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Ridge augmentation in implant dentistry

Manoj Goyal, Neeti Mittal, Gopal Krishan Gupta, Mayank Singhal
Department of Oral and Maxillofacial Surgery, Santosh Dental College and Hospital, Ghaziabad, Uttar Pradesh, India

ABSTRACT
Access this article online
Dimensional changes in the alveolar ridge after extraction often compromises on achieving optimal Website: www.jicdro.org
implant stability and placement of implants in the right prosthodontic positions. These situations demand DOI: 10.4103/2231-0754.172939
augmentation of the residual ridge to achieve successful implant placement and long-term survival. Although Quick Response Code:
the available literature speaks of an overabundance of techniques and agents for ridge augmentation,
there is a relative paucity of quality evidence to guide the selection of suitable techniques and material.
Henceforth, this paper is an endeavor to develop and describe an evidence-based decision pathway for
the selection of suitable techniques for various clinical situations. Additionally, a descriptive overview of
various techniques and materials is presented.

Key words: Bone grafts, ridge augmentation, socket grafting, socket preservation

INTRODUCTION after extraction, efficacy of ridge augmentation, comparative

The fast pace of soaring popularity of implants in dentistry
by clinicians and patients alike is substantiated by the
existence of a booming share of implants in the global
dental market, i.e., worth approximately US$7 billion
with a perceived annual growth rate of 9%.[1] This existent
profitability of implants is incumbent on high success rates
of approximately 95% for placing prosthesis in completely
as well as partially edentulous jaws.[2] However, the local
conditions may not always be favorable for implant placement
as in cases of deficient bone volume after extraction. The
sufficient horizontal as well as vertical bone dimensions are a
prerequisite to warranty the success of implants.[3,4] But the
fact that the maintenance of the alveolar bone is dependent
on the presence of teeth explains the high prevalence of
paucity of sufficient bone after extraction.[5,6] Hence, often
there is the need to augment the available atrophic bone
to make it amenable to implant placement in suitable
prosthetic positions with desirable stability and aesthetics.
To feed this need for augmentation, a plethora of agents
and techniques are available with volumes of literature; yet
there is an absence of consensus for the efficacy of any of
these surgical techniques.[7-9] The present paper will attempt
to summarize the evidence on changes in the alveolar bone
efficacy of various techniques and graft materials, and short
implants versus ridge augmentation. Further, this paper will
give a descriptive insight into various bone graft materials,
techniques, and physiologies of regeneration. Also, an
algorithm to guide the selection of suitable techniques and
materials in commonly presented clinical conditions would
be presented.
POSTEXTRACTION DIMENSIONAL CHANGES IN
RIDGE MORPHOLOGY
As the quantity and quality of the bone is a key determinant
for success of implant prosthesis, it is imperative that the
clinician be aware of postextraction dimensional changes
in ridge/socket morphology. The presence of the tooth and
physiological stimulation is a prime factor for maintenance of
the alveolar bone and thus, following extraction of the tooth
rapid resorptive changes take place.[5,6] A recent systematic
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Address for correspondence:

Dr. Manoj Goyal, Santosh Dental College and Hospital,
No. 1 Santosh Nagar, Pratap Vihar, Ghaziabad, Uttar Pradesh, India. Cite this article as: Goyal M, Mittal N, Gupta GK, Singhal M. Ridge
E-mail: drmanojgoyal@rediffmail.com augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112.

S94 © 2015 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow
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Goyal, et al.: Hard tissue augmentation
review summarized that dimensional changes are rapid in the
first 2-3 months after extraction and thereafter resorption is
gradual. It was reported that horizontal bone loss (3.79 ±
0.23 mm; 29-63%) was more extensive than vertical bone loss
(1.24 ± 0.11 mm on buccal, 0.84 ± 0.62 mm on mesial, and
0.80 ± 0.71 mm on distal sites; 11-22%).[6] However, the extent
of bone loss is affected by multiple factors,[6] i.e., elevation
of flap (full-thickness, split thickness, or none)[1,10] systemic
health status (e.g., diabetes), lifestyle (e.g., smoking), number
of roots ,and preextraction dimensions of alveolar bone,
etc.[6,10-15] Vertical bone loss is dependent on the phenotype
of the buccal bone wall; it is greater and extensive in amount
in thin-walled phenotypes than in thick-walled phenotypes. In
fact, it has been reported to be 3.5 times more severe when
facial wall thickness is <1 mm[1]
EVIDENCE ON RIDGE/SOCKET PRESERVATION
The data presented in this section is an overview of the
recently published systematic reviews and meta-analyses
investigating the outcomes of various techniques as well as
materials for ridge/socket augmentation [Table 1]. Although
definitive outcomes for clinical guidance could not be
extracted from the published literature primarily owing
to heterogeneity, a few conclusions yet noteworthy. The
heterogeneity existed mainly owing to variable research
methods (randomized controlled trials, case series, and/or
retrospective records), heterogeneous outcomes of interest
as well as poorly defined outcomes and short follow-up
periods, etc.
Rationale of ridge augmentation
It can be safely concluded that ridge/socket augmentation is
an efficient procedure for augmenting atrophic/deficient bone.
Statistically significant alveolar volume gains in preserved/
augmented versus nonpreserved sites have been reported,
i.e., +1.89 mm in terms of buccolingual width, +2.07 mm
for midbuccal height, +1.18 mm for midlingual height, +0.48
mm for mesial height, and +0.24 mm for distal height[16] Even
greater alveolar bone volume gain has been reported with
use of Ti-mesh as barrier in combination with autogenous/
allogenic/xenogenic bone grafts, i.e., ≈4.91 mm of vertical
regeneration and ≈4.36 mm of horizontal regeneration.[17] On
the other hand, it is quite interesting as well as contrasting
to note that similar rates of implant success and survival have
been reported for implant placement in augmented versus
naive bone.[18] This seriously questions the rationale of ridge
augmentation. Also, the existing literature points toward the
need for simultaneous augmentation at the time of implant
placement.[7,17] So, instead of routine use, socket grafting
procedures should be performed when there is a possibility
of extended treatment time between extraction and implant
placement. Also, it has been recommended that socket
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
grafting should be performed in aesthetic areas in case of
buccal bone thickness ≤2 mm or when there is a proximity to
anatomic structures, i.e., maxillary sinus or mandibular canal.[7]
Comparative evaluation of types of bone grafts
Although theoretical assumptions state that autogenous
bone grafts are superior to other bone substitute materials,
the literature fails to substantiate this fact.[20-23] The recent
systematic reviews reported no superior clinical outcomes
with autogenous bone graft over other bone substitute
material for routine augmentation, guided bone regeneration
(GBR), or maxillary sinus floor augmentation[20-23]
Comparative evaluation of various techniques of ridge
augmentation
There is no clear evidence supporting any of the specific
techniques but GBR. [24-26] GBR has been shown to be a
predictable technique, especially when Ti-mesh is employed
for horizontal as well as vertical augmentation [mean implant
survival rate (MISR) of 100%].[18] Milinkovic and Cordaro
(2014)[25] extracted data from 53 publications for partially
edentulous patients and 15 publications for edentulous
patients. Although owing to heterogeneity of included studies,
no clear-cut indications could be extracted for specific bone
augmentation procedures, a few suggestions could be drafted
on the basis of magnitude of the mean implant survival rate.
The evidence suggested that dehiscence and fenestrations
can be treated successfully with GBR at the time of implant
placement [MISR 92.2%, mean complication rate (MCR)
4.99%]. In partially edentulous ridges, when a horizontal
defect is present, procedures such as staged GBR (MISR 100%,
MCR 11.9%), bone block grafts (MISR 98.4%, MCR 6.3%), and
ridge expansion/splitting (MISR 97.4%, MCR 6.8%) have been
proved to be effective. Vertical defects can be treated with
simultaneous and staged GBR (MISR 98.9%, MCR 13.1% and
MISR 100%, MCR 6.95%, respectively), bone block grafts (MISR
96.3%, MCR 8.1%), and distraction osteogenesis (MISR 98.2%,
MCR 22.4%). In edentulous patients, there is evidence that
bone block grafts can be used (MISR 87.75%), and that Le Fort
I osteotomies can be applied (MISR 87.9%) but are associated
with a high complication rate. Further, the addition of platelet-
rich plasma (PRP) has been reported to confer no additional
benefit on either bone volume gain or implant survival.[20,27]
Short implants in nonaugmented sites versus long
implants in vertically augmented sites
Esposito et al. (2010)[26] performed a meta-analysis to compare
if vertical augmentation procedures were more advantageous
that short implants. The analysis revealed that vertical
augmentation procedures resulted in [odds ratio (OR) = 5.74]
and more statistically significant complications (OR = 4.9).
Thus, if possible short implants seem to be a better alternative
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 Table 1: Evidence from recent systematic reviews
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Author; year Research question/objective
Klijn et al., Comparative evaluation of
2010[30] histomorphometric outcomes of
different types of autogenous
implants and sites in the maxillary
sinus floor augmentation
Esposito Determination of need of
et al., augmentation of the maxillary
2010[20] sinus techniques and
comparative evaluation of the
efficacy on implant success
Arora et al., Whether PRP with bone and bone
2010[27] substitutes leads to more rapid
and effective bone regeneration in
sinus augmentation procedures
Esposito Finding the most effective
et al., technique for horizontal and
2010[26] vertical bone augmentation
Waasdorp Evaluation of the clinical
and effectiveness and predictability
Reynolds, of allogeneic bone blocks for
201[31] the correction of alveolar ridge
deformities to support dental
implant placement in humans
Del Fabbro Evaluation of the implant survival
et al., 20[32] rate after osteotome-mediated
maxillary sinus augmentation with
or without using grafting materials
Vignoletti Evaluation of efficacy of
et al., techniques on alveolar ridge
2012[21] preservation (ARP) after
extraction and success of
implants
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
Included reports
25 papers were included: 21
prospective controlled studies,
2 randomized clinical trials,
1 pilot study, and 1 case series
Ten randomised controlled trials
out of 29 met the inclusion
criteria. One trial of 15 patients
evaluated the implants of 5 mm
long with 6 mm diameter as an
alternative to the sinus lift in
the bone with a residual height
of 4-6 mm. Nine trials with 235
patients compared the different
sinus lift techniques; of these 4
trials (114 patients) evaluated the
efficacy of PRP
RCTs with a follow-up period of
≥6 months
13 RCTs out of 18 potentially
eligible trials were suitable for
inclusion. Three RCTs dealt with
horizontal augmentation and 10
trials (218 patients) with vertical
augmentation
Nine reports: Two case
reports, six case series, and
one prospective, multicenter,
consecutive case series. No
randomized controlled clinical
trial was identified in the search
Prospective and retrospective
clinical studies with at least 20
patients
A total of 14 RCTs and
prospective cohort studies with
a follow-up period of ≥3 months.
Data from nine of these 14
studies could be grouped in the
meta-analyses
Significant findings
Use of intraoral bone grafts increases the total bone volume (TBV), with 11% for chin bone and 14%
for bone grafted from other intraoral sites
Particulation of the bone graft has a negative effect on the TBV. Surprisingly, no correlation
between TBV and the time of graft healing was found
Grafting from the iliac crest resulted in a significantly lower TBV compared with intraoral bone grafting
No statistically significant difference was observed in favor of platelet-rich plasma (PRP)
It is still unclear when sinus lift procedures are needed
5-mm short implants can be successfully loaded in the maxillary bone with a residual height of 4-6
mm but their long-term prognosis is unknown
Elevating the sinus lining in presence of 1-5 mm of residual bone height without the addition of a
bone graft may be sufficient to regenerate new bone to allow rehabilitation with implant-supported
prostheses
Bone substitutes might be successfully used as replacements for autogenous bone (AB)
If the residual alveolar bone height is 3-6 mm a crestal approach to lift the sinus lining to place
8 mm implants may lead to fewer complications than a lateral window approach, to place implants
at least 10 mm long
There is no evidence that PRP treatment improves the clinical outcome of sinus lift procedures
with AB or bone substitutes
No obvious positive effects of PRP on healing of bone graft material in maxillary sinus
augmentation procedures were noted, the handling of the particulate bone grafts was improved
Various techniques can augment bone horizontally and vertically but it is unclear which are the
most efficient
Horizontal augmentation techniques (three trials): No statistically significant difference was observed.
Comparison of various vertical bone augmentation techniques (eight trials): No statistically
significant differences were observed
More vertical bone gain could be obtained with osteodistraction than with inlay autogenous grafts,
and with bone substitutes rather than AB in guided bone regeneration
Short implants appear to be a better alternative to vertical bone grafting of resorbed mandibles
Goyal, et al.: Hard tissue augmentation
Complications, especially for vertical augmentation, are common
Insufficient evidence (only observational reports, no RCT) is available to establish treatment efficacy
relative to graft incorporation, alveolar ridge augmentation, and long-term dental implant survival
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Mean weighted cumulative implant survival at 1 year, 2 years, 3 years, and 5 years was estimated
as 98.12%, 97.40%, 96.75%, and 95.81%, respectively
No significant difference was found in relation to the use of grafting material or in relation to
implant length
The prognosis of sinus augmentation can be more favorable when the residual ridge is at least
5 mm high
The socket preservation therapies resulted in significantly less vertical and horizontal contraction of
the alveolar bone crest
A statistically significant difference favored the flapped subgroup in terms of bone width
No clear guidelines with regard to the type of biomaterial or surgical procedure could be drawn
(Continued)
 Table 1: (Continued)
Author; year Research question/objective
Clementini Evaluation of success rate of
et al., implants placed in the horizontal
2012[24] and vertical guided bone
regenerated areas using GBR
Horváth Evaluation of the effect of ARP
et al., compared to unassisted socket
2012[17] healing
Ricci et al., Assessment of the success rate
2013[19] of the titanium grids on survival
and success rates of implants
placed in the regenerated areas
Milinkovic Reporting evidence on
and indications for the various bone
Cordaro, augmentation procedures based
2014[25] on defect dimension and type
Avila-Ortiz Evaluation of the magnitude
et al., and efficacy of alveolar ridge
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2014[16] preservation
Al-Nawas Influence of bone substitute
and material (BSM) compared to
Schiegnitz, AB on treatment success in
2014[22] augmentation procedures of the
edentulous jaw was analyzed
Lee et al., To compare the rates of survival,
2014[29] success, and complications of
short implants to those of longer
implants in the posterior regions
Rasia-dal Evaluation of the efficacy of
Polo et al., titanium mesh as a barrier, in
2014[18] conjunction with horizontal and
vertical ridge reconstruction for
implant placement purposes
Carini et al., Intercomparison of Ti-Mesh GBR
2015[23] technique with different percentages
of bone grafts: AB alone; anorganic
bovine bone (ABB) alone; AB and
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ABB in ratio of 50:50 or 70:30
Included reports
Eight prospective and retrospective
studies, involving at least five
consecutively treated patients
Studies reporting only the survival
rate of implants and studies with
a post-loading follow up less than
6 months were excluded
Eight RCTs and six controlled
clinical trials (CCTs) were
identified
Six RCTs were selected
The search yielded 53
publications for partially
edentulous patients and 15
publications for edentulous
patients
52 studies in qualitative and 14
in quantitative synthesis were
included
Four RCTs were included. The
mean follow-up period was
2.1 years.
— A meta-analysis could not be performed due to the heterogeneity of the data. A mean success
— The use of autologous bone is associated with a height and width gain of bone, which are greater
Significant findings
The success rate of implants placed in GBR augmented ridges ranged 61.5-100%; all studies,
apart from three, reported a success rate higher than 90% (range: 90-100%). The data obtained
demonstrated that GBR is a predictable technique that allows the placement of implants in atrophic
areas
Statistically significantly smaller reduction in the ARP groups in five out of seven studies was reported
No superiority of one technique for ARP could be identified; however, in certain cases guided bone
regeneration (GBR) was the most effective
Statistically, significantly less augmentation at implant placement was needed in the ARP group in
three out of four studies
After extraction resorption of the AR might be limited but cannot be eliminated by ARP
Survival and success rates of implants placed in the areas treated with titanium grids were
comparable to those of the implants placed in native, nonregenerated bone and of implants placed
in the bone regenerated with resorbable and nonresorbable membranes
The dehiscence and fenestrations could be treated successfully with GBR at the time of implant placement
In partially edentulous ridges, when a horizontal defect is present, procedures such as staged GBR,
bone block grafts, and ridge expansion/splitting have proved to be effective
Vertical defects can be treated with simultaneous and staged GBR, bone block grafts, and
distraction osteogenesis
In edentulous patients, there is evidence that bone block grafts can be used and that Le Fort I
osteotomies can be applied but are associated with a high complication rate
Alveolar ridge preservation is effective in limiting physiologic ridge reduction as compared with
tooth extraction alone. Subgroup analyses revealed that flap elevation, the usage of a membrane,
and the application of a xenograft or an allograft are associated with superior outcomes,
particularly on midbuccal and midlingual height preservation
For maxillary sinus floor augmentation (MSFA), meta-analysis showed a trend toward a higher implant
survival when using BSM compared to AB; however, the difference was not statistically significant
Goyal, et al.: Hard tissue augmentation
No statistically significant difference in implant survival for MSFA was seen amongst ‘BSM+AB’ and
‘AB alone’.
Meta-analysis revealed no statistically significant difference in implant survival for ridge
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augmentation using BSM or AB
The implant survival seems to be independent of the biomaterial used in MSFA and alveolar ridge
augmentation
There were also no statistically significant difference in the success rates, failure rates, or complications
between short implant in nonaugmented sites versus long implants in augmented sites
Placement of short dental implants could be a predictable alternative to longer implants to reduce surgical
complications and patient morbidity in situations where vertical augmentation procedures are needed
rate of 89.9%, a mean survival rate of 100%, and a failure rate of 0% emerged from the data
evaluation. It could be deduced that titanium meshes represented a reliable solution for alveolar
ridge reconstruction
compared to other techniques, with a lower exposure of the mesh and a lower bone resorption
The use of heterologous graft leads to a lower bone earn and to percentage of resorption greater than
autologous graft but does not differ from the gain and resorption of the bone of AB/ABB in percentage
50:50 and 70:30
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Goyal, et al.: Hard tissue augmentation

to vertical augmentation for implant placement.[28,29]

Economical
PHYSIOLOGY OF BONE GRAFTS AND

−
REGENERATION

Morbidity
There are three basic mechanisms [8,9] by which bone

−
grafts augment recipient bone site, i.e., osteogenesis,
osteoinduction, and osteoconduction. In osteogenesis,
surviving residual cells in the bone graft differentiate into

Osseointegration
osteoblasts and stimulate the formation of new bone.
Osteoinduction is a process where the bone graft stimulates

Delayed

Delayed
Optimal

Optimal
the formation of new bone by virtue of bone growth factors

Fast

Fast
contained in it. In osteoconduction, the bone graft possesses

Need for GBR

neither the ability to regenerate bone nor stimulate the
recipient bone to form new bone. Here, the donor graft

+
merely acts as a scaffold for ingrowth of vascular and
connective tissues. Eventually, all transplanted grafts are
replaced by new bone.

Rigidity
+

+
TYPES OF BONE GRAFTS

accept grafts from animal origin

On the basis of origin, there are mainly four categories

Poor owing to unwillingness to

Poor owing to unwillingness to

Poor owing to unwillingness to

of bone grafts:[33] autografts, allografts, xenografts, and

Poor owing to donor site

Poor owing to donor site

alloplastic materials. All of these possess distinct as well as

accept cadaveric grafts

accept cadaveric grafts

overlapping advantages and disadvantages [Table 2].

Patient acceptance
Autografts
These refer to grafts transplanted from one place to other
morbidity

morbidity
within the same individual. These are referred to as the

Good
“gold standard” owing to the only graft types with all
three mechanisms of bone regeneration, i.e., osteogenesis,
Osteoinduction

osteoconduction, and osteoinduction as well.[30,33-35] These

can be harvested from neighboring intraoral sites [Figure 1]
+

−
or remote extraoral sites.[35] Usually, the intraoral sites, i.e.,
mandibular symphysis (chin), ramus, and tuberosity, etc., are
Osteoconduction

preferred over distant extraoral sites, i.e., anterior iliac crest,

Table 2: Comparative summary of different types of grafts

tibial plateau, and proximal ulna [Table 3]. This is mainly

+

owing to the ease of harvest and the low morbidity associated

Osteogenesis
+

−
Allogenic [demineralized freeze
dried bone allograft (DFDBA)]
Allogenic [freeze-dried bone
Autogenous (cancellous)
Autogenous (cortical)

allograft (FDBA)]

Xenograft

Alloplasts
Graft type

Figure 1: sources of intraoral grafts

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Goyal, et al.: Hard tissue augmentation

with intraoral grafts.[35] On the other hand, extraoral graft
may require a second surgery or even a second surgical team,
which often extrapolates to increased cost and management
in “in-patient settings.” Also, grafting from the extraoral
donor site is associated with greater risk of complications
and longer periods of postoperative management[35] [Table 3].
Autogenous grafts can be cortical, cancellous, or
corticocancellous.[8,35] The prime difference between cortical
and cancellous (particulate) bone grafts is with respect
to healing and the ability to be contoured and adapted
to the recipient site.[8,35] Cancellous grafts undergo rapid
incorporation (within weeks to months) and have greater
osteogenetic potential compared to cortical grafts.[8,35] On
the other hand, incorporation of cortical grafts is rather a
slower process known as creeping substitution where the
revascularization starts from periphery toward the center. In
fact, the remnant pieces of donor graft may persist as necrotic
areas walled off by new bone.[8] It is easier to achieve primary
stabilization with cortical grafts while cancellous grafts often
require to be contained within membranes or titanium mesh
due to the lack of rigidity.[8]
Harvesting autogenous grafts
Ramus graft
Local anesthesia
Mandibular nerve trunk anesthesia is supplemented with
local infiltration in the area of coronoid process, mental
foramen, and buccal part of the mandibular body reaching
toward the mandibular base.
Surgical technique [Figure 2]
The incision extends from the medial aspect of the external
oblique ridge to the first molar area. The concavity where
the external oblique ridge meets the ramus is the prime
landmark to facilitate locating the starting point of this
incision. A mucoperiosteal flap is reflected to visualize the
border between the external oblique ridge and ascending
ramus. The lateral border of the ramus and the external
oblique ridge is dissected free. The soft tissues are retracted
along the anterior border of the ramus till the insertion fibers
of the temporalis muscle are identified. The donor area is
identified and the borders of the osteotomy cuts are marked
by drilling holes through the cortex till the cancellous bone
is identified by marrow bleeding. The superior border of
osteotomy cut is made on external oblique ridge along the
anterior border of the ramus approximately till one-third of
the width of the ramus. The anterior cut is placed along the
distal aspect of the first permanent molar. The inferior cut
is placed approximately 4-5 mm superior to the mandibular

Table 3: Autogenous grafts from intraoral and extraoral origins

Source Type of bone Amount of bone Indications Remarks Possible complications
Anterior iliac Cancellous or 50 mL of Horizontal and vertical Greatest osteogenic Gait disturbances
crest corticocancellous cancellous ridge augmentations potential among all Neurosensory complications
bone or 2 cm × in the maxilla and autogenous graft types Sarcoiliac joint problems
6 cm block of mandible Need for second surgery Pelvic fracture
corticocancellous Sinus lift often by second surgical Peritoneal perforation
bone team Hematoma, infection, etc.
Tibial plateau Cancellous 40 mL of Horizontal and vertical Contraindicated in young No long term complications
cancellous bone ridge augmentation in and growing subjects Immediate complications
maxilla and mandible because of potential such as pain and infection
Sinus lift complications with
growth centers
Proximal ulna Corticocancellous 1 cm × 1 cm Horizontal and vertical Comparatively easy Minimal postoperative
(proximal block ridge augmentation to harvest than other discomfort
humeral in the maxilla and extra-oral donor sites Pain, edema, hematoma,
metaphysis) mandible ecchymosis, or limitations
Sinus lift in the range of motion
Ramus Cortical 0.4 × 3 × 5 cm Horizontal and vertical Can reconstruct up to Inferior alveolar nerve and/
block ridge augmentation in 3-4 cm of the alveolar or lingual nerve injury
maxilla and mandible segment or multiple Trismus, infection,
Sinus lift (less small areas hematoma and trauma
preferred) Provides greatest average
surface area and volume
Symphysis Primarily cortical 0.7 × 1.5 × Horizontal and vertical Largest intraoral source Sensory deficits to lower
Also 6 cm block or ridge augmentation in of cancellous bone teeth, lower lip and/or chin
corticocancellous 2 blocks of 1.5 × maxilla and mandible Less complications Periapical defects
3 cm Sinus lift compared to ramus graft Alteration in chin contour
Fill-in for osteotomy gaps
Tuberosity Cancellous 1-3 mL Small defects (socket — Bleeding from Posterior
grafting, small sinus superior alveolar or
lift, fill-in for osteotomy sphenopalatine artery
gaps) Maxillary antrum floor
perforation

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Goyal, et al.: Hard tissue augmentation

canal. Medially, the osteotomy cut is placed in the lateral
cortex. After delineating the margins of the osteotomy
cuts by drilling holes, the cuts are completed with either
rotary or osteotome or piezotome. The latter is considered
to be the best owing to inherent low risks associated with
its use while osteotome is least preferred due to poor
patient acceptance.[35] Following this, the lateral bone block
is fractured with due care to avoid damage to the inferior
alveolar neurovascular bundle.
Care of donor area and graft
A collagen membrane is used the fill the donor area defect,
which is closed by running sutures after hemostasis. The
graft is stored in blood-soaked gauze till it is particulated
or transplanted.
Chin/symphysis graft
Local anesthesia
Mandibular nerve block is supplemented with local infiltration
in the anterior mandibular labial vestibule.
Surgical technique
The mucoperiosteal flap can be raised by vestibular or
sulcular incision. The former is preferred as the latter
is associated with postoperative gingival recession. The
two-layer vestibular incision is made through the deepest
part between the vestibule and lip. The lateral extent
of the incision depends on the purpose of harvest. For
local grafts, the incision is limited till the canines. On
the other hand, for maxillary sinus grafting the incision
in extended till the premolars to locate the mental
nerves. The superior osteotomy cut is placed at least
5 mm inferior to the apex of the mandibular teeth and
the inferior cut is placed approximately 4 mm superior
to the inferior border of the mandible [Figure 3]. Often,
the graft is given a cut in the midline and is harvested in
two parts using an osteotome.

Care of donor area and graft

As described for ramus graft, the residual symphyseal cavity is
packed with collagen membrane after achieving hemostasis.
The closure is performed in two layers, i.e., periosteum and
muscle layer followed by mucosa. The graft is handled in
same way as described for ramus graft.

Tuberosity graft
Figure 2: mandibular ramus graft; (a) mucoperiosteal flap raised and exposure
of donor site (b) harvesting of graft (c) preparation of recipient site (d) fixing the
Local anesthesia
harvested block onlay graft Posterior superior alveolar nerve block.

Figure 3: symphyseal graft; (a) atrophic ridge with deficient horizontal dimensions (b) exposed symphyseal area (donor site) (c) completed osteotomy (d) harvesting
graft (e) fixation of veneer graft to the recipient site and filling the residual voids with particulate graft (f) immediate postoperative view

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Surgical technique
The mid-crestal incision extending from the hamular notch to
the second molar area is employed to gain access to maxillary
tuberosity. Only a little amount of bone (1-3 mL) is removed
using a rongeur or piezotome. The latter is again a preferred
approach owing to lesser risks.[35]
Care of donor area and graft
For maxillary tuberosity, primary closure can be achieved
due to small residual defect. The graft should be harvested
keeping a minimum of 2 mm clearance from the maxillary
sinus. In case of oroantral communication, the closure can
be achieved using either of the buccal sliding flap, buccal fat
pad, or palatal finger flap.
Allografts
The grafts are harvested from the same species but from a
different donor (genetically heterogeneous).[33] These can
be fresh-frozen, freeze-dried bone allografts (FDBAs) or
demineralized freeze-dried bone allografts (DFDBAs).[8,33] FDBA
and DFDBA are preferred over fresh-frozen allografts in the
wake of their low immunogenicity.[33] Essentially, allografts are
osteoconductive with the exception being DFDBA, which may
possess some osteoinductive potential. This is possibly because
of the exposed organic content (might be growth factors)
after demineralization. The mechanism of incorporation of
allografts involves creeping substitution similar to autogenous
cortical grafts.[33] FDBA undergoes faster replacement and
osseointegration compared to DFDBA and thus enables earlier
implant placement.[33] Whenever it is osseointegration is
desired to be delayed as in cases of poor confines, i.e., sinus
augmentation, DFDBA is preferred over FDBA.[33]
Xenografts
These grafts are derived from genetically dissimilar species,
i.e., bovine, porcine, equine, and coralline, etc. [8,9,33]
The bovine grafts are preferred over other sources of
xenografts. Mainly, inorganic portion of the bone is used.
Commercially, these grafts are available in block or particulate
form. Unfortunately, high failure rates (higher rates of
connective tissue ingrowth, poor vascularization, delayed
osseointegration) are associated with these grafts.[33]
Alloplastic grafts
These are synthetic grafts of nonbiologic origin available
in a range of porosities and densities, i.e., hydroxyapatite,
calcium sulfate, tricalcium phosphate, and bioactive
glass. For clear reasons, these are osteoconductive.
When used alone, these types of materials often
yield suboptimal bone turnover and this fact limits
their use. [33] However, these can be combined with
autogenous grafts in various proportions to yield optimal
results. [23]
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DECISION PATHWAY FOR RIDGE AUGMENTATION
AND SOCKET PRESERVATION
The suitable technique and material for ridge augmentation
is dependent on clinical characteristics of the patients,
i.e., location and type of defect and the surgeon’s own
preference. Latter is often affected by surgeon’s clinical
skill and expertise, and financial aspects but mostly it
is dictated by principles laid by evidence. Here, in this
section simplified evidence-based decision pathways for the
selection of suitable techniques for socket preservation and
ridge grafting are presented [Figures 4 and 5].
The foremost step in treatment planning, i.e., selection
of the right technique as well biomaterial and timing of
augmentation (staged versus simultaneous) is preoperative
patient assessment. These preoperative considerations
include systemic health status and local factors, i.e.,
morphology of soft tissues and bone. Although it is advisable
to employ cone beam computed tomography to scan the
defect in three dimensions, panoramic radiographs in
combination with suitable intraoral radiographs may also be
used. It is essential to have sufficient soft tissue coverage to
ensure primary tension-free closure over the planed area of
augmentation. In cases of probable inadequacy of soft tissues,
the augmentation of soft tissues must be planned prior to
augmenting hard tissues. Assessment of bone morphology at
the planned site of implant placement include adequacy of
bone volume, ridge contour, and position of marginal bone
of neighboring teeth.
SOCKET PRESERVATION
The alveolar bone uneventfully resorbs after extraction and
results in residual ridge morphology with compromised
horizontal and vertical bone volume to receive implant and
a lingually positioned crest due to greater resorption on the
buccal aspect.[5-7] Socket grafting at the time of extraction is a
preventive procedure, which does not inhibit the resorption
but limits it.[17] Moreover, the minimal amount of resorption
after socket grafting happens in a predictable fashion. Also,
the magnitude of volume loss is less in the grafted socket
versus the naive socket. This has been substantiated by a
recent meta-analysis where ≈1.4 mm lesser horizontal bone
loss and ≈1.8 mm lesser vertical bone loss were reported
in grafted sites compared to nongrafted sites.[21] However,
it is interesting to note that similar mean implant survival
rates has been reported for implants placed in preserved
sites versus naive sites. Additionally, the bone grafting may
still be needed at the time of implant placement as it is only
possible to limit the alveolar bone resorption and yet not
possible to completely eliminate it.[17] These facts question
the rationale of socket preservation. In the light of these facts,
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Figure 4: flowchart: decision pathway for ridge augmentation; (a) ridge augmentation in the maxilla (b) ridge augmentation in the mandible

it is recommended that it should be performed in aesthetic or mandibular canal. Also, overaugmentation may help,
areas in case of buccal bone thickness ≤2 mm or when there especially in aesthetically sensitive areas where the buccal
is a proximity to anatomic structures, i.e., maxillary sinus bone contour is critical.[7]

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Figure 5: decision pathway for socket preservation
There is a lack of evidence regarding the choice of
techniques and biomaterials for socket preservation. Benic
and Hämmerle (2014)[36] beautifully described the grafting
protocol on the basis of class defect. The authors described
six phenotypes on the basis of morphology of defects
[Table 4 and Figure 6] and they also provided guidance on
choice of biomaterial and technique for socket preservation
[Figure 6].
TECHNIQUES OF RIDGE AUGMENTATION
The various techniques of ridge augmentation can be
differentiated either on the basis of the form of graft, i.e.,
block or particulate, guidance or use of membrane, i.e., GBR,
transportation of vital structures, i.e., maxillary sinus lift and
inferior alveolar nerve transportation.[8,9,36] None of these
techniques are free from complications and all possess their
unique advantages. A few of the technical considerations
need to be borne in mind ubiquitously for all grafting
procedures [Box 1].
Onlay grafting
Onlay grafting can either be block onlay grafting or particulate
onlay grafting. The latter can further be categorized as
subperiosteal tunnel grafting or direct particulate onlay
grafting.
Particulate onlay grafting
Direct particulate onlay grafting
Indications: The direct particulate onlay grafting [Figure 7]
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Table 4: Classification of bone defects[36]
Class of defect Morphology of defect
Class 0 Optimal ridge contour and sufficient bone volume
for implant placement
Class 1 Intraalveolar defect with space between implant
surface and neighboring bone
Class 2 Periimplant dehiscence with five-walled defect
morphology. Here, volume stability of area to be
augmented is provided by neighboring bone walls
Class 3 Periimplant dehiscence with four-walled defect
morphology. Here, volume stability of area to be
augmented is not provided by neighboring bone walls
Class 4 Horizontal ridge defect
Class 5 Vertical ridge defect
is employed for correcting horizontal deficiencies in the
anterior maxilla and for saddle depressions, i.e., vertical
deficiency. The recipient sites with three-walled and
four-walled defect morphology with an apical stop are
considered to be best amenable to direct particulate onlay
grafting.
Technique: The direct particulate onlay grafting can be
performed as a staged or simultaneous procedure. The
planned recipient area is exposed by raising a mucoperiosteal
flap to visualize the defect. It is important to place releasing
incisions to ensure direct visualization of the defect and
tension-free closure. After drilling holes in the recipient bed
to ensure osseointegration, the particulate graft is condensed
over the defect. For defects with poorly contained boundaries,
(i.e., maxillary sinus) demineralized grafts are preferred over
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mineralized grafts due to their slower resorption.[33] The
coverage with membranes is often recommended but can
be omitted for small defects with sufficient neighboring
walls to provide volume stability.[36,44] The malleability and
workability of particulate graft can be enhanced with tissue
adhesives, i.e., fibrin sealants or protein-based regenerative
gels (Emdogain; Straumann, Andover, MA, USA).
Subperiosteal tunnel grafting
Indications
Small to moderate buccal plate defects are best open to
subperiosteal tunnel grafting. The morphology of such
defects is characterized by wider buccal base with narrow
crestal width (≤4 mm) and intact lingual wall with optimum
vertical dimensions.[8]

Technique
After administration of local anesthesia, access incision
is placed distant (often mesially) from the recipient site.
Subperiosteal tunneling from the incision to graft site
is performed with the help of a periosteal elevator. The

Figure 6: classification of bone defects.[36]

Figure 7: particulate graft

Box 1: Technical considerations for grafting procedures

Graft fixation and stabilization: The success and predictability of grafting procedure depends to a great deal on stabilization of the graft in the
postoperative healing period.[37] Any type of movement of the graft may cause rupture of newly regenerated microvasculature and interferences
with regenerating capillary ingrowths. [37,38] Thus, the micromotion of graft in the consolidation phase interferes with osseointegration and
may lead to graft failure. As a rule, rigid fixation and complete stabilization of block grafts with at least two pins are recommended as single
pin is insufficient to prevent shearing of microvasculature. The particulate grafts are stabilized using membranes fixed with resorbable pins or
screws. [38] If the defect morphology provides volume stability, i.e., four to five walled defects, resorbable membranes are sufficient. However,
in cases of insufficient support from neighbouring walls of defects, i.e., vertical deficiency, rigid membranes, titanium mesh with e-PTFE is
preferred. [36]

Osteoinductive agents: Almost all of the graft materials except autogenous grafts are merely osteoconductive.[33] Imparting osteoinduction by
adding growth factors/osteoinductive agents will help recruitment and differentiation of bone-forming cells.[39] The most popular of these are bone
morphogenic proteins (BMPs), which belong to the family of transforming growth factor-b and are extremely potent stimulants of angiogenesis and
osteogenesis by recruitment and differentiation of pluripotent mesenchymal stem cells.[39] Recombinant human BMP -2 (rhBMP-2) is the most studied
of these and is approved for use in socket grafting and sinus augmentation; yet it is employed for off-label applications as well.[39-41] As it requires
a carrier system for its placement, a commercial system “Infuse” has been developed.[42] Infuse (Infuse Bone Graft, Medtronic Spinal and Biologics,
Memphis, TN, USA) comprises absorbable collagen sponge (highly purified bovine tendon type-1 collagen) and rhBMP-2.[42] rhBMP-2 is provided as
powder and liquid, which is mixed and expressed over absorbable collagen sponge carrier. The activated collagen sponge is then packed in defect
and covered with resorbable membrane.

Graft loading: It is important to provide optimal stimulation at the right time to maintain the graft. The physiological rationale for this is a
necessity of continuous stimulation for the maintenance of alveolar bone or else disuse atrophy will lead to graft involution.[8,43] Usually, implant
placement is performed at 3 months following graft placement. However, corticocancellous grafts may require up to 6 months and xenografts
may require an even longer time for consolidation.[33] Early implant placement minimizes bone resorption and thus, it is advisable to shorten
the consolidation period.

Tension-free closure: The soft tissue closure of the augmented area should be performed in a tension-free manner and to ease this, it is often
necessary to place releasing incisions in the periosteum.[8,9] Failure to do so may result in wound dehiscence and eventually the graft’s exposure
and/or infection.

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demineralized particulate bone graft is placed in this

subperiosteal tunnel with the help of modified 1 mL
carrier syringe. The graft may need digital manipulation
to conform to the recipient bed in the desired form. The
mesial incision is closed in a tension-free manner to ensure
uneventful healing with minimal risks of dehiscence and
graft exposure.

Block onlay grafting

Indications
Horizontal or vertical deficiency or combined horizontal and
vertical deficiency.

Technique
This is one of the most commonly employed techniques Figure 8: veneer graft

for horizontal as well as vertical ridge augmentation.

The block graft can be autogenous graft harvested from
neighboring intraoral donor sites, distant extraoral donor
sites, or commercially available xenografts or alloplastic
grafts. [33] After raising the mucoperiosteal flap, the
recipient bed is prepared by drilling multiple holes till
the underlying spongiosa is reached. Depending on the
type of defect, the graft is contoured to adapt in proximity
to the recipient site as veneer [Figures 8 and 10], block
[Figures 9 and 10], or inverted J Block graft is employed
for the vertical defects while veneer graft is used in the
case of horizontal defects. For combined defects, the graft
is modified to the shape of the inverted letter J. Another
modification is lamellar technique where only the cortical Figure 9: block onlay graft
part of the graft is used as veneer, whereas the underlying
defect is filled with particulate graft. After ensuring proper
adaptation of the graft to the recipient bed, the voids
can be filled with particulate bone graft material. It is
imperative to stabilize the graft with two screw fixations
to allow unimpeded integration while avoiding shearing of
microvasculature and tender connective tissues.[37,38] Due
care should be taken to fix the screws passively as lateral
pressure from screws may either fracture the block graft
or result in undue resorption and graft failure. In case
of insufficient soft tissue coverage, a membrane may be
used for barricading from unwanted connective tissue and
epithelial ingrowth. However, often the block grafts do not
require the use of barrier membrane as the cortical part
of the graft prevents the soft tissue from creeping into Figure 10: block and veneer graft; (a) shaping of harvested graft (b) shaped
the grafted area.[44,45] graft (c) fixation of graft as block and veneer for combined horizontal and vertical
augmentation
These grafts require a little longer time to integrate
with the recipient bone and thus, it is recommended on the graft bone immediate placement of the implant
that the staged approach of implant placement be can be performed.[43,45,46]
preferred. It is preferable to allow healing 4-6 months
prior to functional loading. However, if the basal bone Interpositional bone graft (Sandwich grafting)
is sufficient and the implant stability is not to be relied Indications

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Vertical deficiency with preexisting minimal vertical
alveolar dimensions of 4-5 mm and without any soft tissue
deficit.[8]
Technique
A vestibular incision is placed in nonkeratinized
mucosa to expose the facial aspect of the planned
area of augmentation. First, vertical corticotomies and
osteotomies are performed using micro reciprocating and
sees to the preservation of ≈2 mm of bone around the
roots of neighboring teeth. This is followed by horizontal
corticotomy and osteotomy to mobilize the segment. A
minimum clearance of ≈3-5 mm from vital structures such
as the maxillary sinus or mandibular canal is essential. It is
crucial to perform only as much advancement as permitted
by the soft tissue envelope to achieve tension-free closure.
The free segment can also be advanced buccally or lingually
to achieve the desired prosthodontic position. After careful
Figure 11: interpositional bone graft
Figure 12: case presentation: interpositional ridge graft; (a) recipient site (b) incision placed (c) flap raised (d) osteotomy and splitting (e) interpositioning of bone
graft (f) closure
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transportation preserving soft tissue attachments, the
bone graft block (usually corticocancellous autogenous
graft) is sandwiched between the transported segment
and basal bone [Figures 11 and 12]. The graft fixation is
achieved with miniplates. Periosteal releasing incisions
may be placed to aid tension free closure.
Ridge split technique (book bone flap)
Indications
Horizontal deficiency requiring 2-5 mm of augmentation.[8,45]
Technique
This technique can be utilized in case of alveolar width
≥4 mm so that a minimum of 2 mm thickness of outfractured
buccal and lingual walls can be achieved. [8,45] This is
essential for maintaining the vascularity of the outfractured
segments. The mucoperiosteal flap to expose the donor
area is raised by a crestal incision. A vertical osteotomy
≈10-12 mm in length is performed on the recipient alveolar
crest with a clearance of 2 mm from the roots of adjacent
teeth. After osteotomy is complete, the facial and lingual
walls are spread apart by using osteotomes to make space
for placement of the implant [Figure 13]. Residual voids are
filled with particulate graft and the implant is submerged
at least 1 mm apical to the alveolar ridge crest [Figure 14].
The closure must be tension-free and in case of soft tissue
deficit, collagen membrane with soft tissue graft can be
used to close the defect.
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The technique described above is conventional ridge accessed again. The new bone formed at the osteotomy site
split technique where immediate implant placement is during this healing period is soft and expandable. Thus, ridge-
performed. It can be performed when horizontal deficiency splitting and implant placement at reentry after 3-4 weeks
exists at the crestal part and the ridge widens apically. becomes easier. Due care is taken to raise the flaps only
However, it is not uncommon to encounter challenging minimally. The periimplant spaces are filled with particulate
ridge morphology, i.e., deficient ridge crest combined with graft and the lingual flap is coronally advanced and sutured
severe facial concavity.[45] This may exist in case of chronic back. Uncovering of implants and functional loading is done
periapical infection where longstanding inflammation after 4-6 months.
caused resorption of the labial cortical plate in the apical
Ridge expansion
region. In such a condition, ridge-splitting may lead to
Indications
sudden fracture of the cortical plate at the apical region.
≤6 mm width of the alveolar ridge crest.[47]
Fortunately, with a little modification, the ridge split
technique is still feasible. The flap is raised only in the Technique [Figures 15 and 16]
crestal part to be expanded and the dehiscence in the apical The alveolar ridge crest is exposed by raising a mucoperiosteal
area is left undisturbed. The crestal part is expanded and flap. Horizontal osteotomy is performed extending from
particulate graft is packed over facial dehiscence by the 1 mm distance from neighboring tooth to 8-10 mm distal to
subperiosteal tunnel technique. The advantages of this the axis of the last implant.[47] The horizontal osteotomy is
technique include being less invasive and abolishing the extended as deep as the length of the implants to be placed.
need for placement of the barrier membrane. Following this releasing, vertical osteotomy is performed.
This is essential in case of dense cortical bone. The vertical
The best suited histological bone type amenable to ridge-
osteotomy cuts are placed at the mesial and distal ends of
splitting and expansion is bone with medium density
the horizontal osteotomy cut. With a pilot drill, osteotomy
(maxillary bone), i.e., porous cortical bone with coarse/fine
holes (1.2-2 mm) corresponding to each implant site are
trabecular bone (D3/D4 bone).[45] It is tricky to perform ridge-
placed. Then immediately expansion screws are placed. The
splitting in case of dense cortical bone, i.e., the mandible
maximum diameter of these screws is 2.5 mm and ≈1 mm
where sudden fracture of cortical plates may happen during
expansion. In mandibular ridge with dense cortical plates,
ridge-splitting can be performed using either two-stage or
one-stage approach.[45] The choice between the two depends
on the availability of armamentarium and surgeons’ skill.
The one-stage conventional approach is preferred only when
the surgeon has adequate experience supported with suitable
armamentarium, e.g., piezosurgery. Only modification here in
one stage ridge-splitting for mandibular ridge compared to
conventional ridge split is raising flap from either buccal or
facial side compared to both sides in conventional technique.
Here, the intact mucoperiosteal flap protects in case of
sudden fracture of the cortical plate. In two-stage approach
of ridge-splitting, an osteotomy is performed similar to the
conventional ridge split procedure. But expansion is not
performed at this stage; rather the flap is sutured back.
After a healing period of 3-4 weeks, the osteotomy area is

Figure 14: ridge split; (a) thin alveolar ridge (b) ridge split using MCT disk
(3-mm radius) (c) expansion using rigid osteotome (d) flexible chillet (e) MCT ridge
Figure 13: ridge split technique splitter (gentle separation) (f) bone expanders (g) implant placement (h) closure

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expansion of the buccal cortical plate is achieved. Next,
differential preparation of the implant site is done by reducing
the width of the lingual and sometimes buccal cortical plate
to reduce the need of expansion. This is possible if width
of the alveolar crest is ≈4-5 mm. Second, expansion screws
of 3.5 mm diameter are inserted in differentially prepared
pilot osteotomy sites to enable additional expansion by 0.5
mm. Lastly, implants corresponding to 4 mm diameter are
placed. This results in an additional expansion of 0.5 mm
and a net total expansion of 2 mm. The final outcome is net
Figure 15: ridge expansion; (a) measuring the thickness of the alveolar crest
using periodontal probe (b) horizontal osteotomy (c) drilling first holes every
7.5 Mm (d) first 1 mm of expansion (e) differential preparation (f) placement of
implants (at this stage 2 mm of expansion is observed)[47]
Figure 16: ridge split and expansion; (a) atrophic ridge (b) mucoperiosteal flap raised and osteotomy performed (c) gradual staged expansion (d) implants in position
(e) healing abutments placed
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total alveolar crest width of 6 mm with 1 mm thickness of
the buccal as well as lingual cortical plate.
Distraction osteogenesis
Indications
Significant vertical deficiency.
Technique
This technique allows significant augmentation of both hard
and soft tissues in areas with extensive tissue loss in a staged
manner.[47-50] A transport segment is mobilized in a similar
manner as for interpositional bone grafting, preserving
attachment to the crestal and lingual tissues [Figure 17].[49]
The transport segment can be mobilized in multiple planes
to allow simultaneous correction of buccolingual postions
as well. The distractor is fixed to transported and basal
bone segments with approximately 1-2 mm gap between
the two segments. This is left in situ for a latency period of
5-7 days to allow the formation of soft tissue callus between
the two segments and then activation is started at the rate
of 0.5-2 mm/day for periodic distraction. After completion
of the desired amount of distraction, the distraction device
is removed and quality of the bone is explored. The newly
formed bone is hourglass shaped and placement of additional
grafts may be required for proper implant placement at this
time. The implant placement is performed after a period of
4-6 months.
Inferior alveolar nerve transportation
Indications
To allow placement of dental implants in atrophic mandible
with deficient vertical height as a substitute for grafting[51-53]
Technique
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Goyal, et al.: Hard tissue augmentation

This method involves lateral translocation of the contents This technique is based on the principle of creating a
of the mandibular canal to soft tissues of the mandibular barrier to the ingrowth of connective tissue and epithelial
vestibule. The implants can then be placed traversing the cells and space maintenance for osteogenesis. GBR, also
empty mandibular canal. This technique allows placement known as guided tissue regeneration, is an evidence-
of 8-12 mm long implants without any grafting.[51,52] based predictable approach for separating the bone graft
material (usually particulate) from neighboring soft tissues
Maxillary sinus lift with and without bone graft
to allow unimpeded bone formation.[36] In this technique, a
Indications
membrane is secured covering the graft material to stabilize
≤10 mm of bone height in the posterior maxilla[54,55]
the material, parting it from adjacent connective tissues,
Technique and limiting resorption [Figures 19 and 20]. A plethora of
Lateral wall of the maxillary sinus is exposed by raising a membranes, resorbable/nonresorbable and moldable or stiff
trapezoidal flap with anterior releasing incision adjacent are available [Figure 21].[36]
to the last tooth and posterior releasing incision in the
The choice of membrane mainly depends on volume
posterior part of the infrazygomatic crest. A midcrestal
stability of the graft in defect. Stiff membranes such
incision is placed and mucoperiosteal flap is reflected.
as titanium mesh or metal supported expanded
A bone window approximately 15 mm × 10 mm in size
polytetrafluoroethylene (e-PTFE) are suitable for complex
is created at least 5 mm superior to the sinus floor. A
defects, i.e., vertical defects. For small to moderate defects,
small round bur is used to outline the margins of the
resorbable collagen membrane or platelet-rich fibrin (PRF)
window by placing holes in the bone with due care to
membranes [Figure 22] are preferred. Nonresorbable
leave the underlying membrane intact. The holes are
membranes such as Ti-mesh and e-PTFE have an inherent
connected and the window is created by infracture of
problem of requiring second surgery to remove them.
the outlined bone. The membrane is dissected free from
Further, with Ti-mesh there is a risk of fibrous ingrowth
the bone, i.e., anterior wall and floor of the sinus. After
and exposure of membrane through the gingiva. To limit
dissection and ensuring intactness of the mucosa, it is
this unwanted outcome, use of collagen membrane to
lifted and bone graft in particulate form is condensed to
cover Ti-mesh as an adjuvant barrier is recommended.
fill the created cavity, which is then closed by replacing
Another problem associated with membranes is premature
the oral mucosa [Figure 18]. Postoperative care includes
exposure of membrane resulting in infection and exposure
refraining from sneezing and blowing of the nose and
of graft. This is observed more commonly with alloplastic
decongestants and antibiotic coverage. A modification
membranes, which are occlusive and may interfere with
of this technique involves filling the cavity with blood
blood supply. Although mainly used in conjunction with
instead of graft material. The implant is placed traversing
particulate graft, the barrier technique may also be used
through the created cavity with the membrane resting
for block graft.
on its top. A consolidation period of 3-4 months is
recommended. CONCLUSION
Guided bone regeneration In this paper, a simplified algorithm has been presented

Figure 17: distraction osteogenesis Figure 18: local sinus lift with bone graft

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Goyal, et al.: Hard tissue augmentation

to serve as a clinical guide for decision-making in ridge

augmentation as well as socket preservation. As the
evidence suggests, GBR is the most predictable technique.
The continued thrust of active research in this area may
result in development of more simplified and promiscuous
methods of regeneration.

Acknowledgement
The authors are thankful to Dr. Anuj Aggarwal (former postgraduate
student, Department of Oral and Maxillofacial Surgery, Santosh
Dental College and Hospital, Ghaziabad, Uttar Pradesh, India) for
contributing a few of the clinical photographs.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.

Figure 19: guided bone regeneration; (a) recipient site, (b) raising mucoperiosteal
flap, (c) osteotomy for implant placement, (d) implant placed with particulate
graft, (e) barrier membrane placed and stabilized, (f) healed site, (g) healing
abutment, (h) final prosthesis
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Figure 20: guided bone regeneration, (a) pre-operative clinical view, (b) pre-operative ct showing extensive bone loss, (c) reflecting mucoperiosteal flap, (d) implant
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