned augmen- transient paraesthesiae of the chin area lasting 1 and
tation was not obtained and 7 mm short implants had 4 weeks. Both paraesthesiae were associated with
to be used instead of the planned 10 mm or longer the only two procedures for harvesting bone
implants. These graft failures were associated with from the chin. All procedures for harvesting bone
the fracture of the Bio-Oss blocks at the augmentation from the ramus were complication free. There was
procedure. In the augmented group three patients lost no statistically significant difference for complica-
one implant each vs. one patient in the short implant tions between the two procedures. No implants or
group and the related prostheses could not be placed prostheses failed over the 3-year follow-up period.
when planned; however, all failed implants were suc- The mean bone gain after the augmentation proce-
cessfully replaced and loaded. No statistically signifi- dure was reported for both groups, but without
cant differences between groups were observed. With explaining how it was recorded or which were the
respect to cost and treatment time, short implants reference points. Also data on peri-implant bone
were loaded about 4 months after initiation of the loss were unclear and could not be used. With
treatment, whereas longer implants placed in aug- respect to cost and treatment time, in the GBR
mented bone about 9 months after treatment start. The group the cost of the barriers and the fixing pins
cost of one additional surgical intervention and of the should be considered vs. the cost of the intraoral
Bio-Oss block for patients treated with the augmenta- distractor and related orthodontic therapy when
tion procedure should also be considered. The trial needed. In the osteodistraction group, the time of
was judged to be at low risk of bias. exposing the implants ranged between 6 and a half
months (mandibles) to 9 and a half months (maxil-
The meta-analysis of these two trials for the outcome lae) and patients were not allowed to use prostheses
measures (prostheses failures, implant failures and for about 3 and a half months. In the GBR group,
complications) resulted in statistically significant more the time of exposing the implants ranged between
implant failures OR > 6.54 (95% CI 1.12–38.22) and 6 and 7 months, when implants were placed simul-
complications OR > 5.38 (95% CI 1.22–23.64) in the taneously with the GBR procedure, and to 9–12
vertically augmented group (Fig. 13.1) [14, 33]. months, when implants were placed after the ridge
had been vertically augmented. Patients were left
without removable prostheses for 6–7 months. The
13.4.11.2 Which is the Most Effective trial was judged to be at high risk of bias.
Augmentation Technique? • One trial compared distraction osteogenesis in nine
(8 Trials with 118 Patients) patients vs. autogenous onlay bone grafts taken from
the mandibular ramus in eight patients for verti-
• One trial compared distraction osteogenesis in cally augmenting mandibular edentulous ridges for
11 patients vs. GBR with non-resorbable barriers 3 years after loading [8]. No patient dropped out.
and particulate autogenous bone grafts taken from Three complications occurred in three patients of
the mandibular ramus (if not sufficient also from the osteodistraction group: the bone fragment
the chin) in ten patients for vertically augmenting inclined lingually during the distraction phase prob-
edentulous ridges for 3 years after loading [7]. No ably due to the traction on the osteotomized segment
patient dropped out. Two complications occurred in by muscle forces of the floor of the mouth. The
two patients of the osteodistraction group: the bone complications were successfully treated by applying
fragment inclined lingually during the distraction an orthodontic traction until the bone segment con-
phase probably due to the traction on the osteoto- solidated in the desired position. In the third patient,
mized segment by muscle forces of the floor of the distraction was interrupted before completion
mouth. The complications were successfully treated because of the impossibility to move further the dis-
by applying an orthodontic traction until the bone tracted segment. This was probably caused by an
segment consolidated in the desired position. Five incorrect design of the vertical osteotomic lines.
complications occurred in four patients of the GBR Shorter implants (6 mm instead of the planned
group: three barrier exposures occurred, one of 8 mm) could be placed anyway. Four complications
occurred in four patients of the bone graft group: resorbable barriers supported by osteosynthesis
three paraesthesiae of the alveolar inferior nerve, plates (26). One implant per patient was used for
two transient but one permanent. In the last patient the statistical calculations. No patient dropped out.
the graft became exposed and was partially lost. The Four complications occurred in the resorbable
treatment could be completed anyway using short group: two abscesses that determined the failure of
implants. There was no statistically significant dif- the grafting procedures, and two minor complica-
ference for complications between the two groups. tions not affecting the outcome of the therapy (bar-
No implants or prostheses failed over the 3-year rier exposure without sign of infection, and a
follow-up period. The mean bone gain after the aug- swelling suggesting an early infection successfully
mentation procedure was 5.3 + 1.58 mm for the oste- treated with antibiotics). Five complications
odistracted sites and 5.0 + 1.07 mm for the grafted occurred in the non-resorbable group: one infection
sites. No statistically significant differences were that determined the failure of the graft and three fis-
observed regarding marginal peri-implant bone loss tulas in three patients. The last complication was
between groups at 1 and 3 years. Three years after lymph nodes swelling 1 month after intervention
loading, implants in osteodistracted sites lost on suggesting an infection that was treated with sys-
average 0.9 mm of peri-implant bone vs. 1.3 mm in temic antibiotics. No study implant failed and all
grafted sites. With respect to cost and treatment planned prostheses could be delivered. Both treat-
time, in the bone graft group only the cost of the fix- ments resulted in statistically significant vertical
ing pins should be considered vs. the cost of the bone gain (2.2 mm for the resorbable group and
intraoral distractor and related orthodontic therapy 2.5 mm for the non-resorbable group); however, no
when needed, making bone grafting cheaper. In the statistically significant differences were found
bone graft group, the time occurring for exposing among the two procedures (Fig. 13.2). Three years
the implants ranged between 8/9 months. Patients after loading, both groups lost peri-implant bone in
were left without removable prostheses for at least 2 a statistically significant way (about 0.5 mm) and
months. In the osteodistraction group the time to there was no difference in bone loss between groups
expose implants was 7/8 months and patients were (Fig. 13.2). With respect to cost and treatment time,
not allowed to use prostheses for about 3 months. for the resorbable group the cost of one or two bar-
The trial was judged to be at low risk of bias. riers, the osteosynthesis plates and related fixating
• One trial compared one-stage particulate autog pins should be considered vs. the cost of a titanium-
enous bone grafts from intraoral locations in reinforced barrier and related pins in the non-
11 patients treated with non-resorbable titanium- resorbable group, which could be slightly cheaper.
reinforced barriers vs. 11 patients treated with The healing time for both groups was about four
Study or Non-resorb. Resorb. Mean Difference Mean Difference

Subgroup Mean SD Total Mean SD Total IV, Fixed,95% CI IV, Fixed, 95% CI
3.8.1 Vertical bone gain
Merli 2007 2.48 1.13 11 2.16 1.51 11 0.32 [−0.79, 1.43]
3.8.2 Periimplant bone loss (3 years)
Merli 2007 0.53 0.66 11 0.55 0.58 11 −0.02 [−0.54, 0.50]
−4 −2 0 2 4
Test for subgroup differences: Not applicable Favours resorb. Favours non-resorb.
Fig. 13.2 Forest plot illustrating clinical vertical bone gain at o steosynthesis plates. Both procedures determined a statistically
abutment connection and radiographic peri-implant bone levels 3 significant gain of bone with no statistical differences among the
years after loading of two regenerative techniques for vertical two techniques. Only about 0.5 mm of peri-implant bone was lost
augmentation with autogenous bone using non-resorbable tita- 3 years after loading
nium-reinforced barrier or resorbable barriers supported by
and a half months, slightly less than originally achieve the desired outcome was similar. The trial
planned (5 months), due to premature removal of was judged to be at low risk of bias.
some infected barriers. The trial was judged to be at • One split-mouth trial compared autogenous bone
low risk of bias. blocks taken from the iliac crest vs. anorganic
• One trial compared distraction osteogenesis in five bovine bone blocks used as inlays in ten patients for
patients vs. autogenous inlay bone grafts taken from vertically augmenting posterior mandibular edentu-
the iliac crest in six patients for vertically augment- lous ridges of 5–7 mm height above the mandibular
ing mandibular edentulous ridges of 5–9 mm height canal for 1 year after loading [15]. No patient
above the mandibular canal for at least 1 year and dropped out. Three complications occurred in three
half after loading [3]. No patient dropped out. Three patients: two infections at the sites grafted with
complications occurred in the distraction group and autogenous bone, one determining the complete
one in the inlay group. In the distraction group two failure of the graft and the other a partial loss of the
patients developed progressive lingual inclination graft vs. a minor soft tissue dehiscence at a Bio-Oss
of the distraction segments possibly due to traction treated site. Because of the complete failure of one
by the muscles of the floor of the mouth. Orthodontic autogenous bone graft, the two planned implants
traction was applied to avoid consolidation of the and their prostheses could not be placed. One
distracted segments in an unfavourable position. implant failed in the Bio-Oss group 11 weeks after
One patient developed a minor infection at implant loading. It was successfully replaced and a new
insertion time resolved with local debridement. prostheses was made. There were no statistically
There were no statistically significant differences significant failures for prostheses and implant fail-
for complications between groups. In the inlay ures as well as complications. Both treatments
group recovery of the donor sites was uneventful in resulted in vertical bone gain (6.2 mm for the bone
all cases with no complications. One patient devel- substitute group and 5.1 mm for the autogenous
oped a post-augmentation dehiscence of the distal bone group), and the difference of 1.1 mm was not
fixation screw, infection and partial resorption of statistically significant. One-year after loading, both
the cranial segment. This was resolved with local groups lost statistically significant peri-implant
debridement. Those complications did not jeopar- marginal bone (0.82 mm the autogenous bone group
dise the success of the augmentation procedures. and 0.59 mm the Bio-Oss group), but the 0.21 mm
No study implant failed and all planned prostheses of difference between the two groups was not statis-
could be delivered. Both treatments resulted in vertical tically significant. When asked for their preference
bone gain (8.4 mm for the distraction group and 1 month after delivery of the definitive prostheses,
5.1 mm for the inlay group), with osteodistraction eight out of ten patients preferred the bone substitute
gaining statistically more bone (Fig. 13.3). With vs. two patients who had no preference since both
respect to costs, for the distraction group the cost of interventions were fine for them. This difference
the distractor device should be considered vs. the was statistically significant (OR > 0.03, 95% CI
cost of the osteosynthesis plates in the inlay group, 0.00–0.64, p > 0.02). With respect to costs, the cost
which could be slightly cheaper. The time needed to of the bone substitutes should be considered vs. the
Study or Osteodistraction Inlay graft Mean Difference Mean Difference

Subgroup Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
3.2.1 bone gain

Bianchi 2008 8.38 1.74 5 5.13 0.55 6 3.25 [1.66, 4.84]
−10 −5 0 5 10
Favours inlay graft Favours osteodistraction
Fig. 13.3 Forest plot comparing osteodistraction with inlay bone grafts for vertically augmenting posterior mandibles. Statistically
significant more vertical bone gain was obtained with osteodistraction
need of an additional operation to retrieve autoge- o utcome was similar. The trial was judged to be at
nous bone for the iliac crest which has to be con- low risk of bias.
ducted in general anaesthesia. The time needed to • One trial evaluated the effect of ultrasounds on ver-
achieve the desired outcome was similar. The trial tical distraction osteogenesis in anterior atrophic
was judged to be at high risk of bias. mandibles [30]. Five patients were treated with
• One split-mouth trial evaluated vertical GBR with ultrasounds and four patients with a placebo. The
titanium-reinforced barriers supported by two ultrasounds or placebo were delivered at the start of
“poles” comparing particulate autogenous bone the active osteodistraction phase for about 45 days.
harvested from the retromolar area with a thermo- No patient dropped out. No complication occurred,
plastic allogenic bone substitute (Regenaform) in no implant failed and all planned prostheses could
five patients for vertically augmenting posterior be delivered and followed for 2 years after loading.
mandibular edentulous ridges up to 1 year after The distraction distance obtained was 4.6 mm for
loading [18]. No patient dropped out. Two compli- the ultrasound group and 5.8 mm for the placebo
cations occurred in one patient, one at each of group. The difference of 1.2 mm was not statisti-
treated site. The side treated with autogenous bone cally significant, but clearly in favour of the placebo
showed an infection without barrier exposure group. With respect to costs, the cost of the ultra-
2 months after augmentation. The barrier and the sound equipment should be considered. The time
small tissue portion affected by the infection were needed to achieve the desired outcome was similar,
removed. On the contra-lateral side a buccal bone though patients had to spend about 20 min/day for
dehiscence developed around one of the implants. It about 45 days to deliver the treatment. The trial was
was treated with autogenous bone and a resorbable judged to be at low risk of bias.
barrier. Those complications did not jeopardise the • One trial evaluated inlays (in ten patients) vs. onlays
success of the augmentation procedures. No study (in 13 patients) of autogenous bone grafts harvested
implant failed and all planned prostheses could be from the iliac crest to vertically augment deficient
delivered. Both treatments resulted in vertical bone posterior mandibles of 4.5–10 mm height above the
gain (4.7 mm for the bone substitute group and mandibular canal for 1 year after loading [16]. The
4.1 mm for the autogenous bone group), and the number of patients in each group was unbalanced
difference of 0.6 mm was statistically significant because toss of a coin was used to randomise
(Fig. 13.4). With respect to costs, the cost of the patients. No patient dropped out. Four complica-
bone substitutes should be considered vs. the need tions occurred in four patients of the inlay group
of an additional flap operation to retrieve autogenous (three dehiscence/infection with partial exposure of
bone. The time needed to achieve the desired the miniplates, one determining the failure of the
Mean Difference Mean Difference

Study or Mean
Subgroup Difference SE Weight IV, Fixed, 95% CI IV, Fixed, 95% CI

Fontana 2008 0.6 0.2 100.0% 0.60 [0.21, 0.99]
Subtotal (95% CI) 100.0% 0.60 [0.21, 0.99]
Total (95% CI) 100.0% 0.60 [0.21, 0.99]
Test for overall effect: Z = 3.00 (P = 0.003) −4 −2 0 2 4
Test for subgroup differences: Not applicable Favours Autogenous bone Favours Bone substitute
Fig. 13.4 Forest plot comparing autogenous bone with a bone substitute for vertically augmenting posterior mandibles. Statistically
significant more vertical bone gain was obtained using a bone substitute
Inlay Onlay Mean Difference Mean Difference

Study or Mean SD Total Mean SD Total IV, Fixed, 95% CI IV, Fixed, 95% CI
Subgroup
Felice 2009b 4.52 1.19 10 3.55 1.34 13 0.97 [−0.07, 2.01]
−10 −5 0 5 10
Favours onlay Favours inlay
Fig. 13.5 Forest plot comparing inlay vs. only blocks of autogenous bone for vertically augmenting posterior mandibles. No statisti-
cally significant difference was observed (p > 0.07) but trends (borderline significance) clearly favoured the inlay blocks
augmentation procedure and one peri-implantitis) report any implant related outcome were not consid-
vs. six complications in five patients from the onlay ered of interest since they would not be able to provide
group (three dehiscence/infection with partial expo- reliable clinical information for the prognosis of dental
sure of the miniplates, one determining the failure implant rehabilitation.
of the augmentation procedure, two altered chin/lip Only in three trials was a sample size calculation
sensation, one lasting for 6 months and one perma- undertaken 26, 29, 32; however, the planned sample
nent and one peri-implantitis in the same patient sizes could be achieved only in one trial 29 [14, 15,
who had paraesthesia for 6 months). No implant 23]. Sample sizes of all studies were relatively small.
failed. Both treatments resulted in vertical bone It is, therefore, likely that many of these studies were
gain (3.5 mm for the onlay group and 4.5 mm for underpowered to demonstrate any significant difference
the inlay group), and the difference between the two in outcome measures between groups. Nevertheless,
procedures of 1 mm was not statistically significant some of the included trials did provide limited but
(Fig. 13.5), but was very close to significance indeed useful clinical information and indications that
(p > 0.07). There were no differences in costs and should be carefully evaluated by clinicians when decid-
treatment time. The trial was judged to be at low ing whether to perform an augmentation procedure or
risk of bias. not, or which augmentation procedure to select. We
have spent a great deal of time contacting RCTs’
authors, who have kindly provided useful unpublished
information on their trials. We feel that these contacts
13.5 Discussion have made the present review more complete and use-
ful for the readers. It is also worth observing that all
This review was originally conceived as having a broad authors of the included trials replied to our requests of
focus and was aimed to include any RCT dealing with clarifications. It is unusual to have such a high response
any aspect of bone augmentation in relation to dental rate. This might be partly explained by the serious
implant rehabilitation. In the present update we decided research interests of the investigators conducting RCTs
to split the original review in three more focused in the area, and may be indicative of a growing con-
reviews: the present one dealing with horizontal and sciousness that high quality systematic reviews can be
vertical bone augmentation procedures, one dealing of great benefit to the entire society. We also noticed
with procedures to augment the maxillary sinus, and a a considerable increase in the number of RCTs
third one dealing with minor augmentation procedure published over the last years. This should be viewed
at extraction sockets, immediate implants and implants positively since it may indicate that in the near future
with bone fenestration. We are fully aware that there some currently unanswered clinical questions might
are limitations in this classification, as in many classi- finally get an evidence-based answer, going over the
fications, since the exact borders among the different traditional “opinion-biassed” approach to clinical
categories may not always be clearly identified. Trials decision-making. The priority now is to concentrate
reporting only histological outcomes or which did not research efforts on a few important clinical questions,
increasing the sample size, and decreasing the number When evaluating which are the most effective aug-
of treatment variables in the trials. This might be mentation techniques for horizontal ridge augmenta-
obtained through collaborative efforts among various tion for single implants, only one trial was designed in
research groups. a way to provide clinical useful information [22]. This
We tried to evaluate first, whether a certain aug- trial, which had the largest sample size included in this
mentation procedure is necessary, and second, which review, compared three different two-stage techniques
could be the most effective augmentation techniques. to horizontally augment bone to allow placement of
This distinction is relevant since it is possible that single implants [22]. Thirty-one patients were included
many complicated, painful and even potentially dan- in each group and aesthetic outcomes were assessed
gerous procedures that are widely performed today both by the patients and a blinded experienced evalua-
have no evidence-based justification and do not tor. Unfortunately, most of the data were presented
improve the prognosis or the patients’ quality of life. aggregated and not by study group, meaning that it
No trial evaluated whether and when horizontal was not possible to use them to compare advantages
bone augmentation is necessary, but two trials evalu- or disadvantages of the individual techniques. For
ated whether vertical bone augmentation procedures 62 patients, a block of bone was retrieved from the
are needed or whether shorter implants could be used chin, whereas in 31 patients the defects were recon-
instead [14, 33]. One trial (17) investigated whether it structed with 100% bone substitute (Bio-Oss) and a
was better to use iliac crest bone for inlay augmenta- resorbable barrier. Despite these relatively high num-
tion procedures to allow the placement of 13–18 mm bers, the authors confirmed to us that not a single com-
long implants rather than placing 8–11 mm short plication occurred. These are remarkable results not
implants without augmentation to treat atrophic ante- confirmed by other trials included in the present review.
rior mandibles with a residual bone height of 6–12 mm Only two implants failed early in the bone substitute
[33]. The other trial (32) compared an inlay augmenta- group, although they were successfully replaced. The
tion technique with Bio-Oss blocks to allow the place- healing period used for the bone substitute group was
ment of at least 10 mm long implants, with 7 mm long 3 months longer, but on the other hand, no autogenous
implants for treating posterior mandibles with a resid- bone was needed to complete the procedure. At pres-
ual bone height above the mandibular canal of 7–8 mm ent, it is still difficult to recommend which should be
[14]. The meta-analysis of these two trials showed that the procedure to be used and additional information is
vertical augmentation was associated with statistically needed to confirm these results. The other two trials
significantly more implant failures and complications evaluating aspects for horizontal bone augmentation
than short implants. Caution should be exercised when had too small sample sizes to provide any reliable evi-
extrapolating these results since in one trial (17) 11 mm dence [26, 27]. In fact, only five patients treated with a
implants were used that are not considered to be short, split-mouth design were recruited to evaluate the clini-
and the other trial (32) had only a follow-up of 4 months cal efficacy, if any, of PRP [27]. When comparing tita-
after loading [14, 33]. Nevertheless, when considering nium vs. resorbable screws for holding buccal onlay
resorbed mandibles, inlay augmentation techniques to autogenous grafts, despite no significant differences
allow the placement of longer implants may not be the being observed, although the sample size of eight
optimal treatment choice. It is, therefore, useful to patients was too small to be able to detect any differ-
underline that when evaluating the only two properly ence, the observation that two resorbable screws broke
designed trials to test whether augmentation proce- at insertion and that a considerable amount of rem-
dures are needed, the augmentation procedures resulted nants of the resorbable screws were still visible after 9
in more serious complications (including a life threat- months and were surrounded by fibrotic tissue rich in
ening sublingual oedema), major discomfort and pain, giant cells may suggest that titanium screws are still
significantly more costs for society, longer treatment the best choice [26].
time and clinically poorer outcomes [14, 33]. These When evaluating which are the most effective aug-
examples should clearly illustrate that a more critical mentation techniques for vertical ridge augmentation,
approach should be taken when evaluating the need eight trials were included [3, 7, 8, 15, 16, 18, 23, 30].
for vertical bone augmentation procedures for dental Osteodistraction osteogenesis, various GBR tech-
implants. niques, autogenous onlay block grafting and inlay
grafting with both autogenous bone and bone substi- Autogenous bone is often considered the “gold stan-
tutes can be successful for augmenting bone vertically; dard” material for bone augmentation. Three trials com-
however, there is insufficient evidence to suggest if pared autogenous bone with bone substitutes and
one technique is preferable. The osteodistraction tech- curiously the indications that these trials gave were not
nique may not be used in all circumstances (for instance consistently in favour of autogenous bone [15, 18, 22].
in the presence of thin knife-edge bone) as it is more When augmenting bone horizontally to allow the place-
expensive than GBR and bone grafting, but may reduce ment of single implants, a bone substitute (Bio-Oss)
treatment time and allow for more vertical ridge aug- could be successfully used [22]. Implants placed in bone
mentation, if needed. On the other hand, GBR and augmented with Bio-Oss showed trends to increased
onlay bone grafting techniques also allow for simulta- failure rates, though all failed implants could be success-
neous bone widening, if needed. All the vertical aug- fully replaced without the need of additional augmenta-
mentation techniques evaluated were associated with tion. Another disadvantage with Bio-Oss was that the
high complication rates ranging from 60 (28) to 20% healing time was increased by 3 months, and on the
(29) with only one study on osteodistraction osteogen- other hand, no autogenous bone had to be collected from
esis that reported no complications (31) [3, 15, 30]. the chin, meaning also a less invasive operation, and
However, in few cases (10% in (29) and 15% (26)) the therefore, additional information are needed to establish
vertical augmentation resulted in the failure of aug- which could be the most cost-effective procedure. A
mentation procedure. It is, therefore, recommended split-mouth pilot study evaluated whether anorganic
that both clinicians and patients carefully evaluate the bovine bone blocks (Bio-Oss) could replace autogenous
pros and cons in relation to the desired outcome before bone harvested from the iliac crest for vertical augment-
deciding whether to use vertical ridge augmentation ing atrophic posterior mandibles with an inlay technique
techniques. Results from some of these trials (24, 26) (29). Though no statistical differences for clinical out-
also suggested that the vertically augmented bone comes could be found, eight out of ten patients preferred
can be successfully maintained up to 3 years after the augmentation procedure with the bone substitute and
loading with just a minimal bone loss in the range of this was statistically significant. In addition, general
0.5–1 mm [8, 23]. anaesthesia is not needed when using blocks of bone
One study evaluated the efficacy of ultrasounds to substitute block to augment atrophic. Finally, another
stimulate osteogenesis at vertically distracted mandib- split-mouth pilot study, including only five patients,
ular bone [30]. Ultrasounds are used to stimulate heal- compared a malleable bone substitute (Regenaform)
ing in bone fractures, especially in delayed healing and with particulate autogenous bone for vertical GBR at
non-union fractures. The results of this pilot study sug- posterior mandibles [18]. Significantly more bone
gested that ultrasounds had no positive effects on bone (0.6 mm) was vertically augmented at the sides treated
healing. When looking at the data it can be observed with the bone substitute. While a 0.6-mm of additional
that ultrasound treated sites were distracted for 4.6 mm vertical bone gain may not have a significant clinical
and placebo sites for 5.8 mm. The difference among impact, it is also true that the bone substitute behaved
the two procedures in amount of distracted bone similarly, if not better, than autogenous bone.
(1.2 mm) was not statistically significant, but it was With respect to generalisation of the results of the
clearly in favour of the placebo group. Ultrasounds present review to general practise, many of the aug-
were applied when the active osteodistraction phase mentation procedures evaluated were rather complex,
was initiated. A possible interpretation of the results is were performed by experienced and skilful clinicians,
that ultrasounds were effective in stimulating bone patients were undergoing strict post-operative control
healing, and this could explain why the placebo group regimens, complications were common, and in few
gained more bone. It is possible that ultrasounds were instances, serious. Caution is, therefore, recommended
delivered at the wrong time (the active osteodistraction while deciding to use any augmentation procedure.
phase) and stimulated bone healing, reducing the oste- The first clinical question that clinicians should ask
odistraction potential. The results of this study remain themselves is which could be the added benefits for the
difficult to interpret, but it is possible that ultrasounds patient by applying such procedures. Then the expected
should be delivered when the active osteodistraction benefits need to be carefully weighed against the risk
phase is completed. of complications of the chosen procedure.
13.6 Conclusions • Complications were common, and in some cases, deter

mined the failure of the augmentation procedure.
• Clinicians and patients should carefully evaluate
These conclusions are based on few trials with small or
the benefits and risks in relation to the desired out-
very small sample sizes, relatively short follow-ups
come when deciding whether to use vertical ridge
and being sometimes judged to be at high risk of bias;
augmentation techniques.
therefore they should be viewed with great caution.
In order to understand when bone augmentation proce-
• Two trials investigated whether vertical augmenta-
dures are needed and which are the most effective tech-
tion procedures are necessary to allow placement of
niques, larger and well-designed trials are needed. Such
longer implants when compared to simple place-
trials should be reported according to the Consolidated
ment of short implants.
Standards of Reporting Trials (CONSORT) guidelines
Vertical augmentation of resorbed mandibles with [24] (http://www.consort-statement.org/). It is difficult
inlay techniques resulted in statistically significantly to provide clear indications with respect to which aug-
more implant failures, complications, pain, days of mentation procedures should be tested first; however,
hospitalisation, costs, and longer treatment time than once established in which clinical situations augmenta-
using short implants; therefore the current available tion procedures are actually needed, priority could be
scientific evidence does not justify these procedures given to those interventions which look simpler, less
for placing longer implants in resorbed mandibles. invasive, involve less risk of complications and reach
However, the long-term prognosis of shorter implants their goals within the shortest timeframe. Indications
is yet unknown. for using various bone substitutes should be explored in
more detail and it should be evaluated which donor
• Three trials investigated which are the most effec- sites could provide the sufficient amount of bone with
tive techniques for horizontal bone augmentation. less risk of complications and patient discomfort.
• Various augmentation techniques are able to regener- Patient-centred outcomes should also be considered
ate bone in a horizontal direction; however, there is when designing such trials.
insufficient evidence to indicate which technique
could be preferable. It appears that a bone substitute Acknowledgements We wish to thank Sylvia Bickley
(Bio-Oss) can be used with a slightly higher risk (not (Cochrane Oral Health Group) and Anna Littlewood for their
assistance with literature searching; Luisa Fernandez Mauleffinch
statistically significant) of having an implant failure. and Philip Riley (Cochrane Oral Health Group) for their help
• There is insufficient evidence supporting or confut- with the preparation of this review; Stella Kwan who co-authored
ing the efficacy of various active agents such as a previous version of this review; Matteo Chiapasco, Filippo
PRP in conjunction with implant treatment. Fontana, Giuseppe Lizio, Gerry Raghoebar, Jurjen Schortinghuis
and Kees Stellingsma for providing us with additional informa-
• Titanium screws might be preferable to resorbable poly tion on their trials. We would also like to thank the following
(D,L-lactide) acid screws to fix onlay bone blocks. referees: Stephen Chen, Matteo Chiapasco, Christer Dahlin,
• Eight trials investigated which are the most effec- Mats Hallman, Jayne Harrison, Jan Hirsch, Ian Needleman,
tive techniques for vertical bone augmentation. Gerry Raghoebar and Bill Shaw.
• Various augmentation techniques are able to aug-
ment bone in a vertical direction; however, there is
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2010 - Efficacy of Horizontal and Vertical Bone Augmentation Procedures

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The Efficacy of Horizontal and Vertical

Bone Augmentation Procedures for Dental 13

Marco Esposito, Maria Gabriella Grusovin, Pietro Felice, Georgios

Core Message osteogenesis allows for more vertical bone

13.1 Background each has its own merits and disadvantages. Sometimes,

sections. Le Fort I osteotomy and interpositional bone 13.2 Objectives

13.4.1 Characteristics Geistlich Pharmaceutical, Wolhusen, Switzerland).

13.4.3 Characteristics insertion was evaluated in one study using the oblique

Bone Short Odds Ratio Odds Ratio

0.001 0.1 1 10 1000

Study or Non-resorb. Resorb. Mean Difference Mean Difference

Study or Osteodistraction Inlay graft Mean Difference Mean Difference

3.2.1 bone gain

Mean Difference Mean Difference

3.6.1 Vertical bone gain

Inlay Onlay Mean Difference Mean Difference

13.6 Conclusions • Complications were common, and in some cases, deter

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2010 - Efficacy of Horizontal and Vertical Bone Augmentation Procedures

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2010 - Efficacy of Horizontal and Vertical Bone Augmentation Procedures

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The Efficacy of Horizontal and Vertical

Bone Augmentation Procedures for Dental 13

Marco Esposito, Maria Gabriella Grusovin, Pietro Felice, Georgios

Core Message osteogenesis allows for more vertical bone

13.1 Background each has its own merits and disadvantages. Sometimes,

sections. Le Fort I osteotomy and interpositional bone 13.2 Objectives

13.4.1 Characteristics Geistlich Pharmaceutical, Wolhusen, Switzerland).

13.4.3 Characteristics insertion was evaluated in one study using the oblique

Bone Short Odds Ratio Odds Ratio

0.001 0.1 1 10 1000

Study or Non-resorb. Resorb. Mean Difference Mean Difference

Study or Osteodistraction Inlay graft Mean Difference Mean Difference

3.2.1 bone gain

Mean Difference Mean Difference

3.6.1 Vertical bone gain

Inlay Onlay Mean Difference Mean Difference

13.6 Conclusions • Complications were common, and in some cases, deter­

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13.1 Background each has its own merits and disadvantages. Sometimes,

sections. Le Fort I osteotomy and interpositional bone 13.2 Objectives

13.4.1 Characteristics Geistlich Pharmaceutical, Wolhusen, Switzerland).

13.4.3 Characteristics insertion was evaluated in one study using the oblique

13.6 Conclusions • Complications were common, and in some cases, deter