The International Journal of Periodontics & Restorative Dentistry

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 199

The Bone Core Technique for the

Augmentation of Limited Bony Defects:
Five-Year Prospective Study with a
New Minimally Invasive Technique
Fouad Khoury, DMD, PhD1,2 Dental rehabilitation of the par-
Romain Doliveux, DDS, MSc2 tially or totally edentulous patient
with oral implants has become a
more common practice in the last
decades, with reliable long-term
results. However, unfavorable local
The aim of this study was to evaluate a new minimally invasive surgical technique for conditions for the alveolar ridge due
the reconstruction of critical-size bony defect with local harvested bone core with to atrophy, periodontal disease, and
simultaneous implant placement. In a prospective study, 186 consecutively treated
trauma sequelae may lead to insuf-
patients were included and controlled clinically and radiologically for at least 5 years
ficient bone volume. A bone aug-
postoperative. Every patient presented a bony defect affecting the buccal, lingual,
or palatal wall. In all cases, the alveolar crest was wide enough to allow implant mentation of the alveolar ridge is
placement inside the bony contours. During implant bed preparation, a trephine then necessary to allow implant in-
bur (3.5 mm external diameter and 2.5 mm internal diameter) was used to harvest a sertion into sufficient bone and in a
bone core from the socket. After implant insertion, the buccal/palatal/lingual bony favorable position according to the
defect was grafted with bone chips covered with the bone core stabilized through
prosthetic planning.1,2
compression with microscrews. After 3 months of healing, the implants and the
grafted bone were exposed and the width of the grafted area was measured. After Autogenous bone is still con-
prosthetic restoration, the patients were recalled regularly. A total of 223 grafted sidered as the gold standard, es-
sites were documented. Minor primary healing complications were observed in 3 pecially for large alveolar ridge
sites (1.4%), all in smoker patients, and were treated locally without any influence on augmentation. It presents essential
the prognosis. All other sites healed uneventfully. In 19 cases (4.4%), exposure of the
biologic qualities and properties
screw heads was detected 1 to 3 months postoperatively without any inflammation
or consequences for the grafted bone. The average width of the reconstructed area such as osteogenesis, osteoinduc-
at the end of the grafting procedure was 2.4 ± 0.8 mm, and at the reentry, 2.1 ± tion, and osteocondution. In com-
0.6 mm. There was a difference of remodeling between bone cores grafted totally parison, allografts, xenografts, and
inside or partially outside the bony contours. Bone cores grafted completely inside alloplastic materials used in implant
the bony contours demonstrated no resorption at 3 months postoperative, while
dentistry possess only the property
bone cores grafted partially outside the bony contours in most cases showed partial
resorption of the bone outside the bony contours. After 3 months of healing, all 223 of osteoconduction.2–4 Bone block
implants had achieved primary healing and osseointegration and were restored after grafts, suitable for two- or three-
an average time of 4 months. No implant failed during the control period. According dimensional reconstructions of
to this study, the use of an autogenous bone core harvested during the implant alveolar ridge defects, can be har-
bed preparation is a simple and safe method for the reconstruction of small bone
vested from intraoral sites such as
defects. Int J Periodontics Restorative Dent 2018;38:199–207. doi: 10.11607/prd.3467
the retro- and paramolar area (exter-
nal oblique ridge) or the mandibu-
Professor, Department of Oral & Maxillofacial Surgery of the University of Muenster,
1

Muenster, Germany. lar symphysis (chin area), offering

2Private Clinic Schloss Schellenstein, Olsberg, Germany. sophisticated harvesting techniques
and better diagnostic tools in most
Correspondence to: Prof Dr Fouad Khoury, Am Schellenstein 1, 59939 Olsberg, Germany.
situations where there is sufficient
Fax +49-2962-9719-22. Email: prof.khoury@t-online.de
bone quantity.5–8 Previous studies
 ©2018 by Quintessence Publishing Co Inc. reported possible complications

Volume 38, Number 2, 2018

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
200
during the harvesting procedure in
the retromolar or chin region.9–13 The
reconstruction of small or limited
bony defects with locally harvested
bone chips usually requires the ad-
dition of biomaterial and mem-
branes to stabilize the bone graft.14,15
An alternative to this technique is
the use of a stable bone core har-
vested locally with a trephine from
the implant site during implant bed
preparation. This avoids the use of
biomaterials and membrane and the
morbidity of other harvesting sites.16
The aim of the present prospective
study is to evaluate the outcome of
this minimally invasive approach al-
lowing implantation with simultane-
ous bone grafting.
This article was written following
the STROBE guidelines (Strengthen-
ing the Reporting of Observational
Studies in Epidemiology; www.
strobestatement.org).17
Materials and Methods
Patients who were treated between
2009 and 2011 for a limited bony de-
fect with a bone core augmentation
with simultaneous implant place-
ment were included in this study
and followed up for at least 5 years
postoperatively. All patients were
older than 18 years and gave in-
formed consent to the surgery. Ethi-
cal approval for the study was not
necessary. The study inclusion cri-
teria were partially or totally missing
vestibular and or palatal bone wall
and a sufficiently wide crest/socket
platform to allow implant placement
inside the bony contour. The exclu-
sion criteria were as follows:
The International Journal of Periodontics & Restorative Dentistry
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
• General contraindication
to implant surgery, such
as uncontrolled diabetes
or current intravenous
bisphosphonate treatment
• Pregnant or nursing
• Untreated severe periodontitis
with poor oral hygiene
• Immediate implantation
• Clinically infected sockets
• Vertical bone loss > 4 mm in
the whole site
Visual examination and digital palpa-
tion allowed for a preliminary estima-
tion of the morphologic contours,
dimensions of the alveolar crest, and
quality of the soft tissue. Panoramic
radiographs provided additional in-
formation. Cone beam computed
tomography (CBCT) scans (Galileos,
Sirona) were only performed in case
of patients receiving multiple bone
augmentations for the reconstruction
of additional severe bony defects.
Surgical Procedure
All patients underwent at least one
session of oral hygiene instruction as
well as ultrasonic debridement and
0.2% chlorhexidine mouthrinse for 2
minutes immediately preoperatively.
Preoperative antibiotic administra-
tion was performed, either intra-
venously (penicillin G, 1 × 106 IU)2
immediately before local anesthesia
was injected (before vasoconstric-
tion occurred) or by mouth (penicil-
lin V, 1 × 106 IU/day) at least 1 hour
prior to surgery. Antibiotics were
continued for 7 days postoperatively
at 3 × 106 IU/day. In case of a penicil-
lin allergy, clindamycin 300/600 mg
was administered at 1.2 g/day.2 The
surgery was generally performed
under local anesthesia in conjunc-
tion with intravenous sedation. Local
vestibular and palatal/lingual infiltra-
tion with 4% articaine and 1:100,000
epinephrine (Ultracain DS forte,
Sanofi Aventis) was administered.
After a midcrestal incision reflecting
a mucoperiosteal flap and exposing
the alveolar crest, the bony defect
was explored to determine whether
a bone core augmentation with si-
multaneous implant insertion was
appropriate. An important criterion
was that the implant must be placed
fully inside the bony contours. The
implant threads on the crestal side of
the socket had to be at least 1 mm
inside the bony contours with a mini-
mum width of 6 mm of the implant
bed to assure a good vascular supply
to the grafted bone, independent of
the location of the bony defect (ves-
tibular, palatal, or both). The bony
contours were determined through
the volume and shape of the bone of
the neighboring teeth and through
the bony walls of the implant bed.
The bony defect was measured with
a PCPNC periodontal probe and
documented.
The implant bed preparation
was started with a trephine bur
(outside diameter 3.5 mm, Dentsply
Sirona Implants), offering inside and
outside irrigation (Fig 1) and at the
same time harvesting a bone core
graft about 10 mm in length (Figs
2a to 2c). Care was taken to achieve
sufficient cooling with physiologic
serum without heavy pressure on
the trephine bur to avoid high tem-
peratures and subsequent ther-
mal damage and bone burning.

The core was removed with a core
removal instrument (Dentsply Sirona
Implants). If the core was retained
in the trephine bur, a thin needle
was pushed into the inner irriga-
tion canal of the bur to remove the
core from the trephine bur (Fig 1).
The implant bed preparation to the
definitive length and width were
continued using the original im-
plant system burs under low-speed
drilling (< 80 rpm) without irriga-
tion for the collection of additional
bone chips (Fig 2d). In cases where
insufficient bone chips were ob-
tained from the socket, more bone
chips were harvested with a bone
scraper from the neighboring area.
The implant was inserted inside the
bony contours, and the exposed
threads were covered with bone
chips (Fig 2e). The bone core was
then adjusted to the defect on the
buccal or palatal side, or both, and
stabilized through compression with
the heads of microscrews (Stoma
Instruments) screwed in local bone
near the core (Fig 2f). Pressing of
the bone core with the microscrew
against the implant body provided
a good primary stability. In some
cases, depending on the volume of
the bony defect, two or more cores
(harvested from other implant beds)
were necessary to reconstruct the
whole bone deficit. Remaining gaps
between implant, bone core, and
implant bed were filled with autoge-
nous bone chips. The amount of the
bone augmentation was measured
with the PCPNC periodontal probe
and documented. No bone substi-
tute materials or membranes were
used. The flap was repositioned
after a releasing incision was made
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Fig 1  Trephine with an outside diameter of 3.5 mm, thin pin, and core removal instrument
(above the bone core).
on the basal periosteum, offering
tension-free coverage of the aug-
mented area, and sutured in place
with 60 monofilament resorbable
suture (Glycolone 60, Resorba).
Postoperative Management
Sutures were removed after 2
weeks. In case of complications
related to primary healing as im-
plants or bone exposure, the area
was treated by rinsing with H2O2,
photodynamic decontamination
(Helbo, Bredent),18 and application
of chlorhexidine gel on the exposed
areas. After 4 weeks, the remaining
exposed bone and the exposed
microscrew were removed. All oth-
er implants were exposed after 3
months in combination with soft
tissue management to improve the
quality of the peri-implant tissue: roll
flap technique was indicated in case
of missing a small amount of volume
on the buccal site, and the addition
of a connective tissue graft with api-
201
cal reposition flap was indicated in
case of missing greater volume and
keratinized gingiva. During this re-
entry, the width of the augmented
crest was measured with the peri-
odontal probe (PCPNC, Stoma In-
struments) and documented along
with the healing quality. The results
were evaluated by repeated clini-
cal and radiographic examinations
according to a standard protocol:
clinical postoperative examinations
were made after 2, 4, and 12 weeks,
then following completion of the
definitive prosthetic treatment the
patients were seen twice a year for
evaluation and hygiene maintenance
(Figs 2g to 2j). All examinations
included assessment of the peri-
implant status, dental hygiene, and
functional relationships. Panoramic
and/or periapical radiographs were
taken preoperatively, postopera-
tively, after implant exposure, after
definitive prosthetic treatment, and
then annually. In 21 patients, CBCT
scans were performed because of
other augmentation procedures.
Volume 38, Number 2, 2018
202

a b c

d e f

g h i j
Fig 2  (a) The vestibular bone wall was completely missing. (b) The bone core was prepared with the trephine bur on the palatal side of
the crest. (c) The harvested bone core. (d) Autogenous bone chips were collected during definitive implant bed preparation. (e) Implant
insertion in the prepared socket completely inside the bony contour. (f) Reconstruction of the missed vestibular bone wall with locally
harvested bone chips and the bone core. The bone core was placed on the top of the crest and stabilized through compression with
microscrews. (g) Clinical appearance 3 months postoperative demonstrating good regenerated buccal bone wall. (h) Clinical situation of
the restored implant in the canine area 7 years postoperative. (i) Radiograph 7 years postoperative. (j) CBCT section demonstrating good
stability of the grafted regenerated area on the buccal bone.

Outcome Measures used), moderate pain (4 to without inflammation 2 weeks

This study tested the outcome of
the bone core augmentation tech-
nique with simultaneous implant
placement. Outcome measures
were as follows:
• Postoperative pain. This was
classified in three groups:
Minimal pain (< 4 painkillers
[ibuprofen 400 mg] were
8 painkillers), and severe
pain (> 8 painkillers taken
postoperatively).
• Good healing of the surgical
site. This was clinically
determined by the primary
healing of the soft tissue over
the grafted area without any
tissue necrosis, suppuration,
or bone exposure. The soft
tissue had to show normal color
after the surgery and at the
reentry.
• Good healing of the grafted
bone. This was clinically
determined 3 months after the
surgery by the normal color
of the soft tissue without any
pathology. The reentry had to
show a good integrated bone
graft with macroscopic good
revascularization.

The International Journal of Periodontics & Restorative Dentistry

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 203

a b c
Fig 3  (a) Bony defect on the vestibular and palatal bone wall. (b) Reconstruction of the bony defects with bone cores stabilized through
compression with micro screws. (c) Clinical regeneration 3 months postoperative.

• Volume of the gained bone and
its stability after 3 months of
healing. This was determined
by measuring the amount of
missing bone on the buccal
and/or palatal/lingual bone
wall and comparing the width
and height of the crest after
core grafting and later during
the reentry with the PCPNC
periodontal probe.
• Implant failure. Implant
mobility was observed, or
stable implants were removed
because of infection or
progressive marginal bone loss.
• Prosthetic failures. The planned
prosthetic restoration could not
be performed due to implant
failure (wrong localization/
angulation) or any other reason.
• Any biologic complication,
for example the presence of
symptoms related to thermal
bone damage caused by
the trephine during bone
harvesting (burned bone).
This was determined through
the presence of chronic pain
in the implant region and the
presence of demineralization
at the apical peri-implant bone
area.
Outcome assessment was not con-
ducted by the operator and was
therefore independent.
Results
During this 5-year study, 186 con-
secutively treated patients (114
[61.3%] women and 72 [38.7%] men)
underwent minimally invasive bone
augmentation with the bone core
technique in combination with si-
multaneous implant placement. The
age range was 26 to 76 years, and
the average age was 54.6 years. In-
cluded were 47 (25.3%) smokers and
139 (74.7%) nonsmokers or previous
smokers (who had stopped smok-
ing at least 4 weeks before the sur-
gery); most of the smokers (83%)
consumed more than 10 cigarettes
per day. All patients were treated
under local anesthesia with intra-
venous sedation. Some patients
underwent more than one grafting
procedure on different sites during
the control period, so that a total of
223 grafted sites were documented.
The main indication with 195 graft-
ed sites (87.5%) was the first grafting
of a limited bony defect, but in 28
sites (12.5%) core augmentation was
performed as a reinforcement after
healing of a previous bone block
grafting procedure with insufficient
bone volume. Most of the core
augmentations were performed
for the bony reconstruction of 201
sites missing one (partially or totally;
length 3 to 9 mm; average 5.3 ± 3
mm) alveolar bone wall (lateral bone
augmentation): 172 augmentations
for missing vestibular bone (92 in
the maxilla and 80 in the mandible),
23 for missing palatal bone, and 6
for missing lingual bone wall. The
other 22 core augmentations were
performed for the reconstruction
of missing bone on 2 or more bone
walls (vertical bone augmentation;
Fig 3); 20 sites were in the maxilla
and 2 in the mandible. A total of 431
microscrews were needed to stabi-
lize the grafted bone cores around
202 Xive and 21 Ankylos implants
(Dentsply). In 87 sites, the grafted
core was stabilized completely in-
side the bony contours, and in 136
the grafted core was partially stabi-
lized outside the bony contours.
Postoperatively, minimal pain
was observed in 132 patients (71%).
Another 52 patients (28%) reported
moderate pain, and only 2 patients
(1%) reported severe pain. A total of

Volume 38, Number 2, 2018

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
204

a b c
Fig 4  (a) Implant insertion inside the bony contour in the area of vertical bone defect in the right maxilla. (b) Three-dimensional
reconstruction with bone cores compressed with microscrews. (c) Clinical appearance 3 months postoperative.

7 3.5
posure of 3 mm, and the other 2 cas-
es showed a partial resorption of the
6 3.0 core with implant thread exposure
5 2.5 up to 2 mm. All these cases were
successfully reaugmented with local
4 2.0 harvested bone. In all the remaining
3 1.5 sites, no significant resorption of the
grafted bone after primary healing
2 1.0
was observed (Fig 5). The average
1 0.5 width of the reconstructed area at
the end of the grafting procedure
0 0
Immediately After 3 mo Immediately After 3 mo was 2.4 ± 0.8 mm and at the reen-
after augmentation healing after bone graft healing
(mm) (mm) (mm) (mm) try 2.1 ± 0.6 mm (Fig 6). There was
a difference in remodeling between
Fig 5  Stability of the grafted bone in the Fig 6  Bone thickness at the implant
vertical dimension. shoulder. bone cores grafted totally inside or
partially outside the bony contours.
Bone cores grafted completely
3 sites (1.3%), all in smoker patients, at the time of surgical exposure of inside the bony contours demon-
showed complications related to the implants. No fistula or suppura- strated no resorption at 3 months
primary healing: one early expo- tion nor any symptom of infection postoperative, in contrast to bone
sure of an implant cover screw, one was present, and the soft tissue had cores grafted partially outside the
early exposure of a microscrew, and normal color around the head of the bony contours, which showed in
one minor exposure (2 mm) of the screw without any inflammation. All most cases some resorption of the
grafted core documented 2 weeks other sites healed uneventfully with- bone outside the bony contours
postoperatively as the patient re- out any infection. There were no (Fig 7). All 223 implants healed and
turned for suture removal. The areas dropouts at reentry. The reentry in osseointegrated and were restored
were treated as described in the most cases showed a well-integrat- after an average of 4 months. Of
postoperative management section, ed bone graft with volume stability the implants, 49 received a single
without any effect on the implant (Fig 4). At 3 sites, severe bone re- crown, 152 were connected with
prognosis. Late exposure of another sorption of the grafted core was ob- other implants in bridge form, and
2 implant cover screws (0.9%) and served (1.3%): 1 case demonstrated 22 were connected with other im-
19 microscrews’ head (4.4%) were an intensive resorption of the bone plants in bar form for the treatment
detected 3 months postoperatively, core with buccal implant thread ex- of edentulous jaw. After a minimum

The International Journal of Periodontics & Restorative Dentistry

© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

control of 5 years, all the implants
were still in function without any im-
plant loss (survival rate 100%). Only
2 implants showed, at 6 months
postoperative, a periapical round
radiolucency similar to that found
in burned bone syndrome. After a
local revision using the bony lid ap-
proach with removal of granulation
tissue and photodynamic decon-
tamination, complete remineraliza-
tion of the area was observed up to
6 months later.
All patients were seen twice a
year for follow-up examination. In
the 5-year observation period, no
pathologies or soft tissue dehis-
cence were observed. A total of 16
patients who were observed for a
minimum of 3 years did not return
for recall (dropout rate 8.6%). Pan-
oramic and periapical radiographs
taken during the treatment and then
once a year revealed normal pat-
terns of remodeling. In 21 patients,
CBCT performed for other reasons
confirmed the stability of the recon-
structed area (Fig 2j). The mean mar-
ginal bone loss around the implants
after 5 years was 0.56 ± 0.61 mm.
Discussion
Many options are availble to treat
sucessfully limited defects around
noncontaminated implants using
autogenous bone chips with or
without biomaterials supported by
resorbable or nonresorbable mem-
branes.19–21 The use of biomaterial
with membranes makes the treat-
ment more expensive and increases
the risk of membrane exposure and
infection. The use of autogenous
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
205
4
Horizontal bone resorption
3
after 3 mo (mm)
2
1
0
0 1 2 3 4 5
Position of the core in the bony contours at the
end of the surgery (mm)
Fig 7  Bone loss in relation to the position of the core in the bony contour. The more the
bone core was placed inside the bony contours, the less resorption was observed.
bone blocks for the bony recon- the alveolar crest with a trephine bur
struction usually requires a second are composed of thin cortical and
surgical site, increasing the stress for large cancellous bone and are rich
the patient as well as postoperative in cells and growth factors. It has
consequences.11 The use of autog- been observed that bone particles
enous bone core harvested locally harvested by trephine bur or bone
from the implant site presented scraper have a higher cell content, a
here is an easy and minimally inva- higher expression of osteoinductive
sive treatment for the reconstruction proteins and paracrine function, and
of bony defects with simultanous an increased ability to differentiate
implant placement. An undoubted and produce mineralized tissue than
advantage of using autogenous bone chips collected by implant bur
material is the biologic compat- and piezoelectric device.22 The re-
ibility with the receipient site and sults of the presented study confirm
the osteogenetic capacity of the this observation: only 1.3% (three
graft.22,23 Autogenous bone, in ad- sites), all in smoker patients, showed
dition to the surviving osteocytes minor complications related to pri-
and osteoblasts, acts as a source mary healing including early ex-
of bone morphogenetic proteins, posure of the implant cover screw,
which stimulate the pluripotent early exposure of a microscrew,
mesenschymal cells to transform and a minor exposure (2 mm) of the
into osteoblasts.22 Thus, the capac- grafted core. Most of the grafted
ity of regeneration of autogenous cores demonstrated very good
bone depends on the harvesting healing with volume stability. Se-
area and technique.24 Bone cores vere bone resorption of the grafted
harvested from the middle part of core with implant thread exposure
Volume 38, Number 2, 2018
206
Fig 8  Two-piece trephine (Meisinger).
of 3 mm was observed in only one
case (0.45%), and moderate resorp-
tion of the core with implant thread
exposure up to 2 mm was detected
in two other cases (0.9%). In each of
these three cases, the area was suc-
cessfully regrafted with local har-
vested bone. The poor healing of
the bone cores in these three sites
may be related to heating damage
of the bone core through friction
between the trephine bur and the
bone walls25 during the harvest-
ing procedure. No resorption was
documented during reentry in all 87
grafted bone cores inside the bony
contours 3 months postoperatively.
In contrast, most of the bone cores
grafted partially outside the bony
contour demonstrate partial resorp-
tion of the core part grafted outside
the bony contours but without ex-
posure of any implant threads. This
phenomena may be related to mus-
cle activity during remodeling of the
nonprotected part of the core graft.
Similar observations were docu-
mented in cases of bone splitting or
bone block grafts.7
Although all the 223 implants
were osseointegrated and were re-
stored as expected, two patients
The International Journal of Periodontics & Restorative Dentistry
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
demonstrated radiologic signs of
burned bone syndrome.25 Removal
of the granulation tissue through a
bony lid approach26 and photody-
namic decontamination18 were suc-
cessful in these two cases and could
be a good alternative to surgical
removal of the apical part of the im-
plant or explantation.
In comparison to grafting pro-
cedures with biomaterials (eg, xeno-
grafts or allografts), the presented
technique using bone core presents
the following advantages:
• The grafted material is totally
autogenous and harvested
through minimally invasive
surgery without any morbidity.
Autogenous bone grafts are
still the gold standard, and
their advantages have been
confirmed.2,5,12,27,28
• No membranes or other foreign
materials are needed, reducing
the risk of infection and
eliminating the risk of disease
transmission or allergy.29–31
• There are no additional costs,
as would be needed for
biomaterials and membranes.
Although the presented technique
offers a good solution to treat limit-
ed bony defects, problems can oc-
cur during the treatment. In case of
very soft bone or in case of fracture
of the bone core during the har-
vesting procedure and retention of
the core inside the trephine bur, no
stable bone core can be harvested.
It is usually possible to push out the
bone core from the trephine bur
with a thin pin, but this can be ex-
tremely difficult in case of very hard
cortical bone. Use of a two-piece
trephine, allowing easier removal
of the core, can solve this problem
(Fig 8).
Conclusions
The present study demonstrates
a predictable, minimally invasive
technique for the treatment of small
bony defects with local harvested
autogenous bone without any bio-
materials or membranes. The results
of the study confirm the predictabil-
ity of such treatment, reducing the
fees and the risk of infections.
Acknowledgments
This study was completely self-supported,
and no contribution from any commercial
party was received, even in the form of free
materials. The authors reported no conlicts
of interest related to this study.
References
 1. Esposito M, Grusovin MG, Felice P,
Karatzopoulos G, Worthington HV,
Coulthard P. Interventions for replac-
ing missing teeth: Horizontal and
vertical bone augmentation tech-
niques for dental implant treatment.
Cochrane Database Syst Rev 2009;
(4):CD003607.
 2. Khoury F, Khoury C. Mandibular bone
block grafts: Diagnosis, instrumenta-
tion, harvesting techniques and surgical
procedures. In: Khoury F, Antoun H, Mis-
sika P (eds). Bone Augmentation in Oral
Implantology. London: Quintessence,
2007:115–213.
  3. Klijn RJ, Meijer GJ, Bronkhorst EM, Jan-
sen JA. A meta-analysis of histomorpho-
metric results and graft healing time of
various biomaterials compared to au-
tologous bone used as sinus floor aug-
mentation material in humans. Tissue
Eng Part B Rev 2010;16:493–507.

 4. Jackse N, Seibert FJ, Lorenzoni M, Es-
kici A, Pertl C. A modified technique of
harvesting tibial cancellous bone and its
use for sinus grafting. Clin Oral Implants
Res 2001;12:488–494.
  5. Misch CM. Comparison of intraoral do-
nor sites for onlay grafting to implant
placement. Int J Oral Maxillofac Im-
plants 1997;12:767–776.
 6. Clavero J, Lundgren S. Ramus or chin
grafts for maxillary sinus inlay and lo-
cal onlay augmentation: Comparison of
donor site morbidity and complications.
Clin Implant Dent Relat Res 2003;5:
154–160.
  7. Khoury F. Surgical procedures and long-
term results of pre implantation surgery
[in Japanese]. Quintessence Dental Im-
plantology 1995;2:225.
  8. Khoury F, Happe A. Zur diagnostik und
methodik von intraoralen knochenent-
nahmen. Z Zahnärtzl Implantol 1999;
15:167–176.
 9. Nkenke E, Radespiel-Tröger M, Wilt-
fang J, Schultze-Mosgau S, Winkler G,
Neukam FW. Morbidity of harvesting
of retromolar bone grafts: A prospec-
tive study. Clin Oral Implants Res 2002;
13:514–521.
10. Joshi A. An investigation of post-oper-
ative morbidity following chin graft sur-
gery. Br Dent J 2004;196:215–218.
11. Khoury F, Hanser T. Mandibular bone
block harvesting from the retromolar
region: A 10-year prospective clinical
study. Int J Oral Maxillofac Implants
2015;30: 688–697.
12. Pikos MA. Atrophic posterior mandibu-
lar reconstruction utilizing mandibular
block autografts: Risk management.
Int J Oral Maxillofac Implants 2003;18:
765–766.
13. Khoury F. Augmentation of the sinus
floor with mandibular bone block and si-
multaneous implantation: A 6-year clini-
cal investigation. Int J Oral Maxillofac
Implants 1999;14:557–564.
© 2018 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
14. Hutmacher D, Hürzeler MB, Schliephake
H. A review of material properties of
biodegradable and bioresorbable poly-
mers and devices for GTR and GBR ap-
plications. Int J Oral Maxillofac Implants
1996;11:667–678
15. Simion M, Dahlin C, Trisi P, Piattelli A.
Qualitative and quantitative compara-
tive study on different filling materials
used in bone tissue regeneration: A
controlled clinical study. Int J Periodon-
tics Restorative Dent 1994;14:198–215.
16. Khoury F, Hidajat H. Secure and effec-
tive stabilization of different sized au-
togenous bone grafts. Eur J Oral Surg
2011;2:65–70.
17. Vandenbroucke JP, von Elm E, Altman
DG, et al. Strengthening the Reporting
of Observational Studies in Epidemiol-
ogy (STROBE): Explanation and elabo-
ration. Epidemiology 2007;18:805–835.
18. Neugebauer J, Kistler F, Kistler S,
Vizethum F, Scheer M. Aktuelle Behan-
dlungs strategien bei periimplantären
Erkrankungen—Antimikrobielle photo-
dynamische Therapie nach dem HEL-
BO-Verfahren. Implantologie 2015;23:
273–285.
19. Springer IN, Terheyden H, Geiss S, Härle
F, Hedderich J, Açil Y. Particulated bone
grafts—Effectiveness of bone cell sup-
ply. Clin Oral Implants Res 2004;15:
205–212.
20. Thorwarth M, Schlegel KA, Wehrhan F,
Srour S, Schultze-Mosgau S. Accelera-
tion of de novo bone formation follow-
ing application of autogenous bone to
particulated anorganic bovine material
in vivo. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2006;101:309–316.
21. Widmark G, Ivanoff CJ. Augmentation
of exposed implant threads with au-
togenous bone chips: Prospective clini-
cal study. Clin Implant Dent Relat Res
2000;2:178–183.
207
22. Miron RJ, Gruber R, Hedbom E, et al. Im-
pact of bone harvesting techniques on
cell viability and the release of growth
factors of autografts. Clin Implant Dent
Relat Res 2013;15:481–489.
23. Gruber R, Kandler B, Fischer MB, Watzek
G. Osteogenic differentiation induced
by bone morphogenetic proteins can
be suppressed by platelet-released su-
pernatant in vitro. Clin Oral Implants Res
2006;17:188–193.
24. Berengo M, Bacci C, Sartori M, Perini
A, Della Barbera M, Valente M. Histo-
morphometric evaluation of bone grafts
harvested by different methods. Miner-
va Stomatol 2006;55:189–198.
25. Khoury F, Pape FW. “Burned Bone Syn-
drome”: Das syndrom des verbrannten
knochens. Z Zahnärztl Implantol 1999;
15:12–18.
26. Khoury F. The bony lid approach in pre-
implant and implant surgery: A prospec-
tive study. Eur J Oral Implantol 2013;
6:375–384.
27. Pikos MA. Block autografts for local-
ized ridge augmentation: Part I. The
posterior maxilla. Implant Dent 1999;8:
279–285.
28. Chiapasco M, Casentini P, Zaniboni M.
Bone augmentation procedures in im-
plant dentistry. Int J Oral Maxillofac Im-
plants 2009;24(suppl):s237–s259.
29. Chiapasco M, Zaniboni M. Clinical out-
comes of GBR procedures to correct
peri-implant dehiscences and fenestra-
tions: A systematic review. Clin Oral Im-
plants Res 2009;20(Suppl 4):s113–s123.
30. Soldatos NK, Stylianou P, Koidou VP,
Angelov N, Yukna R, Romanos GE. Limi-
tations and options using resorbable
versus nonresorbable membranes for
successful guided bone regeneration.
Quintessence Int 2017;48:131–147.
31. Kim Y, Nowzari H, Rich SK. Risk of prion
disease transmission through bovine-
derived bone substitutes: A system-
atic review. Clin Implant Dent Relat Res
2013;15:645–653.
Volume 38, Number 2, 2018