Chapter 15 Bone Enhancement

Increasing the Volume of Available Bone

A basic premise of this book is that ones first few implant cases should involve mainstream
treatment. By definition, in mainstream cases available bone is sufficient for the implant modality
to be used. No bone enhancement is required. Therefore, the entry-level applications of bone
enhancement procedures are supplemental to mainstream implant dentistry. Bone enhancement
procedures show promise and can be useful. Because the understanding and practice of bone
enhancement is rapidly growing and evolving, it is recommended that one thoroughly understand
its principles and clinical applications. The importance of this adjunctive discipline will continue to
increase over time. As one progresses toward the treatment of intermediate and advanced
implant dentistry cases, one can help more and more patients through the judicious use of bone
enhancement procedures.
This chapter examines the current scientific understanding of bone enhancement, and certain
clinical applications that may be used to treat atypical conditions or complications that are
sometimes encountered in mainstream implant dentistry cases.

STATE OF THE ART OF BONE ENHANCEMENT

Bone enhancement is a rapidly developing area of treatment. Little consensus exists regarding
many aspects of its underlying science and clinical application. [1][2][3][4] A literature review reveals
inconsistent and sometimes contradictory use of vocabulary. Industry has complicated this
situation by coining words with implications that can be contrary to the understanding of scientists
in the field. Therefore, much of this chapter is devoted to terminology and appropriate definitions,
as the scientific community understands them.
In addition, there is a diversity of opinion regarding what materials should be employed for typical
clinical applications, the rationale for their use, the rationale for using combinations of materials, [5]
the percentages of each material used in combination, [6] and how these percentages are best
determined. Therefore, following a review of terms, this chapter highlights specific clinical
applications of bone enhancement that are useful to supplement mainstream implant dentistry,
and identifies specific materials with known safety and effectiveness for use in such cases

BONE GRAFTING/AUGMENTATION
Vocabulary and General Considerations
Bone grafting/augmentation materials can be separated into four broad categories, as shown in
Box 15-1 .
Box 15-1
CLASSIFICATION OF BONE GRAFTING MATERIALS

Autogenous: harvested from a donor site within the same individual

Allogenic: harvested from a different member of the same species
Xenogenic: harvested from a different species
Alloplastic: synthetic or chemically derived from a nonliving source

Classification of Grafting Materials

Autogenous.
Also autograft, autochthonous, or autologous graft. Autogenous grafting material is harvested
from one or more donor sites within the same individual.

Allogenic.
Also allograft or homograft. Allogenic grafting material is harvested from the same species as
the recipient, but is of a different genotype. It is a graft taken from one human and transplanted
into another.

Xenogenic.
Also xenograft, heterograft, or heterologous graft. Xenogenic grafting material is harvested
from a species different from that of the recipient.

Alloplastic.
Also alloplast. Alloplastic grafting material is synthetic or chemically derived from a nonliving
source, and is inert.

Nature of Grafting Materials

Autogenous.
The consistency of the autogenous grafting material required for a specific treatment is dictated
by the character and volume of bone required to correct or enhance the host site, as well as the
location of the donor site and the method of harvesting. Small amounts of cancellous bone are
best harvested from osteotomy twist drill shavings or sterile suction slur filtration products. [7][8]
Greater amounts of cancellous bone are easily harvested distal to the last maxillary molar, and
from the tuberosity.[9] Should cortical bone also be desired, the ascending ramus and symphysis
of the mandible can contribute what is required. Larger amounts of autogenous bone are
commonly taken from the iliac crest, ribs, and certain long bones. [10] Substantial cortical grafts can
be harvested from the occipital area of the cranium.
The consistency of the harvested autogenous grafting material is variable. It may be a viscous
slur, or a plastic mass of cancellous bone, often in combination with cortical bone. It can also take
the form of essentially cortical blocks, which can be harvested in different volumes and shapes
and carved to nest within or against a host site as accurately as possible.
Harvested autogenous material is best used fresh and as quickly as possible. It may also be
frozen or stored in isotonic saline for future use. Because cells lyse, autogenous material should
not be stored soaked in blood.[11]

Allogenic.
The consistency of allogenic grafting material required for a specific treatment depends on first
determining the character and volume of bone required at the host site. If autogenous material is
used as the primary graft component, the requirements of the secondary allogenic components
change. If autogenous material is not employed, use of a combination of particulate sizes of the
allogenic component may be indicated. Thus, host site requirements and the use of other

augmentation components affect whether the allogenic bone should be cortical and/or cancellous,
its particulate size, and its configuration if a cortical and/or cancellous bone block is required.
Various allogenic materials of every type of bone, texture, and particulate size are available,
including bone blocks in a wide variety of shapes and volumes. In addition, each variation is
available in treated forms to further enhance effectiveness and safety.

Xenogenic.
The consistency of the xenogenic grafting material required for a specific treatment generally
depends on the same considerations as when using materials of allogenic sources. Xenogenic
materials are usually harvested from treated bovine cadaver bone, and are supplied in a similar
array of variations useful for the many requirements of host sites. [12][13]

Alloplastic.
The consistency of alloplastic grafting materials depends on whether the case permits their use
alone, or requires their use in combination with autogenous and/or allogenic and/or xenogenic
materials. The character and volume of the host site, as well as the diagnostic reason for the
graft, help determine the type of alloplastic material required, its density, porosity, texture, and
particulate size or block shape and volume. Commonly used alloplastic materials are ceramics,
composites, polymers, hydroxy-apatites, calcium phosphates and carbonates, titanium oxides,
and bioactive glass granules.[5] Alloplastic materials are dense, porous, or microporous, and
sometimes have undergone treatments to enhance effectiveness and safety.

Barrier Membranes.
Barrier membrane materials may be natural, such as the dura protecting the brain or tendons
harvested from human or bovine cadavers, or synthetic, such as expanded or high-density
polytetrafluorethylene (PTFE).[14][15] Some are resorbable,[16][17] and others are not and therefore
must be surgically removed as part of the treatment protocol. Autogenous cortical plate is also
used as a barrier.

Physiology of Grafting Materials and the Host Site.

Several aspects of bone healing in general, and of bone healing following osteotomy preparation
and implant insertion in particular, both in the presence of and in the absence of micromovement,
are presented throughout this book. The host site provides all the elements necessary for healing.
Angiogenesis is the most important process that occurs at the host site. Led by sprouting, new
blood vessels extend throughout the healing area. Collagen and then bone follow their course.
Biomechanical, biochemical, and bioelectric signals, some cell-mediated and others ground
substancemediated, can help initiate or enhance bone formation. [18][19]
Certain grafting materials are bioinert in relation to the healing taking place around them. Others
are more or less bioactive, and can enhance healing. Bioactive natural graft materials can bring
their components to bear on healing, as can synthetically prepared components that have been
surface adsorbed. The intended effect on the host site is to promote the formation of host tissues
to envelop, encompass, and incorporate the graft mechanically and physiologically.
The host site healing process, and the influence of any grafting material(s) present, has given rise
to an extensive vocabulary. To select an appropriate grafting material on a case-by-case basis, it
is important to distinguish commonly used terms from one another and to understand their
significance.

A list of many of the physiologic considerations and processes that bear on the success of
grafting/augmentation is shown in Box 15-2 .
Box 15-2
PHYSIOLOGIC CONSIDERATIONS AND PROCESSES THAT INFLUENCE
GRAFTING/AUGMENTATION TREATMENT

Graft material, volume, and consistency

Presence of pluripotential stem cells
Osteogenesis
Osteoinduction
Osteostimulation
Osteoconduction
Bioactivity

Bone Graft.
A bone graft is a tissue or material used to repair a defect or deficiency. It adds bulk or volume to
existing bone to solve a diagnosed problem.

Pluripotential Cells.
A pluripotential cell can differentiate into a fibroblast, osteoblast, osteoclast, or erythro-blast.
Only the physiologically functioning osteoblast produces bone, and this is the primary
consideration in bone grafting procedures. The sources of osteoblast-producing cells at the host
site are the blood supply, in which they circulate freely; the inner layer of the periosteum; and the
endothelial lining of marrow spaces within cancellous bone. [20]

Osteogenesis.
Osteogenesis is the development and formation of bone. The only entity that is osteogenic is a
physiologically functioning osteoblast. Osteoblasts exist at the host site and in autogenous graft
material, and can differentiate from pluripotential cells from all sources.

Osteoinduction.
Osteoinduction is the induction of bone formation in the absence of a bony host site. For instance,
certain bone morphogenic proteins (BMPs) refined from treated cortical bone have induced the
formation of bone when placed in muscle or liver tissues. [21][22] The probable source of required
osteoblasts to form bone in such locations is differentiation of pluripotential stem cells freely
circulating in the blood supply. In a series of events not yet completely understood, BMPs signal
stem cells to differentiate into osteoblasts to produce bone. [23][24][25]

Osteostimulation.
Osteostimulation is a physiologic action that stimulates, enhances, or accelerates the formation of
bone at a host site or healing endosteal implant. Osteostimulation is a far broader term than
osteoinduction, in that every osteoinductive material is osteostimulatory but not every
osteostimulatory material is osteoinductive. Cellular and ground substancemediated signals of
biomechanical, biochemical, and bioelectric origin are osteostimulatory. The regional

acceleratory phenomenon (RAP) is a biochemical response to a physical injury that promotes

bone healing, and is also considered osteostimulatory.[26][27] Fifteen residue peptide (P-15), a
synthetic peptide irreversibly bound to anorganic bovine mineral (ABM) (PepGen, CeraMed
Dental), promotes the migration of reparative cells from surrounding material, and is therefore
also considered osteostimulatory. This substance is supplied in particulate sizes of 250 to 420
m. BMPs and recombinant bone morphogenic protein (rhBMP-2) are also considered
osteostimulatory, as is platelet-rich plasma (PRP).
The physiologic processes that promote homeostasis and, of particular importance in implant
dentistry, that maintain existing or grafted bone volume for tissue integration are known. Both
hypofunction and hyperfunction of bone lead to resorption, and the functional limits between them
are termed the physiologic limits of health.[28] In a sense, bone maintenance is always the goal of
any treatment of bone. This goal directly bears on the concept of case engineering in implant
dentistry, wherein overengineering can lead to hypofunction and bone atrophy, and
underengineering can lead to hyperfunction and bone resorption.

Osteoconduction.
Osteoconduction is the process by which a synthetic and inorganic material provides a bioinert
scaffolding that conducts and is compatible with bone growth. Osteoconductive materials do not
necessarily enhance bone formation, nor do they inhibit it. Rather, they guide the path and
progress of its formation. In general, alloplastic graft materials are osteoconductive. Some are
also osteostimulatory. It is interesting to note that healing around dental implants that exhibit
areas of direct bone apposition at the light microscopic level is an essentially osteoconductive
process.[8]

Bioactivity.
In bone augmentation, the term bioactive is similar to the term osteostimulatory. Consider the
enhanced bone growth observed in response to the wetting of particulate Bioglass with body
fluids. Because this material is inorganic, the nature of the signals it sends to enhance bone
growth is not clear, although it is hypothesized that particulate Bioglass may affect covalent bonds
and alter van der Waals forces, as suggested for AW (alumina/woolsonite) Glass.[29][30]
A nonreactive material that sends no ionic signals is referred to as bioinert.

Freeze-Dried Bone Allograft and Demineralized Freeze-Dried Bone Allograft.

Freeze-dried bone allograft (FDBA) and demineralized freeze-dried bone allograft (DFDBA)
can eliminate the need for a donor site. They are available in various particulate sizes, and as
cortical or cancellous bone blocks of almost any shape and volume. Human cadaver allogenic
material may be irradiated to reduce the immune reaction. Desiccation also reduces
antigenicity. In the preparation of FDBA, calcium (Ca) and phosphate (PO 4) salts are retained to
support the organic and inorganic matrices. The organic portion contains the BMPs found in
cortical bone. The inorganic portion serves as a mineral source of scaffolding for bone formation.
FDBA is essentially osteoconductive, because the osteostimulatory BMPs are released too slowly
and in quantities too minute to be effective. [6]
DFDBA is created by removing the Ca and PO4 salts to take better advantage of BMP for its
osteostimulatory properties. Irradiation or the use of ethylene oxide (EO) for sterilization may be
counterproductive because this may render the allograft unable to stimulate bone formation.
DFDBA has a probability of 1 in 2.8 billion of transmitting infection with the human
immunodeficiency virus (HIV). No such cases have been reported in the literature. Because only

0.01mg of BMP is yielded per kilogram of treated human cadaver bone, the synthesis of P-15 [31]
irreversibly bound to ABM (PepGen, CeraMed Dental) in sufficient concentrations to be effective
in the promotion of reparative cell migration from surrounding tissues represents a seminal
advance in grafting/augmentation materials.

Platelet-Rich Plasma.
Another emerging area is the use of platelet-rich plasma (PRP) as a grafting adjunct. This
autogenous material is sequestered from the patients blood and compacted by gradient density
centrifugation. The PRP thus collected is concentrated in excess of 300%. The beneficial
ingredients of the concentrate are a platelet-based growth factor and a beta transforming growth
factor. The addition of PRP to bone grafts increases the available amounts of these bone growth
factors, resulting in a substantial increase in the rate of healing. Histologic examination reveals
that these grafts exhibit greater bone density after healing. In-office systems are available to
ensure a dependable fresh supply of PRP to use in conjunction with a variety of implant dentistry
procedures.

CLINICAL CONSIDERATIONS THAT INFLUENCE SUCCESSFUL BONE

GRAFTING
Successful bone grafting in dentistry requires the presence of and proper relationships among
several factors to ensure success, as listed in Box 15-3 . Some of these factors may be naturally
present in a case, and others may not. A definitive diagnosis is therefore essential to determine
which required factors are present at the host site, and which must be added. The main factors
that contribute to success are an adequate local host blood supply; the absence of actual or
probable infection (an antiseptic host site); the ability to achieve dependable and secure
softtissue coverage; the nature, size, and shape of the host site; provision of adequate healing
time; ability to seed the graft with fresh autogenous bone; the use of treated allogenic and
xenogenic graft materials; the use of alloplasts as required; protection of extensive grafting during
healing; graft immobilization during healing[32]; availability of collagen inclusion during healing;
bone mineralization requirements during healing; and treatment of complications. Certain
systemic conditions and habits such as smoking may contraindicate a grafting/augmentation
procedure.[33]
Box 15-3
CLINICAL CONSIDERATIONS THAT INFLUENCE GRAFTING/AUGMENTATION
TREATMENT

Soft-tissue coverage
Infection control at host site
Volume and configuration of defect
Use or absence of autogenous bone in graft
Protection of extensive grafting during healing
Adequate healing time
Graft immobilization
Host blood supply
Bone mineralization requirements

Soft-Tissue Coverage

Secure, dependable closure following grafting is essential to success. First, determine that soft
tissue is sufficient following grafting to allow for tension-free closure. In cases of extensive
grafting, carefully estimate the potential adequacy of soft tissue for closure before placing the
material. The most common postoperative complication of grafting is dehiscence at the suture
line.
If insufficient tissue is present when the soft-tissue flaps are coapted, reflect tissue a bit more
extensively, and/or carefully score the periosteal lining of the inner portion of the flap with relief
incisions, and by applying tension, expand the soft tissue. Preserve as much attached gingiva as
possible. The second important element of dependable soft-tissue closure is adequate suturing.
Try to avoid friable tissue while suturing, and when possible penetrate through tough, dense,
attached gingiva, taking a deep bite with the needle. Generally, 3-0 black silk interrupted sutures
are placed with atraumatic needles. For friable tissue, 4-0 sutures are used. Tension-free suturing
is required to avoid tearing tissue. No particulate grafting material should remain in the suture
line. If a removable prosthesis is to be replaced provisionally following grafting, relieve the tissue
surface over the grafted area.

Aseptic Host Site/Infection Control

Infection lowers pH, and among other complications causes accelerated resorption of some
grafting particulates. Do not graft in the presence of probable or actual infection. Even the
resident bacterial population of the oral cavity can contaminate a graft. Grafting materials may be
mixed with antibiotics such as parenteral penicillin or clindamycin. Tetracycline, commonly used in
periodontal grafting related to collagen regeneration, is not advised for bone augmentation,
because it chelates calcium and retards bone formation.

Volume and Configuration of the Defect

Think of a potential grafting host site as though it were a lidded box. Six walls surround a void.
This void is the augmentation host site. If the lid is removed, a five-wall configuration results. As
walls are removed, the procedure becomes more challenging, until one is faced with the
demanding treatment required for a one-wall host site requiring an onlay graft.
Consider treatment of an extraction site in which the residual socket has five walls. With no
infection present; an adequate amount of acceptable soft tissue for secure, dependable, strainfree closure; and an ideal host blood supply, the site is perfect for grafting. In this hypothetical
case, several of the aforementioned prerequisites for successful grafting are in place, such as
absence of infection, the ability to perform secure tension-free closure, ideal configuration and
volume of the defect, and adequate host blood supply from both hard and soft tissues. Because
hydroxyapatite is the principal inorganic component of bone and teeth, it is a logical choice for
grafting fresh extraction sockets. Grafting a four- or five-wall defect with resorbable
hydroxyapatite maintains the ridge anatomy and reduces the negative effects of residual ridge
resorption on the final prostheses.
A synthetic, resorbable hydroxyapatite (OsteoGraf/ LD-300, CeraMed Dental, Lakewood,
Colorado) will resorb through solution mediation.[34] This dissolution process releases calcium and
phosphorous, and provides a scaffold for initial bony proliferation. The particulate supplied is
pure, with a consistent particle size range of 250 to 420 m. Because of its bulk, it also acts as a
barrier to inhibit soft-tissue ingrowth.
Tooth removal should be performed as atraumatically as possible. Preservation of the
bucco/labio-lingual width of the arch aids in esthetic reconstruction. After the tooth has been
removed, thorough curettage of the socket walls is essential. The formation of new bone in a four-

or five-wall defect, such as an extraction socket, occurs by adhesion to existing bone. Irrigation
and aspiration complete the preparation of the socket to accept the graft material.
Placement of the hydrated grafting material is accomplished in approximately 5-mm increments to
ensure uniform density. Each layer is applied into the socket firmly but remains loose enough to
permit blood supply throughout the area. The close approximation of the grafting material to the
fresh bony socket wall optimizes the osteostimulatory potential of the site.
Primary closure over extraction sites usually is difficult. Epithelium proliferates from the margins
of the wound at a rate of approximately 0.5 mm per day, to help seal over the socket to complete
the coverage and retain the graft material. Healing immediately following the extraction and
grafting must be protected. If tissue available for closure seems inadequate, a containment
device is needed. A surface-acting hemostatic material such as Gelfoam protects closure, slows
the flow of blood, and offers a framework for the deposition of cellular elements. This is an
inexpensive way to achieve containment of the graft material.
Preservation of ridge height and width is the benefit of this procedure. This is an ideal way to
introduce bone grafting into a clinical practice.
Clinically, few cases ideal for grafting immediately following tooth extraction exist. More often,
teeth are removed precisely because of inflammation and infection. Also, tissue closure over a
fresh extraction site often creates excessive tension at the closure line, or is not possible at all.
For these reasons, approximately 4 weeks of healing should be allowed after tooth removal
before grafting is performed. This time period resolves any present infection and allows adequate
soft tissue for dependable, secure closure to mature and keratinize. Dependable, secure, tensionfree suturing is possible, and success is more predictable. The disadvantages of this delay are
the need for extended treatment time and an additional surgical intervention.
The socket can heal without grafting, but with the loss of ridge height and width. Five-wall and
four-wall sockets or defects of other etiology require only small amounts of autogenous, allogenic,
xenogenic, and/or alloplastic grafting particulate. Following grafting, allow 5 to 6 months of
healing before inserting a dental implant. An exception is when an implant inserted into a new
extraction site fits imprecisely into its extraction site/implant osteotomy.[6]

Autogenous Bone
An important component of predictable bone grafting, autogenous bone is the only material that
forms bone with the aid of transplanted osteoblasts generally sourced from cancellous bone. This
cancellous bone provides few BMPs, if any.[8] Osteoconductive human cadaver bone products are
not viable. If autogenous bone is used, a minimal time between harvesting and grafting is advised
to retain as much cell viability as possible. In all instances in which autogenous bone is used, it is
placed directly against or into the host site.[11]

Protection of Extensive Grafting During Healing

As the number of walls at the host site decreases, the need for an artificial means of retaining
grafted particulate in the host site increases. Grafting against one- or two-wall sites requires that
no functional forces be applied to the site, because compression of the graft may alter volume
and configuration and may cause mobility. Thus, if a removable denture is used, it must be
relieved generously over and around the graft. Tent screws, barrier membranes, and sometimes
autogenous, allogenic, or xenogenic bone blocks can be used for this purpose. [11] These
represent intermediate and advanced bone grafting cases.

Adequate Healing Time

Required healing time varies case by case. If in doubt, opt for additional healing time. Variation in
required healing time is related to graft volume, configuration, and host site location, and whether
or not autogenous bone is used. Generally, grafts up to 5 to 6 mm 2 require up to 6 months to
heal, while larger grafts require up to 10 months.

Graft Immobilization
If one incorporates the graft within the anatomy of the host site, mobility may be absent. [35]
Movement reduces the value of the host blood supply, and may promote fibrous encapsulation
and sequestration of the graft. In cases of larger grafts with fewer bony host site walls, screw
fixation can promote immobilization during healing. Again, provisional dentures, if used, are
relieved over all grafts.

Host Blood Supply

Host blood vessels invade the graft to supply cells and nutrients. Vascularization may extend from
the rich vascular network in the cancellous bone, cortical bone (which should be liberally
fenestrated, and occasionally removed to accelerate angiogenesis), and nearby soft tissues of
the host site. In addition, pluripotential cells of the inner layer of the periosteum and the
endothelial lining of host marrow spaces are stimulated by grafting procedures, and contribute to
the rate and quality of bone healing.

Bone Mineralization Requirements During the Healing Process

Role of Collagen.
At the time of the earliest woven bone formation, type I collagen is synthesized by the body and
incorporated into the healing process.[36] An additional source of collagen can be DFDBA,
although this material is rarely used alone. Certain xenogenic grafts (ABM) that are irreversibly
bound with a synthetic P-15 help fulfill collagen requirements. [31]

Role of Calcium and Phosphate Salts.

Calcium and phosphate salts are required for the mineralization of healing bone and grafts. They
are derived from the host site blood supply and nearby host bone, with contributions from
autogenous and allogenic particulate. Alloplasts of Ca and PO 4 and xenografts are also a source
of calcium and phosphate salts. They may be used to occupy space and thus prevent ingrowth of
fibrous tissue into areas in which bone is desired. In this sense, alloplasts can serve as barriers in
a combination of grafting materials.[37][38]

GRAFTING COMPLICATIONS
Complications are well documented and variable because of differences in host site location,
volume, configuration, and physiologic and functional deficiencies that, when diagnosed, led to
the need for grafting. Improper diagnosis, treatment planning, grafting materials selection, and/or
case sequencing can all cause complications. In addition, poor soft-tissue management, the
immediate placement or placement of too many implants into a graft at the time of surgery in
certain cases, inadequate planning at the time of grafting to provide for proper esthetics, the
presence of undetected sinus or periapical pathology at the time of grafting, periodontal disease,
and certain adverse systemic and local conditions can compromise soft-tissue and/or bone
healing following grafting.

Biomechanically, a graft may be unable to function within physiologic limits of health if, for
example, too many or too few implants are placed into an autogenous graft. However, the greater
the number of implants placed at the time of grafting, the more one risks improper placement,
host bone fracture, or block graft cracking or fracture. Failure to institute progressive and careful
bone loading of large autogenous grafts can lead to complications.
Common postoperative complications are wound dehiscence, pain, and sinusitis. Poor flap
design can compromise blood supply. For reasons not fully understood, poor soft-tissue
management over autogenous grafts can lead to significant complications, to the extent that in
most cases it is advised that implants only be inserted into autogenous grafts following healing.
Autogenous soft-tissue grafts and gingivoplasty are often required for graft patients. Grafts are
best stabilized with fixation screws, not with implants. Stabilization wiring techniques are not as
predictable as fixation screws.

TREATMENT OF ENTRY-LEVEL GRAFTING CASES

Considerations Common to Entry-Level Cases
Entry-level grafting procedures have many of the following considerations in common. Sufficient
soft tissue for secure, dependable closure of the graft site is present, or can be provided easily.
The site is free of infection. The volume of the host site defect is minimal, to the extent that bone
blocks are not required. Particulate material is used, which can easily graft irregularities of any
configuration. Entry-level cases have four or five osseous walls to support the grafting material,
except for minor perforation during osteotomy preparation for an endosteal implant. The small
amount of autogenous bone used, if any, is harvested from the host site as part of the curettage
process for creating an ample fresh vascular bed. The problem of inadequate host site vascularity
at the site of an osteotomy perforation resulting in a one-wall defect in cortical bone is solved by
decorticating the area, or piercing the host site liberally through cortical bone and into cancellous
bone, to produce a vascular bed and viable bone cells. Entry-level grafts need little protection
because their exposed areas are small and may be encased in four or five host site walls. Barrier
membranes are not required.

Examples of Entry-Level Grafting Cases

Grafting into new or recent extraction sites, to cover exposed threads or interface of a dental
implant at the ridge crest, to cover the recessed shoulder of an inserted plate/blade form, to seal
a perforation below the ridge crest during osteotomy preparation, to even areas of an exposed
ridge crest that harbored a retained root or residual granulation tissue, to fill small areas around
dental implants seated into immediate extraction sockets, and to supplement areas around dental
implants seated into expanded ridges following the use of osteotomes are all considered entrylevel grafting cases.

Selection of Grafting Material

Because of the grafts minimal size and the ample blood supply at the curetted or fenestrated bed
of the host site, autogenous bone need not be harvested. Allogenic grafts are generally used for
entry-level cases; sometimes, xenogenic grafts are used. Alloplasts, which are most effective in
providing scaffolding and bulk for large treatment areas, are used less often in entry-level cases,
in which the size of the treatment area is usually small. P-15 (PepGen, CeraMed Dental) can
provide a biomimetic environment for bone regeneration, and PRP can also be an efficacious
grafting adjunct.

Grafting Procedure for Entry-Level Cases

Following tissue reflection, the host site is exposed. The host site is curetted or fenestrated to
create an ample vascular bed seeded with viable cells. The chosen graft material is inserted or
carefully applied against the host site. Soft-tissue flaps are coapted and securely sutured. No
grafting material remains within the suture line. Sutures are removed 10 to 14 days
postoperatively. Ample time for healing is allowed. The pre- and postoperative considerations
common to the mainstream applications of the abutment-providing modalities, such as protection
from excessive load and maintenance of proper diet and hygiene, also apply for entry-level
grafting procedures. The details of this procedure were discussed previously in the section on
volume and configuration of the defect

ALVEOLAR RIDGE EXPANSION

In implant dentistry, the object of bone enhancement is to increase the volume and improve the
contours of available bone to enable implant insertion into areas that can sustain long-term
function. In the case of endosteal implants, and particularly in the case of root forms, the
dimensions of the implant may preclude insertion into residual alveolar ridges with insufficient
bucco/labio-lingual width. To mitigate the need for the use of bone block grafts to increase ridge
width, because of the technique-sensitivity and more guarded prognosis of such treatment, the
concept of ridge expansion evolved. Through the serial use of graduated chisel-like, cylindrical, or
tapered cylindrical osteotomes, thin ridges can be slowly expanded to increase their width. [39]

Clinical Considerations
The most common anatomic area in which ridge expansion is performed is the anterior maxilla,
followed by the posterior maxilla, and then the anterior and posterior mandible. As discussed in
Chapter 3 , the residual alveolar ridge in the maxilla is variable, and has a much higher
percentage of cancellous bone than in the mandible. Cancellous bone is pliable, and when
treated carefully, can be slowly expanded. In the case of the tapered Innova Endopore implants, a
series of graduated tapered osteotomes are available for this purpose. If exposure of the ridge
reveals inadequate width, a primary penetration is made at the crest in the planned long axis of
implant insertion with a 1-mm diameter XL carbide bur in a high-speed contra angle with copious
coolant. After penetrating 5 to 7 mm, the bur is moved mesially and distally no more than 2 mm. A
small, tapered cylindrical osteotome is introduced, aligned axially in the direction of intended
implant insertion, and tapped apically with a mallet to the correct depth for the chosen implant.
The assistant supports the ridge crest with finger pressure applied from both the labial and lingual
during malleting. A second osteotome is introduced and malleted to the appropriate depth, and
then a third graduated osteotome if required, to finally coordinate with the diameter and depth of
the selected implant. Seated round osteotomes are removed by rotating them only clockwise to
loosen their hold. Rotating both clockwise and counterclockwise can overexpand the site. The
coordinated trial fit gauge is malleted to position and twisted clockwise for removal, and the
implant is inserted. Crestal voids at the mesial and distal of the implant, if present, are grafted.
The case is sutured.
The parallel-sided Nobel Biocare/Steri-Oss RHL Immediate Insertion Implants use coordinated,
graduated, parallel-sided osteotomes in a manner similar to that described for the Innova
Endopore implants.
The Oratronics plate/blade form implants use graduated, tapered chisels inserted into preliminary
osteotomies and malleted to the desired depth to expand the ridge slowly. These are removed
through mesial and distal tilting only.

In many ridge expansion cases, implants are not immediately inserted. Rather, slow-resorbing
hydroxyapatite or another grafting material may be used to graft the internal void within the
expanded ridge. For example, ABM (OseoGraf/N-Block, CeraMed Dental) in block form can be
contoured for insertion into an expanded ridge. This type of graft benefits from excellent
protection, stability, and host blood supply. The grafted site is sufficiently rigid to maintain the
desired architecture and reduce the risk of ridge relapse during healing. The graft remodels to
vital bone through a cell-mediated resorption mechanism. After healing for 6 months, the
expanded and grafted ridge is exposed to prepare the osteotomies for implant insertion. Dense,
nonresorbable ceramic alloplastic grafting material is not used in such cases because it is difficult
to penetrate for osteotomy preparation.
Dental implant insertion in an expanded and grafted ridge is considered an intermediate or
advanced procedure.

NERVE REPOSITIONING
Cases that require nerve repositioning are rare. In implant dentistry, nerve repositioning is
performed to increase the volume of available bone for the insertion of endosteal implants, or in
the case of subperiosteal implants, to permit a superior framework design.

Clinical Indications
Nerve repositioning treatment is usually performed in the mandible. Rarely, to enable deeper
seating of an endosteal implant in an advanced case, an osteotomy is planned to pass either
lingual or buccal to the inferior alveolar nerve. In such cases, the nerve is approached from the
buccal and carefully repositioned either lingually or as close to the buccal as possible. This
creates a zone of safety either to the buccal or lingual of the repositioned nerve for the
preparation of one or more osteotomies.
In subperiosteal implantology, a mental nerve that exits the mental foramen at or near the crest of
the ridge can compromise the location and strength of the buccal main bearing struts designed to
clear the nerve at implant seating. To correct this, the position of the mental foramen can be
surgically lowered by judicious removal of bone, and the mental nerve repositioned apically as it
exits the altered area.
Other clinical conditions may indicate treatment requiring nerve repositioning. These procedures
are generally considered to be at the advanced level of practice.

DISTRACTION OSTEOGENESIS
A treatment that is currently gaining acceptance to enable predictable extension or lengthening of
bone is distraction osteogenesis.[40][41] In implant dentistry, this technique has direct applications
for patients with micrognathia and associated occlusal disharmony. As part of the preinsertion
regimen in implant dentistry, correction of an unfavorable occlusal relationship is accomplished
first to improve the prognosis of implant-supported prostheses. In addition, the esthetic
improvement can be striking.

Clinical Considerations
Distraction osteogenesis is a process by which bone is gradually lengthened by the action of an
appliance following the creation of a sectioning osteotomy at the anatomic area at which
additional bone is desired. Historically, in repositioning the mandible, such appliances have been

placed with an extraoral mechanism to control the rate of separationdistractionof the

surgically separated portions of bone. Bone continuity is reestablished as new bone forms across
the created segmental defect.[42]
Some root form systems are designed to take advantage of the benefits of distraction
osteogenesis to increase alveolar ridge crestal height and/or width during the healing stage. [43]
Long-term evaluation is required for proof of the predictability, safety, and efficacy of such
systems.
The current state-of-the-art technology for distraction osteogenesis is represented by the Innova
Bi-directional Telescopic Mandibular Distractor. This boneborne device is placed transorally
directly against the lateral border of the mandible, distal to the mental foramen, and inferior to the
inferior alveolar canal ( Figs. 15-1 , 152 , 153 ). This placement precludes paresthesias, and
avoids the percutaneous screw and pin tract scars and supplemental bone augmentation
associated with extraoral fixation. The appliance remains submerged in the mucosa, and after
installation and a 7-day period of quiescence, transoral appliance activation lengthens and
positions the mandible in two planes for optimal control. Distraction takes place at the rate of 1
mm per day, until desired correction is achieved ( Fig. 15-4 ). Following correction, the
submerged devices are left in place for 2 to 3 months to allow consolidation of the new bone, and
then removed ( Fig. 15-5 ).
Figure 15-1 Predistraction radiograph (lateral view). (Courtesy David Walker, Toronto, Canada.)

Figure 15-1 Predistraction radiograph (lateral view). (Courtesy David Walker,

Toronto, Canada.

Figure 15-2 Distractors in position preactivation (lateral view). (Courtesy David Walker, Toronto,
Canada.)

Figure 15-2 Distractors in position preactivation (lateral view). (Courtesy David

Walker, Toronto, Canada.)

Figure 15-3 Distractors in position preactivation (inferior view). (Courtesy David

Walker, Toronto, Canada.)

Figure 15-4 Distractors in position postdistraction (inferior view). (Courtesy David Walker, Toronto,
Canada.)

Figure 15-4 Distractors in position postdistraction (inferior view). (Courtesy David

Walker, Toronto, Canada.)

Figure 15-5 Two months healing after distractor removal (lateral view). (Courtesy David Walker,
Toronto, Canada.)

Figure 15-5 Two months healing after distractor removal (lateral view). (Courtesy
David Walker, Toronto, Canada.)

Distraction osteogenesis procedures are considered to be at the advanced level of treatment

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Dental System, 1999 (brochure).