Duffy, John.

(2007) An overview of bone grafting techniques and materials in

implant dentistry. BDS Elective Report.

http://hdl.handle.net/1905/742
15th January 2008

Enlighten

http://www.gla.ac.uk/enlighten

An overview of bone grafting

techniques and materials in
implant dentistry.

0305319

Word count: 4310

Index

1. Introduction

2. Materials
Autograft bone

Allograft bone

Xenografts

Alloplast materials

3. Techniques
Localised deficiencies

Larger deficiencies

Onlay grafting (minor and major)

Maxillary sinus grafting

Guided bone regeneration

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4. Future

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5. Clinical experience

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6. Summary

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7. References and Acknowledgements

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8. Appendix

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Introduction:
The use of dental implants to provide support for replacement of missing teeth has
become an important component of modern dentistry. As a result of advances in
research in implant design, materials and techniques the use of dental implants has
increased dramatically in the past few years and is expected to expand further in the
future. Many types of implants have become available for application to different
clinical cases, and an increasing number of dentists have become involved in this
form of treatment.
Dental implants are small, typically screw-shaped attachments, usually made from
titanium. They are inserted into the jawbone to replace missing tooth roots. Following
osseointegration(when the bone attaches firmly to the implant) a replacement tooth
can be secured to the top of the implant. The replacement tooth can look, feel and
perform like a natural tooth.
Implants have several advantages over fixed bridgework or partial dentures in patients
with gaps in their dentition.
Unlike dentures, implant-stabilised teeth are integrated into the patients natural bone,
meaning that there is no slipping or movement. This can greatly improve confidence
and function.
Implant-secured teeth can also prevent further bone loss around edentulous areas and
prevent excess forces being applied to abutment teeth.
However, dental implant placement can be a difficult and expensive treatment option,
and bone grafting procedures are often needed.
Bone grafting is the process of surgically placing new bone into spaces around a
broken bone or bone defect. Defects are replaced with bone from the patients own
body (autogenous bone), or an artificial, synthetic or natural alternative. The graft not
only replaces missing bone, but also helps your body to regrow its own lost bone.
For successful implant placement, a sufficient amount and quality of bone is essential
around the site of insertion. However, many patients seeking implant treatment are
deficient in bone volume, and hence bone grafting has become an integral part of
implant surgery.
In about 40% of all implantations, clinicians use regenerative procedures to build up
bone and soft tissue. The use of bone substitutes and membranes is now one of the
standard therapeutic approaches.
Today, bone grafting procedures have become an almost integral part of implant
reconstruction. In many instances, a potential implant site in the upper or lower jaw
does not offer enough bone volume or quantity to accommodate a rootform implant of
proper size or in the proper place. This is usually a result of bone resorption that has
taken place following loss of one or more teeth. Bone grafting procedures usually try
to re-establish bone dimension, which was lost due to resorption.

Materials:
With respect to bone graft materials used, we have to differentiate between several
choices. The complexity of the bone deficiency and the patients decision will
influence the graft material chosen.
Autograft:
The autograft remains the gold standard to which all other materials are judged. It is
defined as tissue transplanted from one site to another within the same individual. It is
basically your very own tissue, taken from a donor site and placed somewhere else in
the body, into the recipient site. The best success rates in bone grafting have been
achieved with autografts, because these are essentially living tissues with their cells
intact. Autogenous bone has many advantages over the alternatives. It is
osseoinductive/conductive, sterile, biocompatible/non-immunogenic, easy to
manipulate and readily available from adjacent or remote sites. The microscopic
architecture is perfectly matched.
The main disadvantage of autografting is that is has to be harvested from a secondary
(either intra- or extra-oral) site, which usually means more complicated surgery and
higher morbidity.
Favoured intra-oral sites include the chin, retro molar areas and other edentulous
areas.
Chin grafts are indicated for use in unilateral sinus lifting procedures or (buccal)
onlay grafting for widening of a thin crest due to the limited amount of bone
available. Chin bone is harvested from the parasymphyseal region, ensuring a
minimum distance of at least 5mm from the anterior teeth apices is maintained. This
is crucial to assure the vitality of the teeth and to avoid contact with the anterior
branch of the inferior alveolar nerve. A very limited volume of cancellous bone can
be harvested from this region, although the cortical bone is very hard but can be
particulated if necessary.
Mandibular angle grafts are also indicated for unilateral and occasionally bilateral
sinus grafting procedures, and onlay grafting. It is useful in block or particulated form
but there are certain limitations to the size of the graft, although more material is
available than from the chin.
However, almost no cancellous bone can be harvested from this site. Again great care
has to be taken to avoid contact with the inferior alveolar nerve, which should be
released from the cortical bone before harvesting.
Iliac crest grafts are the most common form of extra-oral grafts used in implant
dentistry. Iliac grafts are indicated when large amounts of bone are required to
achieve the desired volume and shape for implant placement. Cortical and cancellous
bone can both be collected in sufficient amounts to restore severely resorbed maxillae.
Iliac crest bone is also used for larger grafting needs, such as bilateral sinus lift
procedures combined with nasal inlays. Blocks and particulated bone can be grafted
from this site.
Tibial grafts are the other commonly used extra-oral grafting site, with a limited
amount of cancellous graft material available, indicated for use as onlay graft material
or for sinus lifts (unilateral).
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For minor procedures which require very little amounts of bone graft, bone collecting
devices may be useful. These collect particles of bone during drilling of the implant
site. This technique is conservative of other bone tissue and provides autogenous bone
which functions well as a grafting material.
Autogenous bone is the ideal material for bone grafting in dentistry. However, it adds
further complications and the benefits/risks and alternatives must be discussed
pre-operatively. There are no substitutes for autogenous bone; there are, however,
synthetic alternatives.

Allograft:
Allograft material can also be used for dental implant treatment. An allograft is a
tissue graft between individuals of the same specimen but of non-identical genetic
composition. The source is usually cadaver bone, which is available in large amounts.
This bone has to undergo many different treatment sequences in order to render it
neutral to immune reactions and avoid cross contamination of host diseases. In
practice, fresh allogenic bone is rarely used because of immune response and the risk
of disease transmission.
Human bone material in the form of freeze dried bone or demineralised freeze dried
bone (DFDB) has been used widely in periodontology and implant dentistry. A wide
range of grafts are available, which may be particulate, thin sheets of cortical plate or
much larger bone blocks.
Allografts have been used as an alternative, but have little or no osteogenicity,
increased immunogenic and resorb more rapidly than autogenous bone.
Allograft bone is a useful material in patients who require bone grafting of a
non-union type but have inadequate autograft bone. It is predominantly used as a
scaffold for bone repair and are resorbable.

Xenografts:
Defined as tissue grafts between two different species (i.e. bone of bovine origin).
Some have received wide acclaim and are used to provide inert framework for bone
regeneration either alone or in combination with autogenous bone graft.
Currently, Bio-Oss and Bio-Gide are widely used as dental xenograft materials.
Bio-Oss is a xenograft consisting of deproteinized, sterilized bovine bone with
7580% porosity and a crystal size of approximately 10 m in the form of cortical
granules; it has a natural, non-antigenic porous matrix and is chemically and
physically identical to the mineral phase of human bone; it has been reported to be
highly osteoconductive and to show a very low resorption rate (Furst et al, 2003;
Orsini et al, 2005).
The organic material is completely removed to leave the mineralised bone
architecture, which renders it non-immunogenic and presumably safe from possibility
of infection.
A more recent study (Orsini et al, 2005) demonstrated a favourable long-term tissue
response to Bio-Oss particles with mainly woven immature bone shown at 20
months, which was replaced with lamellar bone with time.

Bio-Oss is becoming increasingly popular for use in bone grafting in implant

dentistry, and is often used in combination with Bio-Gide.
Bio-Gide is a membrane made of collagen which facilitates planned soft tissue
management during augmentation. Bio-Gide is composed of highly purified natural
collagen from pigs which has a natural bilayer design, has native collagen for soft
tissue compatibility and forms a barrier for undisturbed bone regeneration.
Studies have shown Bio-Gide to allow successful bone regeneration in combination
with Bio-Oss (Wallace et al, 2005) and provide a barrier function lasting several
months (Yamada et Al, 2002)

Alloplast:
Graft material which is synthetically derived and does not originate from humans or
animals. Materials such as hydroxyapatite and similar formulations are easily used as
fillers on their own or combined with autogenous bone. They provide an
osteoconductive framework for bone but are not osteoconductive and are unable to
contribute to osseointegration.
Hydroxyapatite is available in a variety of forms. The most commonly used
non-resorbable form becomes embedded in newly formed fibrous tissue and bone, and
the resulting tissue combination is a less than ideal implant bed.
The use of alloplastic grafting materials on their own is not routinely recommended.
Hydroxyapatite and other bone substitutes require further clinical research and should
not be used on their own as grafting material until their efficacy is
evidence-supported.
Growth factors are natural proteins found in our bodies that stimulate growth of
certain tissues. With respect to bone, genetic engineers have been able to isolate and
clone Bone Morphogenic Proteins (BMPs), which have been shown to induce
tremendous bone growth in many animal and more recently human clinical studies.
BMPs may very well become a potential substitute for autogenous graft material for
certain applications in the future.

Techniques:
Localised deficiencies:
Simple techniques can be used to treat small deficiencies in the alveolar ridge.
Implants can be placed at the same stage as augmentation (1 step surgery) or
following bone regeneration (2 step surgery).
It is important to consider whether grafting is necessary to achieve a stable implant at
the time of placement or whether it is being used to promote bone repair over areas of
the implant.
Depending on the particular situation, 1 step surgical implant placement technique
may be used. Usually, a round piece of the gum in the area of projected implant is
cut off (punch technique) rather than making a line incision and opening a flap.
Osteotomy is performed through this opening and the implant is placed directly. In
this method, the implant remains exposed and there is no need for re-opening of the
implant (second stage).
When a tooth has to be extracted, and implant treatment is the preferred choice of
treatment for substitution of the removed tooth, immediate placement of implant into
the extracted site can be performed. There are several advantages to this method.
Immediate implant placement into the extraction site prevents the time needed for
bone regeneration following grafting (~3-6 months) as is required in 2 step surgery.
The healing process of the implant (osseointegration) runs as a natural process - the
body builds up the new bone in the extracted site where the implant was placed. There
are also contra-indications to immediate implant placement at extraction sites, such as
cortical bone loss and severe infection.
2 step surgery is the most common treatment method for dental implant placement.
Bone augmentation before implantation is generally the preferred option. This is
particularly the case for non-submerged or single stage implants. Alveolar defects
should be augmented at least 3 months before implant placement but delays greater
than 6 months may result in resorption of the graft.
Larger deficiencies:
Larger deficiencies in bone quality or amount usually arises due to progressive
resorption following:
-tooth loss and trauma
-developmental anomalies
-pathological conditions (e.g. cysts)
Techniques to resolve the lack of appropriate bone can involve the entire edentulous
jaw, aim to improve the height and/or width of the bone available as well as to
provide bone of sufficient quality to provide implant anchorage. There are several
different implant placement techniques commonly used, each dependant on the
individual patients circumstances.

Onlay grafts:
Minor grafts:
Onlay grafts are versatile in that they are able to augment the bone in either the
vertical or lateral dimension or a combination of the two. Onlay grafting is a method
of increasing bone volume but can also be used to level deformities in the bone
contour or to cover dehiscences. In cases where only small amounts of one material is
needed it may be enough to collect bone during preparation of the fixture site or take
small pieces of bone from an adjacent area (e.g. tuberostiy).
Small grafts may be harvested from the chin or retro molar area, although large
cortico-cancellous grafts are usually taken from the iliac crest. Miniscrews and plates
or wires should be used to secure grafts to the recipient bed. The host bed is
perforated with a small bur to allow blood clot to form between the 2 bone surfaces
and allow communication with the cancellous bone which contains osteoproginetor
cells. Any remaining voids may be packed with cancellous bone chips to maximise
the healing potential. The bone particles are placed over the defect with or without a
covering membrane.
Healing before abutment connection is dependant upon the initial stability of the
fixture and may take 3-6 months.
The bone used for the onlay technique can be particulated or in the form of a block.
Onlay block grafts are indicated where there is a need to improve the width of the thin
alveolar process or to increase the height in localised defects. Minor onlay grafts used
to increase widths are often placed bucally on the crest (buccal onlays) and secured
with titanium plate screws. Cortical bone is best used as onlay while particulated bone
can be used as a filler around the onlay bone. As mentioned, it is advisable to drill
small holes with a round bur to stimulate bleeding and improve healing potential.
Implants can be placed simultaneously but it is advisable to let the bone heal before
implant insertion, especially if the original crest is too thin for implant site
preparation. Good closure of the flap is also essential to prevent contamination of the
bone graft material with saliva and bacteria from the oral cavity.
Major onlay bone grafts (block form):
Larger block bone grafts are indicated where there is an edentulous maxilla or almost
edentulous maxilla with severe bone deficiency. The height and width of the alveolar
process should be improved by this procedure, enabling appropriate implant
positioning.
A flap technique which does not jeopardize the healing of such a large bone graft
volume is essential. Tension-free closure of the flap is also indicated.
Bone from the iliac crest is most commonly used for major onlay bone grafts. The
whole block can be attached to the maxilla, or it can be divided into 2 or 3 blocks and
then attached. The blocks should be trimmed to fit the alveolus as tightly as possible.
Again, a large number of small holes should be drilled to allow for good healing. The
block(s) can then be attached to the residual bone with titanium plate screws or by the
implants (usually 6 or more).
The remaining alveolus must be capable of stabilising the grafted bone and implants
but, when used appropriately, this technique can be very useful in altering jaw
relations with simultaneous implant placement.

Maxillary sinus grafting (sinus lift):

Lack of bone volume beneath the maxillary sinus cavity often causes difficulties in
placing implants in the posterior maxilla region.
Following loss of posterior maxillary tooth support, resorption of the alveolar process
occurs either at the oral side, or by expansion of the sinus cavity into the alveolar
process, or both.
This often results in a lack of adequate amount and quality of bone available for
implant placement, and hence a sinus lift is required.
Maxillary sinus grafts, a procedure which can be performed under local anaesthesia,
involves carefully cutting a window in the lateral antral wall using surgical burs but
retaining the integrity of the sinus membrane. It is well known that foreign particles
passing into the maxillary sinus will usually cause an inflammatory reaction, leading
to loss of graft material. This can lead to failure of both the graft and the implants
placed, hence it is vital to maintain the integrity of the sinus membrane.
The condition of the maxillary sinus must be assessed pre-operatively. It may be
impossible to avoid mucosa perforation. If the sinus membrane is torn it is not
advisable to graft particulate material although blocks or corticocancellous bone can
be secured in position.
After a window has been cut in the lateral antral wall, the window may be in-fractured
to create a discrete cavity on the superior aspect of the residual alveolus. Graft
material can then be inserted which serves to keep the bone trap-door in its elevated
position. This technique is often used as a pre-implant procedure when the residual
alveolar ridge has to a point where initial implant stability is compromised.
Maxillary ridges with less than 5mm of available bone height should be augmented at
least 3 months prior to implant placement. This improves the likelihood of stable
implants and the success rates.
A fairly recent study (Zitzmann et al. 1998) indicated the choice of approach for sinus
floor augmentation. A 2-step procedure should be carried out if residual bone height is
less than 4-5mm whereas a residual bone height greater than 5mm with sufficient
primary stability suggests a simultaneous procedure. An osteotome technique should
only be indicated where residual bone height is greater than 6mm.
If necessary, block graft material can be fixed by wire osteosynthesis or by titanium
screw plates if the stability is insufficient.
If block grafts are used in the procedure, the blocks can be combined with artificial
bone material to cover small defects and allow for adequate healing.
Research has indicated that coverage of the lateral window with a membrane results
in a significantly higher graft survival rate (Wallace S, Froum S 2003).
Maxillary sinus grafting is sometimes combined with nasal inlay grafting if it is also
necessary to increase the bone volume in the sub nasal area for placement of implants.

Guided bone regeneration:

One of the most popular methods for treating localised ridge deficiencies is GBR. The
concept of treatment is simple. A biocompatible barrier membrane is placed between
the gum and bone. This barrier prevents downgrowth of the gum into the underlying
bone as it heals. Bone progenitor cells then migrate into the defect, instead of the soft
tissues. This allows bone to form within the void.
This technique can be used before or at the same time as implant placement. Barrier
membranes can be non-resorbable (e.g. Gore-Tex) or resorbable, meaning a second
surgical procedure to remove the membrane is not necessary.
GBR can be used to promote bone fill of a defect before implant placement or used to
regenerate bone in dehiscences around implants at the time of placement.
Recent research (Hammerle CH, Lang N 2001) has demonstrated the successful
combination of implantation and GBR in a single procedure without the need for
further surgical interventions.

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Future:
Research and studies have identified new techniques and materials for bone grafting
in dentistry.
Piezo surgery is a recent development which has many uses for bone surgery in
dentistry.
In implantology, piezosurgery can be used for implant site preparation, bone
harvesting (chips and blocks), osteoplasty, ridge expansion, bony window osteotomy
in sinus lifts, as well as many other applications. There are a variety of insert tips
available depending on the treatment required.
Piezosurgery allows selective cuts to be made, allowing for maximum safety of the
soft tissues. Micrometric cuts allow for maximal surgical precision and intra-operative
sensitivity. The cavitation effect in piezosurgery give maximal intra-operative
visibility (blood free surgical site).
Although expensive, piezosurgery units are being used increasingly in bone grafting
procedures for many applications, and their use may well expand in the future.
Nobel Biocare has created the Teeth-in-an-Hour process. The name is
self-explanatory, but what is so unique is the state-of-the-art process this product
employs.
This system is all computer enabled. The majority of work is done in the planning
stage, so the patient only needs surgery for quite literally one hour. Once complete,
the patient goes from totally toothless to a full mouth of functioning permanent teeth.
The pre-surgery visit is very important and involves CT scans of the jaw bones and
use of CAD/CAM.
Bioactive glasses have also been the subject of considerable investigation. Bioactive
glass is a synthetic, non-toxic biocompatible material (Wilson et Al 1981) which has
been shown to be highly osteoconductive in animal studies (Turunen et al. 1997).
They may also be used more widely in the future.

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Clinical experience:

A wide variety of clinical procedures were carried out during my elective. I have
selected five different cases to present, with a brief explanation of the procedures
carried out, and photographs to help illustrate the cases.
Case 1 (Mrs Clark)
This case shows the full sequence of the restoration of a missing lower left first molar
tooth. Following tooth extraction, bone grafting was placed (Bio-Oss) and the area
allowed to heal for 5 months. Following this the implant was placed and again
allowed 3 months healing prior to being restored with an abutment and crown. The
final picture shows a two year review.
Case 2 (Sinus Lift)
This case shows a pre-operative OPG radiograph showing large maxillary air sinuses
bilaterally. Pneumatisation over the years since the tooth loss has led to bone
deficiency with increasing sinus volume. The second OPG shows the patient after
bilateral sinus lift surgery. This was carried out under local anaesthesia using the
Piezo surgery system. Graft material used was chin harvested chips and Bio-Oss.
The case has since been restored using NobelGuide Teeth in an Hour.
Case 3 (Int. Sinus Lift)
This case demonstrates the use of internal sinus elevation. This is also known as bone
added osteotome sinus floor elevation. Part of the implant osteotome is drilled, with
the apical portion being prepared with osteotomes and a mallet to in fracture the sinus
floor, thus tenting the sinus membrane. Graft material is then pushed into the tented
area and the implant placed. Where possible this technique avoids the need for the full
invasive sinus floor elevation.
Case 4 (J Hammond)
This case shows the complex rehabilitation of the severely atrophic maxilla. Severe
bone loss has occurred after many years of tooth loss. Chin grafting is utilized with
Bio-Oss to restore the maxillary bulk. Following this the area is restored using two
implants and Zirconia bridgework.
Case 5 (C Edgar)
This case demonstrates immediate loading in the aesthetic zone. It utilizes bone
harvested during the preparation of the implant osteotomy. The tooth is extracted
atraumatically using periotomes and the socked debrided. The implant is placed using
flapless surgery and harvested bone graft packed bucally. An immediate temporary
abutment is then used to retain a temporary crown. The final photographs show the
same case at 2 month review. It will be restored in 3 months time. This is a difficult
technique to perfect, but can be used in this case to fully support the soft tissues with a
superb aesthetic result in the aesthetic zone.

All patient have consented to their names and photographs being used.
Clinical photographs of each case shown in appendix.
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Summary:
Dental implants have provided an additional treatment option for patients who have
lost one or more teeth. They have several advantages over the alternatives of fixed or
removable prosthesis, and their use is widely growing.
Advances in the ability to increase bone volume before or during treatment has
allowed implants to be carried out in a wider variety of clinical cases.
Small bone defects can easily be corrected with simple grafting techniques, to allow
effective implant insertion.
Various inlay, onlay and grafting techniques can be utilized to allow bone
reconstruction in cases where large defects exist, meaning patients with very little
bone levels can also benefit from implants.
There also advances in the materials used for grafting. Traditional materials like
autogenous bone are still routinely used for grafting, while newer materials have been
scientifically proven and also play an important role in modern day grafting.
Other grafting materials may well be used in the near future, once scientifically
proven, potentially making bone grafting for dental implants less difficult.
The various implant cases I observed clinically has greatly enhanced my knowledge
of both bone grafting and implants in dentistry. I have developed an understanding for
the indications for bone grafting, and when and how to apply the different techniques
and materials in practice. The clinical experience has been both valuable and
enjoyable, and I have learned about a component of dentistry that is expected to
expand in the near future.

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References and Acknowledgments:

A Clinical Guide to Implants in Dentistry, R M Palmer.
Bone Grafting In Oral Implantology, Federico Hernandez Alfaro
Geistlich Professional Information for Implantology Guide.
Introducing Dental Implants, John A. Hobkirk, Roger M. Watson, Lloyd J. Searson
Bone Grafting Techniques for Maxillary Implants, Karl-Erik Kahnberg
The Sinus Bone Graft, Second Edition, Jensen, Ole T.
www.azom.com The A-Z of materials, accessed 18/8/07
http://www.dental-implants.com/cms/ Dental Implants by S.Robert Davidoff,
accessed 18/8/07
www.nobelbiocare.com Teeth-in-an-Hour, accessed 10/09/07
http://www.flexident.ch/index.php?id=23 Piezosurgery, accessed 30/09/07
http://ajouimplant.blogspot.com/ Dental Implant Professional, accessed 20/09/07

A special thanks to Dr Philip Friel, for all the help with this elective project.

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Appendix:
Case 1:

Case 2:

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Case 3:

Case 4:

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Case 5:

The full range of clinical photographs are provided on disc.

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