1. Fritz, Eke et al. Clincal and Microbiological Observations of Early PTFE Membranes Exposure in GBR. Case Report in Primates.

JP 1996.67: 245-249 (Avi) The present study describes membrane placement and subsequent premature exposure at one week post-insertion and the microbiology associated with this condition in a primate model. Standardized bony defects were created to allow for a formation to establish a chronic osseous defect of the alveolar ridge. A semi-lunar incison was made with a vertical. A split thickness flap was made, and the cortical bone was fenestrated to allow for medullary bleeding. The ePTFE membrane was used and set in place with titanium mini-screws. Primary closure was obtained. Four samples were obtained at the failed titanium membrane sites: 1. the exposed membrane surface, 2. alveolar bone surface after the membrane was removed, 3. inner surface of the membrane, 4. subgingival plaque from the adjacent tooth. The core of the polymicrobial infections associated with these falied titanium reinforced membranes contained B. fragilis, S. pneumoniae, S. intermedius, and P. intermedia. P. maltophilia, S. pneumoniae, and P. intermedia were the predominant organisms detected and consisted of more than 10% of the total anaerobic count. 2. Fugazzato. Success and failure rates of osseointegrated implants in function in regenerated bone for 6 to 51 months: A preliminary report IJOMI 1997; 12: 1724 (Jesse) -Six hundred twenty-six titanium plasma-sprayed cylindrical implants that had been functioning in regenerated bone for a period of up to 51 months were evaluated. -These implants had been placed either with concomitant guided bone regeneration procedures or in bony ridges that had previously been augmented. -According to Albrektsson's criteria, absolute success rates of 97.6% overall, 98.8% in the maxilla -98.2% in the mandible were recorded, as were cumulative success rates of 94.9% in the maxilla and 91.9% in the mandible. -The overall cumulative success rate was 93.8%. - One patient, who underwent protracted chemotherapy 14 months after implant function began, accounted for 33% (3 of 9) of the total implant loss in the study. - If this patient is excluded from the study, the cumulative success rates are 94.9% (maxilla), 96.7% (mandible), and 95.8% (overall). -These findings support the theory that regenerated bone will achieve osseointegration with titanium plasma-sprayed cylindrical implants, and that this osseointegration can be maintained under function over time.

3. Hurzeler,MB et al. Guided bone regeneration around dental implants in the

atrophic alveolar ridge using a bioresorbable barrier. Clin Oral Impl Res.1997, 8:323-331. (Josh)

If bone does not encircle the implant, parts of the implant, including threads may be exposed. Threads exposed, leads to recession of the soft tissue with denudation of the implant surface and or threads, which may mechanically irritate the soft tissue and prevent proper hygiene. Bone grafting can take place either before implant placement or in conjunction with implant installation. Factors involved include: biomechanical stability of the healing wound complex, prevention of acute inflammation resulting from bacterial challenge, isolation of the regenerative space from undesirable competing tissue types and the creation and maintenance of a blood clot-filled space. GBR with non-resorbable barriers has been well established. However, the use of bioabsorbable membranes has only been established with GTR. It is speculated that the degredation and resorption kinetics should be controlled fso that the device stays intact for at least 6-9months, depending on the defect size and volume. This study used a barrier membrane made from: POLY(D,L-lactid cotrimethylencarbonate) M&M: 8 Rhesus Monkeys had the maxillary lateral and canine teeth removed and the remaining alveolar bone was reduced to create atrophic ridges. 3 months later a tunnel flap was performed in the edentulous ridges Tissue expander was used to increase the amount of tissue present Expanders increased the tissue present, they were removed and implants were placed on each side (IMZ Plasma sprayed cylinder implant) 3.3mm wide x 10mm height. Coronal aspects of the implants were exposed between 4-5mm. On the test sites the implants were covered with the bioresorbable barrier, where as on the control sites an ePTFE barrier was placed. The test sites were stabilized with 3 titanium minipins. On the test sites the pins were made of POLY(L-lactid co D,L-lactid). The flaps were sutured with a non-resorbable suture. Animals sacrificed at 5 months, and block sections were taken. Results: Mean direct mineralized bone to implant contact length fraction was 32% of the total implant length in the test site and 58% in the control site after 5 months (significant)

Hard tissue defects remained, the distance from top of the implant to first mineralized bone to implant contact was greater buccally than lingually in both control and test groups. In addition, the histometric analysis demonstrated that the control sites exhibited significantly more bone than compared to the experimental sites both buccally and lingually. Histological observations of the specimens from the test site demonstrated an inflammatory foreign body reaction due to the degradation and resorption process of the bioresorbable barrier. In a few test specimens the bioresorbable barrier had lost its integrity. In other test specimens, complete resorption of the barrier was found. 4. Tinti & Benfenati, Vertical Ridge Augmentation: Surgical Protocol and Retrospective Evaluation of 48 Consecutively Inserted Implants,.Int JP Rest Dent 1998;18: 445-453 (Christine) the purpose of this study was to evaluate the possibility of obtaining regenerated bone tissue around implants in vertical ridge defects in consecutive cases when a surgical protocol was meticulously followed. 18 patients, 14 partially edentulous and 4 full edentulous all having insufficient vertical bone height and a total of 48 Nobel Biocare implants were consecutively placed in 22 surgical sites implant defects were selected for treatment and included in the study based on anatomic residual bone structure that had: a bone width and height greater than 5mm and adequate interarch space for the placement of a fixed prosthesis only supracrestal bone deficiencies were included in the retrospective clinical study and they were all treated at phase 1 surgery incisions were very long, full thickness flaps were elevated - this was to ensure that the flap could be raised to the occlusal surfaces of the adjacent teeth implants were placed and the cortical bone was perforated and autogenous bone particles were placed to cover the exposed implant threads, titanium reinforced ePTFE membrane was used with fixation screws in the maxilla the implants were "exposed about 2 to 7mm" with the goal to completely cover them at 12 months post op membranes were removed (3 membranes were exposed prior to the 12 month mark and were removed "early" - in only one case was the implant lost and in two cases no regeneration was noted) - at this time it was noted that the space under the membrane was completely filled with regenerated tissue and a biopsy was taken histology from the biopsy revealed new immature bone tissue and spongy lamellar bone with osteoblastic cells remaining in 19 or the 22 cases upon removal of the membrane a very thin layer of CT was noted immediately underneath the membrane

 the authors believe that regeneration can be predictable around implants if the practitioner is to follow the surgical protocol meticulously and pay attention to all the details the key is to have a tension free flap which means that in the mandible on the lingual aspect the flap must be reflected beyond the mylohyoid muscle 5. Dahlin, Histological morphology of the e-PTFE/ tissue interface in humans subjected to GBR in conjunction with oral implant treatment, Clin Oral Imp Res 1998; 100-106 (Lindsay) The purpose of this study was to histologically examine and characterize the tissue found in the interface between an e-PTFE membrane and the underlying newly formed bone using light and electron microscopy. This information would be uselful because if the soft tissue layer in between membrane and bone has osteogenic potential, it should not be striped away during the membrane removal procedure. M and M: 5 humans undergoing GBR . periodontally diseased teeth were extracted. 1 to 2 months later, Implants (branemark) inserted and special 3mm high cover-screws with horizontal slits for tissue ingrowth were put on the implants such that the coverscrews were 2mm subcrestal. Then the site was covered with e-PTFE membranes (no graft). Re-entry was made 7 months later in 4/5 cases. Circular biopsies comprising membranes, tissues and cover-screws were retrieved. This ePTFE membrane has pores 50 micrometers in diameter allows invasion by cells and small vessels. Results: The space between the membrane and the cover-screw was occupied by fibrous tissue and varying amounts of bone. Fibrous tissue was rich in cells and vessels (fibroblasts and macrophages predominate) . Membrane itself was penetrated by fibrous tissue There were irregularly shaped cells with increased amounts of rough endoplasmic reticulum and unevenly distributed collagen fibers adjacent to the barrier. This is thought to maybe be the result of continual stress and micromovements in the membrane/tissue interface transferred from removable prosthesis. Further away from the membrane, the cells and collagen matrix fibers became more elongated and arranged more orderly. There was lamellar bone right next to coverscrew. Conclusions: Micromovements in the interface region prevents bone formation in the area directly contacting the membrane. There does not appear to be bone forming activity within the soft tissue next to the barrier material. Nonetheless, it might make sense to leave this tissue in place when removing the membrane as vascular support for the underlying maturing bone material 6. Simon, Von Hagen. Changes in Alveolar Bone Height and Width Following Ridge Augmentation Using Bone Graft and Membranes. JP 2000 71: 1774-1791

(Neil) - This study was designed to quantitively determine the amount of bone added to the alveolus during augmentation and to assess the amount of the added bone that remains after a 4-month healing interval. It was hypothesized that after guided bone regeneration using DFDBA and a resorbable membrane that 1) a significant amount of the osseous augmentation height and width placed during the GBR procudure is lost during healing; and 2) this loss is not uniform over the area treated. MATERIALS AND METHODS - Conducted at UNDMJ, all patients required extraction of one more hopeless teeth. - Standardized measurements using an acrylic stent were taken immediately after extraction, immediately after grafting and 4 months after healing in the middle of the edentulous site and 3mm mesial and distal to this point. These measurements included: - Ridge width 3mm, 5mm and 10mm apical to the alveolar crest using a boley gauge - Alveolar height from a fixed point on the occlusal surface of the stent to the crest of the ridge - The areas were grafted with DFDBA and a ePTFE resorbable membrane was placed over it using a standard technique with primary closure - Sites <6mm in width were augmented to provide at least 6mm of width in the center of the edentulous site 3mm from the crest. - Sites >6mm were augmented by about 2mm in the center of the site 3mm apical to crest. - The height was augmented to the extent needed to at least level the experimental site with the adjacent osseous walls. - The site was re-entered 4 months later for implant placement and measurements were re-taken RESULTS: - At 4-months, the loss of augmented width ranged from 39.2% to 67.4% and it was not uniform over the area grafted with the greatest loss 3mm and 5mm from the alveolar crest. - At each of the 3 distances from the crest, the loss was generally greater in the center of the crest compared to 3mm mesial and distal to this point. - In terms of height, the center of the edentulous site lost only 14.7% compared to 60.5% 3mm distal and 76.3% 3mm mesial to the center. - The greater the amount of bone added during the surgery, the greater the gain after healing. - At locations 3mm and 5mm from the crest, there had to be a minimum amount of bone added in order to have a net gain in width after 4 months. At 3mm from the crest, there had to be at least 1.5mm of augmentation and at 5mm, there had to be 1-1.5mm of augmentation. At 10mm from the crest, almost any amount of augmentation resulted in a net gain in width. - The greater the pre-operative alveolar width, the less the net gain in width after 4 months of healing. Conversely, the narrow the pre-op width, the greater the net gain after healing. A net gain was not noted when pre-op width was >7-8mm.

- The greater the pre-op height, the greater the net gain. The greater the amount of osseous augmentation, the greater the net gain in height after 4 months. - There was an average of 1.138mm loss in width after augmentation. Most loss occurred at 3mm from the crest and decreased at 5mm from the crest and the least loss was 10mm from the crest - The average loss of height was 1.4mm after healing. - The data indicates that approximately 1-1.5mm loss of augmented bone width and height will take place during healing. CONCLUSIONS: - The results clearly indicate that a highly significant percentage ranging from 39.176.3% was lost during a 4-month healing interval. The results have further demonstrated that this loss is not uniform throughout the area treated with greater loss in height compared to width. The implications of these findings should impact pre-op planning when augmentation is necessary for successful implant therapy. 7. Zitzmann, et. al Long-term Results of Implants Treated with Guided Bone Regeneration: A 5-year Prospective Study Int J Oral Maxillofac Implants. 2001;16:355 366. (Leigh) The aim of this study was to follow endosteal implants in which guided bone regeneration was applied during implant placement. In 75 patients, defects around implants were treated with Bio-Oss and Bio-Gide (122 implants) brandemark system. In split-mouth patients in this group, Bio-oss and Gore-Tex were used in the second defect site (41 implants). All patients had at least 1 implant entirely surrounded by bone that served as the control. After placemnt of the prosthesis (single tooth, fixed, or removable) patients where recalled after 6 months and then every 12 months during a 5 year observation period. The variables that where investigated where 1) implant survival (the absence of peri-implant radiolucency , absence of clicnial symptoms such as pain, infection, neuropathies, and paresthesia) 2) marginal bone loss 3) presence of plaque 4) peri-implant mucosal conditions 5) heights of keratinized mucosa 6) marginal soft tissue level The cumulative survival rate after 5 years was between 93-97% for implants with or without GBR--- biogide 95.4, Goretex 92.6 and control 97.3% - Meant MBL after 60 months was 1.83mm at sites with Biooss and Biogide , 2.21mm for biooss and goretex sites and 1.73 for control sites- MBL was found to increase significantly with time and differed significantly among the treatment groups - KM varied between 3.16 and 3.02 slight recession of .1mm was observed and plaque was found in 15% of all sites assoc with inflammatory symtoms of the periimplant mucosa. it was observed that symptoms and recession correlated more with type of restoration than with type of treatment mucosal problems occurred more in removable restorations then fixed single tooth restorations - the presence of plaque was associated with mucosal problems and the likelihood of

having plaque decreased with larger KM values - ** the study demonstrated that implants placed with or without GBR techniques had similar survival rates after 5 years , but that bone resorption was more pronounced in sites with GBR treatment . It was assumed that the use of GBR is indeed indicated when the initial size is larger then 2mm in vertical dimension 8. Buser et al. Lateral Ridge Augmentation using autografts and barrier membranes: a Clinical Study with 40 edentulous patients. J Oral Maxillofacial Surgery, 1996,(54) 420-432. (Elana) Purpose: To evaluate the predictability and treatment outcome of the use of autografts and e-PTFE membranes for lateral ridge augmentation in partially edentulous patients using a staged approach. Materials and Methods: 40 partially edentulous patients between the ages of 16 and 73 were treated. The most common indication was a single tooth gap in the maxilla and a distal extension in the mandible. Lateral incision technique was used with a splitthickness/ full-thickness flap and divergent relieving incisions . A caliber was used to measure the width of the ridge. Corticocancellous block grafts were harvested from the retromolar area or chin. The cortex of the recipient site was perforated, the graft was secured using fixation screws and small bone particles were placed around the graft. ePTFE membranes were placed over the graft and tension free primary soft tissue closure was acheived. After 7 to 13 months, the sites were reopened for membrane removal and implant placement. Results: All but one patient showed complication during the soft tissue healing. After reopening, 38 patients exhibited excellent ridge augmentation whereas 2 had compromised results with soft tissue encapsulation of some bone chips. None of the applied block grafts showed clinical signs of resorption. Often, the block graft was partially covered with a thin layer of bone. Pre and post-augmentation measurements showed an enlargement of the crest width from a mean of 3.5mm to 7.1mm. This allowed the placement of implants in all 40 patients with at least 1mm thickness of bone surrounding them. Conclusions: This study demonstrates that the combined application of autografts and e-ptfe membranes is a predictable procedure for lateral ridge augmentation. The autografts support the membrane and activated bone formation with their osteoinductive and osteoconductive properties. The cortical layer of the block will reestablish a new cortex and the particulate graft and the cancellous portion of the block graft will allow faster revascularization and remodeling. The membrane acts as a physical barrier to nonosteogenic soft tissue cells, it protects the autografts against resorption during healing, and it stabilizes the bone graft. 9. Simion et al, Vertical Ridge Augmentation Around Dental Implants Using a membrane Technique and Autogenous Bone or Allografts in Humans,Int J P Rest Dent 1998;18:8-23 (Daniel)

Aim; to investigate the beneficial effect on vertical bone formation of the addition of DFDBA or autogenous bone chips to a membrane technique.( a clinical and histologic human study) M&M; 22 partially edentulous patients, between 34 and 66 years of age with vertical jawbone deficiencies were selected for this study. The patients were divided into 2 groups (A & B) of 10 individuals each. The 10 patients from group A received a total of 26 branemark implants in 10 surgical sites. The patients from group B received a total of 32 implants at 12 surgical sites. The implant heads were positioned in an ideal vertical position located 3mm from the CEJ of the adjacent teeth. 52 out of 58 implants extended 1.5-7.5mm superior to the bone crest. In 5 sites of each group a pure titanium miniscrew was allowed to protrude 2-7mm from the bone level to improve the support of the membrane and provide biopsy specimen. Titanium reinforced ePTFE membrane were used to cover the implants. After partial fixation of membrane, DFDBA particles (for group A) and autogenous bone chips (for group B) were condensed under the membrane. The sites were reentered in 7-11 months for membrane removal, 2nd stage and biopsies collected for histology. Results; The overall % of healing complications (membrane exposure, abscess) was 18%. The clinical measurement from group A demonstrated a mean vertical bone gain of 3.1mm (range from 1-5mm) with a mean % of bone gain of 124%. The measurement from group B showed a mean vertical gain of 5.02mm (range 1-8.5) with a mean % of bone gain of 95%. Sites with membrane exposure showed less bone regeneration compared to sites with uneventful healing. Histomorphometric analysis demonstrated a direct correlation between the density of pre-existing bone and the density of the regenerated bone. In the specimen that demonstrated pre-existing cortical bone, the vertically regenerated bone showed mean density of 53.1% and was distinguishable from the pre-existing bone. In the specimen that demonstrated pre-existing spongious bone, the regenerated bone density was 36.6% and hardly distinguishable. The mean % of new bone contact with the retrieved titanium screws was from 39.1% to 63.2% depending on the quality of the pre-existing bone. All 58 implants were osseointegrated (100% survival rate). Conclusions; 1.addition of DFDBA and autogenous bone to the membrane technique for vertical ridge augmentation is beneficial. 2. There is direct correlation between the density of pre-existing bone and the density of the regenerated bone 3. The % bone implant contact of the regenerated bone is within the normal range for implants inserted in native bone 10. Feuille, Knapp, Brunsvold, Mellonig, Clinical and Histologic Evaluation of Bone Replacement Grafts in the Treatment of Localized Alveolar Ridge Defects Part 1: Mineralized Freeze Dried Bone Allograft Int J Perio Rest Dent 2003; 23: 2935 (Shervy)

Purpose of the study: To evaluate the use of mineralized freeze-dried bone allograft (FDBA) in conjunction with a titanium-reinforced expanded polytetrafluoroethylene (TR e-PTFE) barrier in the treatment of localized alveolar ridge deficiencies prior to endosseous dental implant placement Materials and Methods: 12 patients (aged 23 to 65 years) requiring tooth replacement with ridge augmentation Inclusion criteria: o At the augmentation site, the alveolar ridge must be deficient in a buccolingual dimension (<5.5 mm); the deficiency must be at the level of the alveolar crest o Ridges to be augmented must have a minimum of 4 mm of keratinized gingiva extending the length of the planned augmentation During ridge augmentation surgery, measurements were made prior to grafting with FDBA plus a TR e-PTFE barrier 6 months later, ridge measurements were repeated , and suitability for implant placement was assessed At each implant site, a biopsy was taken from the grafted site Implants were placed and allowed to osseointegrate for 13 weeks prior to phasetwo surgery Clinical data analyzed were horizontal ridge width changes and vertical ridge height changes Results: 10 patients completed the study Histologic evaluation revealed the formation of new bone and residual particles in each graft site at the time of implant placement The mean alveolar ridge width increased by 3.21.0 mm at the 6-month re-entry o Mean alveolar ridge width prior to augmentation was 4.32.0 mm. o Mean alveolar ridge width at re-entry was 7.42.4 mm Histomorphometric analysis revealed a range of new bone from 42.9% to 70.5%, with a mean of 47.6% 14.2% Graft particles remaining ranged from 29.5% to 57.1%, with a mean of 52.4% 15.1% No statistically significant relationship between percent new bone as compared to patient age In 9 of the 10 patients who completed the study, the augmented ridges were suffieciently augmented for implant placement Conclusion: The clinical and histologic findings of this study demomstrate that sites grafted

with FDBA in conjunction with an e-PTFE barrier can provide a predictable way to augment deficient alveolar ridges prior to implant placement. 11. Veis et al. Effect of autogenous harvest site location on the outcome of ridge augmentation for implant dehiscences. IJPRD 2004;24:155-163 (Michael) The purpose of this study was to evaluate bone regeneration around the uncovered surfaces of implants placed simultaneously in humans, using autogenous bone grafts from the three most common intraoral sites (mandibular symphysis, ramus, and tuberosity). MATERIALS AND METHODS: Inclusion criteria included patients with thin crestal ridges and exclusion included heavy smokers and those with systemic chronic diseases. The patients were divided into three groups. Potential exposure implant area measurements were taken pre-op. Flaps were gently reflected and a stent was used for placement. Trephines and burs were used to harvest bone cores from the donor sites and ground in a mill with saline. 4 mm 3i implants were placed (lengths varied in each patient). Initial stability was achieved in all implants. A probe was used to measure the distance between the level of the implant cervix and the most apical extent of the buccal uncovered threads and this ranged from 3 to 7 mm. Decortication was done and graft placed 2 mm distal and mesial to the implant. All cases had e-PTFE barriers placed. Follow up was 15 days and 1 month. Exposure of membrane occurred in 5 patients and these were excluded from the study. A 2nd stage surgery to open the grafted sites was done at 6 months post-op. Membranes were removed and the bone gain measured by measuring the distance from the implant cervix to the most apical extent of the uncovered implant portion and healing abutments were placed. RESULTS: No implants were lost. Bone was regenerated in all cases to varying degrees. The best result was observed in the mandibular symphysis group while the tuberosity group produced the poorest results. DISCUSSION: Significant differences existed between the initial and final bone level distances for each of the three groups, and this indicates that all three intraoral sites provided bone grafts capable of producing bone regeneration. Mandibular symphysis bone grafts produced the highest mean bone level changes, followed by the ramus bone grafts; the tuberosity bone grafts produced the lowest mean change in linear bone growth. 12. Wallace, Froum , Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review Ann Periodontology 2003, 32843 (Sara) BACKGROUND: Grafting the floor of the maxillary sinus has become the most common

surgical intervention for increasing alveolar bone height prior to the placement of endosseous dental implants in the posterior maxilla. Outcomes of this procedure may be affected by specific surgical techniques, simultaneous versus delayed implant placement, use of barrier membranes over the lateral window, selection of graft material, and the surface characteristics and the length and width of the implants. RATIONALE: The primary objective of this systematic review was to determine the efficacy of the sinus augmentation procedure and compare the results achieved with various surgical techniques, grafting materials, and implants. FOCUSED QUESTION: In patients requiring dental implant placement, what is the effect on implant survival of maxillary sinus augmentation versus implant placement in the non-grafted posterior maxilla? SEARCH PROTOCOL: MEDLINE, the Cochrane Oral Health Group Specialized Trials Register, and the Database of Abstracts and Reviews of Effectiveness were searched for articles published through April 2003. Hand searches were performed on Clinical Oral Implants Research, International Journal of Oral and Maxillofacial Implants, and the International Journal of Periodontics & Restorative Dentistry and the bibliographies of all relevant papers and review articles. In addition, researchers, journal editors, and industry sources were contacted to see if pertinent unpublished data that had been accepted for publication were available. SELECTION CRITERIA: INCLUSION CRITERIA: Human studies with a minimum of 20 interventions, a minimum follow-up period of 1-year loading, an outcome measurement of implant survival, and published in English, regardless of the evidence level, were considered. EXCLUSION CRITERIA: Studies involving multiple simultaneous interventions (e.g., simultaneous ridge augmentation) and studies with missing data that could not be supplied by the study authors were excluded. DATA COLLECTION AND ANALYSIS: Where adequate data were available, subgroups of dissimilar interventions (e.g., surgical techniques, graft materials, implant surfaces, membranes) were isolated and subjected to meta-regression, a form of meta-analysis. MAIN RESULTS: 1. Forty-three studies, 3 randomized controlled clinical trials (RCTs), 5 controlled trials (CTs), 12 case series (CS), and 23 retrospective analyses (RA) were identified. Thirty-four were lateral window interventions, 5 were osteotome interventions, 2 were localized management of the sinus floor, and 2 involved the crestal core technique. 2. Meta-regression was performed to determine the effect of the variables of block versus particulate grafting techniques, implant surface, graft material, and the use of a membrane over the lateral window. 3. The survival rate of implants placed in sinuses augmented with the lateral window technique varied between 61.7% and 100%, with an average survival rate of 91.8%. For lateral window technique: 4. Implant survival rates reported in this systematic review compare favorably to reported survival rates for implants placed in the non-grafted posterior maxilla. 5. Rough-surfaced implants have a higher survival rate than machine-surfaced implants when placed in grafted sinuses. 6. Implants placed in sinuses augmented with particulate grafts show a higher survival rate than those placed in sinuses augmented with block grafts. 7. Implant survival rates were higher

when a membrane was placed over the lateral window. 8. The utilization of grafts consisting of 100% autogenous bone or the inclusion of autogenous bone as a component of a composite graft did not affect implant survival. 9. There was no statistical difference between the covariates of simultaneous versus delayed implant placement, types of rough-surfaced implants, length of follow-up, year of publication, and the evidence level of the study. REVIEWERS' CONCLUSIONS: Insufficient data were present to statistically evaluate the effects of smoking, residual crestal bone height, screw versus press-fit implant design, or the effect of implant surface micromorphology other than machined versus rough surfaces. There are insufficient data to recommend the use of platelet-rich plasma in sinus graft surgery. 13. Esposito et al, The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of randomized controlled clinical trials, Int Journal of Oral Maxill Implants 2006-696-710 (Ewa) PURPOSE: To test (a) whether and when bone augmentation procedures are necessary and (b) which is the most effective augmentation technique for specific clinical indications. Trials were divided into 3 categories: (1) major vertical or horizontal bone augmentation (or both); (2) implants placed in extraction sockets; (3) fenestrated implants. MATERIALS AND METHODS: An exhaustive search was conducted for all randomized controlled clinical trials (RCTs) comparing different techniques and materials for augmenting bone for implant treatment reporting the outcome of implant therapy at least to abutment connection. No language restriction was applied. The last electronic search was conducted on October 1, 2005. RESULTS: Thirteen RCTs of 30 potentially eligible trials reporting the outcome of 332 patients were suitable for inclusion. Six trials evaluated techniques for vertical and/or horizontal bone augmentation. Four trials evaluated techniques of bone grafting for implants placed in extraction sockets, and 3 trials evaluated techniques to treat fenestrated implants. CONCLUSIONS: Major bone grafting procedures of extremely resorbed mandibles may not be justified. Bone substitutes may replace autogenous bone for sinus lift procedures of extremely atrophic sinuses. Both guided bone regeneration procedures and distraction osteogenesis can be used to augment bone vertically, but it is unclear which is the most efficient. It is unclear whether augmentation procedures are needed at immediate single implants placed in fresh extraction sockets; however, sites treated with barrier + Bio-Oss showed a higher position of the gingival margin than sites treated with barriers alone. More bone was regenerated around fenestrated implants with nonresorbable barriers than without barriers; however, it remains unclear whether such bone is of benefit to the patient. Bone morphogenetic proteins may enhance bone formation around implants grafted with Bio-Oss, but there was no reliable evidence supporting the efficacy of other active agents, such as platelet-rich plasma, in conjunction with implant treatment.

14. Aghaloo, Moy, Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? I JOMI 2007, Supplement 49-70 (Melissa) Aim: to identify the most successful techniques to provide the necessary alveolar bone to place a dental implant and support longterm survivial Method: A systematic online review of a main database and manual search of relevant articles from refereed journals were performed between 1980 and 2005. The hard tissue augmentation techniques were separated into two anatomic sites, the maxillary sinus and the alveolar ridge. Within the alveolar ridege augmentation technique, different surgical approaches were identified and categorized, including: guided bone regeneratin (GBR), onlay/veneer grafting (OVG), conbinations of onlay, veneer, interpositional inlay grafting (COG), distraction osteogenesis, ridge splitting (RS), free and vascularized autografts from discontinuity defects (DD), mandibular interpositional grafting (MI) and socket preservation (SP). All identified articles were evaluated by two independent reviewers to meet strict inclusion criteria. The initial search identified a total of 526 articles from the electronic database and manual search. Of these 335 met the inclusion criteria after a review of the title and abstract. From the 335 articles, further review of the full text produced 90 artilces that provided sufficient data for extraction and analysis. Results: For the maxillary sinus grafting technique, the results showed a total of 5,128 implants placed with follow up ranging from 12 to 102 months. Implant survival was 92% for implants placed in autogenous and autogenous/composite grafts, 93.9% for implants placed in allogeneic nonautogenous composite grafts, 81% for implants placed into alloplast and alloplast/xenograft materials and 95.6% for implants placed into xenograft materials alone. For alveolar ridge augmentation, a total of 2,620 implants were placed with follow up ranging from 5 to 74 months. The implant survival rate was 95.5% for GBR, 90.4% for OVG, 94.7% for DO and 83.8% for COG. Other techniques were difficult to analyze because of the small sample size. Conclusions: The maxillary sinus augmentation technique has been well documented and longterm clinical success/survival (>5 years) of implants placed regardless of graft material compares favorably to implants placed conventionally with no graft procedures. Alveolar ridge augmentation techniques do not have detailed documentation or longterm follow up studies with the exception of GBR. However, studies that me the inclusion criteria seemed to be comparable and yielded favourable results in

supporting dental implants. The alveolar ridge aumentation procedures may be more technique and operator experience sensitive and implant survival may be a function of residual bone supporting the dental implant rather than grafted bone.

15. Rocchietta, Fontana, Simion, Clinical outcomes of vertical bone

augmentation to enable dental implant placement: a systematic review, JCP 2008:35 (8 Supplement 203-15 (Bram) This review addressed the focused question of what is the predictability of vertical ridge augmentation techniques for patients, who were diagnosed with insufficient alveolar bone volume for the placement of dental implants. MATERIAL AND METHODS: A systematic online review of three main databases was performed between 1966 and 1 November 2007. Four groups of vertical bone augmentation techniques have been identified and evaluated: (1) guided bone regeneration, (2) distraction osteogenesis, (3) onlay bone grafting, and (4) an array of different techniques. Data extraction was based on the following outcomes: (a) success and failure rate of the procedure (vertical bone gain/loss), (b) complication rate of the procedure, and (c) implant survival, success and failure rate. RESULTS: The initial search identified 189 papers from the electronic database. The review produced seven papers for GBR, 13 reporting distraction osteogenesis, five for onlay bone grafting and three describing different techniques. CONCLUSIONS: For the concept of vertical ridge augmentation to enable dental implant placement, there are clinical and histological data supporting its potential use. Given the confined number of investigators using these techniques and the low number of patient treatments reported in the literature, the generalizability of this approach is limited at this time. 16. Esposito, et al, The efficacy of horizontal and vertical bone augmentation procedures for dental implants- a Cochrane systematic review. European J Oral Implantol, 2009 Autumn: 2 167-84 (Avi) BACKGROUND: dental implants require sufficient bone to be adequately stabilised. For some patients implant treatment would not be an option without horizontal or vertical bone augmentation. A variety of materials and surgical techniques are available for bone augmentation. OBJECTIVES: to test whether and when augmentation procedures are necessary and which is the most effective technique for horizontal and vertical bone augmentation. SEARCH METHODS: the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were hand searched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. The last electronic search was conducted on 11 June 2009. SELECTION CRITERIA: randomised

controlled trials (RCTs) of different techniques and materials for augmenting bone horizontally and/or vertically for implant treatment that reported the outcome of implant therapy at least to abutment connection. Trials were divided into two broad categories: horizontal augmentation and vertical augmentation techniques. DATA COLLECTION AND ANALYSIS: screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit of the analysis was the patient. RESULTS: 13 RCTs out of 18 potentially eligible trials were suitable for inclusion. Three RCTs (106 patients) dealt with horizontal and 10 trials (218 patients) with vertical augmentation. Since different techniques were evaluated in different trials, only one meta-analysis could be performed. When comparing whether vertical augmentation procedures were more advantageous than short implants, a meta-analysis of two trials resulted in more implant failures OR = 5.74 (95% CI 0.92 to 35.82; borderline significance, P = 0.06) and statistically significantly more complications OR = 4.97 (95% CI 1.10 to 22.40) in the vertically augmented group. When comparing various horizontal augmentation techniques (three trials) no statistically significant differences were observed. When comparing various vertical bone augmentation techniques (eight trials) no statistically significant differences were observed except for three trials which showed that more vertical bone gain could be obtained with osteodistraction than with inlay autogenous grafts (mean difference 3.25 mm; 95% CI 1.66 to 4.84), and with bone substitutes rather than autogenous bone in guided bone regeneration (mean difference 0.60 mm; 95% CI 0.21 to 0.99) in posterior atrophic mandibles, and that patients preferred a bone substitute block over a block of autogenous bone taken from the iliac crest (OR = 0.03; 95% CI 0.00 to 0.64; P = 0.02). CONCLUSIONS: conclusions are based on few trials including few patients, sometimes having a short follow-up, and often being judged to be at high risk of bias. Various techniques can augment bone horizontally and vertically, but it is unclear which are the most efficient. Short implants appear to be a better alternative to vertical bone grafting of resorbed mandibles. Complications, especially for vertical augmentation, are common. Some bone substitutes could be a preferable alternative to autogenous bone. Osteodistraction osteogenesis allows for more vertical bone augmentation than other techniques, which, on the other hand, can allow for horizontal augmentation at the same time. Titanium screws may be preferable to resorbable screws to fixate onlay bone grafts. 17. Chiapasco, Zaniboni, Clinical outcomes of GBR procedures to correct periimplant dehiscences and fenstrations: a systematic review, Clin Oral Implants Research 2009; 20 Suppl 4 113-23 (Jesse)

OBJECTIVE: To analyze the clinical outcomes of endosseous implants following guided bone regeneration (GBR) procedures to correct dehiscence/fenestration defects associated with implant placement. METHODS/SEARCH STRATEGY: A Medline search was performed for human studies published in English focusing on GBR procedures for the correction of dehiscence/fenestration defects associated with the placement of screw-shaped titanium implants. The selected studies had to include at least 10 consecutively treated patients with a minimum follow-up of 12 months after the start of prosthetic loading. The clinical outcomes in terms of the complication rate of the GBR procedure, implant survival, and stability of marginal soft tissues around implants were evaluated. RESULTS: Seven publications were included in this review. A total of 238 patients received 374 implants. Defects were treated with resorbable or nonresorbable membranes, in association with or without graft materials. Patients were followed for 1-10 years after the start of prosthetic loading. In the postoperative period, 20% of the non-resorbable membranes and 5% of the resorbable ones underwent exposure/infection. However, in the majority of cases, a complete or an almost complete coverage of the initial defect was obtained. The overall survival rate of implants, irrespective of the type of membrane and grafting materials, was 95.7% (range: 84.7100%). No significant modifications of probing depth and/or variation of clinical attachment level around implants were observed during the follow-up period. CONCLUSION: Despite the favorable results obtained, it was difficult to draw a significant conclusion as far as the more reliable grafting material and membrane barrier for the correction of dehiscence/fenestration defects are concerned, due to the limited sample of patients and the wide variety of grafting materials and membranes, used alone or in combination. Moreover, due to the lack of randomized clinical trials, it was impossible to demonstrate that such augmentation procedures are actually needed to allow the long-term survival of implants. 18. Kazakos, eet al, Application of PRP gel alone or in combination with guided bone regeneration dos not enhance bone healing process: A experimental study in rabbits. J Craniomaxillofacial Surg 2010 (Josh) Gold standard for bone substitues is Autogenous bone, which provides the necessary components for bone regeneration. However there is a demand for bone graft substitues that enhance bone regeneration. PRP (platelet rich plasma) is an autologous source of various growth factors including PDGF, TGF-beta, IGF (insulin like), EGF (epithelial like) The hypothesis was that application of PRP in rabbits mandibular defects, alone or in combination with GBR techniques could enhance the bone healing process. The aim was to test this hypothesis. 3 groups of 10 white rabbits. Group 1 HFL (Human Fascia Lata membrane used to cover defect), Group 2 PRP (PRP gel used to fill defect), Group 3 HFL + PRP (PRP was used to fill the defect after which that was covered by Human Fascia Lata membrane)

Before surgical procedure, blood was drawn from 5 donor rabbits and left to sit for 15 min. Then the blood was centrifuged and the upper half was considered PPP (platelet poor plasma) and was removed with pipettes. The lower half (the PRP proper) was retrieved. Approx 2ml was obtained from 8ml samples. The PRP was applied in a gel form by adding 0.5ml of procoagulant solution in the tube with the liquid PRP. 15 and it became a gel. Trephines were used to make circular defects 10mm in diameter anterior to the mandibular angles. A 5mm diameter hole corresponds to the critical size in this experimental model (have been shown to spontaneously heal during animals lifetime). Controls flaps were sutured back to cover the trephined defects. Animals sacrificed 12 wks later None of the control sides and the PRP treated sides had full development of bone or filling of the defect through bone bridging. The sides on which the Fascia Lata Membrane or the combination of membrane and PRP had been applied showed development of newly formed bone that bridged the gap. The membrane was visible in all specimens and no signs of an inflammatory reaction were seen. Membrane and PRP/Membrane the bone defects were covered by a mature newly formed bone that fully bridged the bone defect. These two groups were statistically superior to the controls and the PRP group in terms of the bone quality and quantity. No signif difference between Membrane and PRP/Membrane. Both PRP and control groups resulted in failure of gap bridging in 100% of the cases. Given that platelets initiate the formation of a scar, it is not surprising that PRP is unable to enhance the specific nature of bone healing. We believe that research around PRP must focus in the area of soft tissue repair, and more specifically of tendon and ligament healing. 19. Langer, Langer, Sullivan, Vertical ridge augmentation procedure using guided bone regeneration, demineralized freeze-dried bone allograft, and imiscrews: 4 to 13 year observations on loaded implants, IJPRD 2010 227-35 (Christine) ARTICLE IS NOT AVAILABLE 20. McAllister, Haghighat, Bone Augmentation Techniques, J Perio 2007, 78:377396 (Lindsay) BACKGROUND: The advent of osseointegration and advances in biomaterials and techniques have contributed to increased application of dental implants in the

restoration of partial and completely edentulous patients. Often, in these patients, soft and hard tissue defects result from a variety of causes, such as infection, trauma, and tooth loss. These create an anatomically less favorable foundation for ideal implant placement. For prosthetic-driven dental implant therapy, reconstruction of the alveolar bone through a variety of regenerative surgical procedures has become predictable; it may be necessary prior to implant placement or simultaneously at the time of implant surgery to provide a restoration with a good long-term prognosis. Regenerative procedures are used for socket preservation, sinus augmentation, and horizontal and vertical ridge augmentation. METHODS: A broad overview of the published findings in the English literature related to various bone augmentation techniques is outlined. A comprehensive computer-based search was performed using various databases that include Medline and PubMed. A total of 267 papers were considered, with non-peerreviewed articles eliminated as much as possible. RESULTS: The techniques for reconstruction of bony defects that are reviewed in this paper include the use of particulate bone grafts and bone graft substitutes, barrier membranes for guided bone regeneration, autogenous and allogenic block grafts, and the application of distraction osteogenesis. CONCLUSIONS: Many different techniques exist for effective bone augmentation. The approach is largely dependent on the extent of the defect and specific procedures to be performed for the implant reconstruction. It is most appropriate to use an evidenced-based approach when a treatment plan is being developed for bone augmentation cases.