—— PROACTIVE

INTERVENTION DENTISTRY——

Bone
Grafts For
Implant
Dentistry:
The Basics
Fay Goldstep, DDS, FACD, FADFE

T
he implant restoration is an essential
who needs to know more GRAFTS FOR IMPLANTS:
everyday treatment to replace missing teeth,
– whether it is to provide THE BASICS
advance function and enhance esthetics for
guidance to patients, or RATIONALE
patients in the general dental practice. An
to increase understanding INDICATIONS
understand- ing of implant hardware design REQUIREMENTS
of the surgical protocols
and place- ment for optimum clinical results CLASSIFICATION
of implant treatment.
is common knowledge for the dental BY MATERIAL SOURCE
practitioner. This CLINICAL CONSENSUS
The Rationale for Bone
is not the case when it comes to the understanding of Grafts Outline of topics
bone grafting needs and procedures that are the Placement of implants re-
foundations for implant treatment. quires sufficient bone
This article will address the basic principles for bone grafts
volume
in implant dentistry: the rationale, indications, locations, and biologic quality. This is due to the macro design of the
requirements, types, materials, and some guiding implant, which demands certain dimensional properties
consensus on surgical techniques and materials. This will for long-term success.1
help clari- fy a somewhat murky new area for the general Other factors which make bone grafting necessary are:
practitioner

36 oralhealth DECEMBER 2015

 • The resorption of the BONE GRAFT CLASSIFICATION BY MATERIAL SOURCE
edentu- lous ridge post
extraction TYPE SOURCE PROS CONS
• Presence of bony defects due
AUTOGRAFT PATIENT TRUE OSTEOGENIC PAIN
to trauma or infection
LIVING CELLS INFECTION
• The need to place implants in
GROWTH FACTORS COMPLEX SURGERY
strategic sites for functional
NO DISEASE TRANSMISSION LIMITED SUPPLY
and esthetic success. In
GOOD WITH CORTICAL BONE
esthetic
areas, soft tissue requires a bony ALLOGRAFT OTHER HUMAN OSTEOINDUCTIVE RISK OF DISEASE
base since “soft tissue follows OSTEOCONDUCTIVE EFFECTIVE TRANSMISSION
hard tissue”1 AS “SHELLS”
Treatment planning for bone XENOGRAFT OTHER SPECIES HA: SIMILAR TO HUMAN OSTEOCONDUCTIVE
graft placement requires the se- (mostly bovine) VOLUME STABILITY ONLY
lection of an appropriate surgical COLLAGEN: ACCELERATES
technique and graft material. Poor BONE FORMATION
planning or execution may lead to ALLOPLAST SYNTHETIC NO RISK OF DISEASE OSTEOCONDUCTIVE
resorption of the graft material or TRANSMISSION ONLY
its failure to integrate. In addition,
HYDROXYAPATITE RESORBED SLOWLY
the lost tissue may be replaced by
🡒PRESERVES
fibrous tissue rather than
VOLUME GOOD
functional bone.2
GROWTH FACTOR
Grafts are suitable for a variety
CARRIER
of clinical situations.
TCP RESORBED QUICKLY
Locations/Indications for 🡒REPLACED BY NEW
Bone Grafts in Implant BONE
Treatment BIOGLASS BIOACTIVE 🡒ACCELERATES
Bone graft materials are placed BONE FORMATION
in different locations for various RESORBED QUICKLY
indications:1 Bone graft classification by material source
• In alveolar sockets
post extraction
• To refill a local bony defect due to trauma or infection Ridge preservation procedures seem to delay bone forma-
• To refill a peri-implant defect due to peri-implantitis tion in the early healing phases5; however, studies show that
• For vertical augmentation of the mandible and maxilla procedures are effective with significantly lower ridge atrophy
• For horizontal augmentation of the mandible and reported than in non-treated groups.6
maxilla Following the extraction of a tooth, 40 to 60 percent There is always some bone loss after extraction, since the
of the original height and width of the surrounding alveolar alveolar bundle bone into which the collagen fibres of the
bone is periodontium are anchored, is dependent on the presence
expected to be lost; the greatest loss is in the first two years3 of a tooth; this bone is always absorbed following tooth
(Fig. 1). loss.7 The prime objective of ridge preservation is to diminish
With this loss of hard and soft tissue, conditions are less or completely eliminate the necessity of more invasive aug-
favourable for the proper axial alignment of the implant for mentation procedures in the future.
function and esthetics. To minimize alveolar atrophy post Techniques are available to effectively and predictably
extraction, healing procedures termed “socket preservation” or increase the width of the alveolar ridge (horizontal augmenta-
“ridge preservation” have been developed. These procedures tion). Vertical augmentation techniques are not as predictable
involve filling the socket with bone or bone substitute as those for horizontal augmentation and are subject to more
material, with or without a membrane. The objectives of complications.8
ridge preservations are.4 Bone grafts are more likely to succeed when the conditions
• Filling the socket (wound care) at the recipient site are favourable and certain requirements are
• Preservation of ridge volume (ridge preservation) fulfilled.
• New bone formation (osteogenesis)
—PROACTIVE INTERVENTION DENTISTRY—
www.oralhealthgroup.com 37
1A. 1B. 2.

Following extraction, bone loss can be up

Poor esthetics can result from implant Placement of an autogenous bone block
to 60 percent of the original height and
placement without consideration of taken from the chin area. Courtesy of Dr.
width of the alveolar ridge.
post-extraction changes. Courtesy of Dr. M. Leventis, Athens University, Greece.
M. Leventis, Athens University, Greece.

Requirements for the Ideal Bone Graft

the osteoblasts.2
Bone healing and new bone formation after grafting occur
Graft stabilization – Mechanical stresses on the graft
through osterogenesis, osteoinduction and osteoconduction:3
during healing can lead to disruption of the fibrin clot. Move-
•Osteogenic graft materials supply actual viable
ment will cause fibrous tissue to fill the defect instead of
osteoblasts themselves
bone. This is a form of repair and is not true regeneration.
•Osteoinductive materials stimulate primitive mesenchy-
Fixation devices like GBR (guided bone regeneration)
mal cells brought in via the blood supply from adjacent
collagen mem- branes, titanium mesh and bone screws may
bone or periosteum to differentiate into osteoblasts
be used.2
•Osteoconductive materials merely act as a lattice or
No tension on the soft tissue – Bone is the slowest growing
framework for cell growth, allowing osteoblasts from the
tissue. Guided bone regeneration is based on the separation
wound margin to infiltrate the defect and to migrate
of the grafted site from the surrounding soft tissue. The GBR
across the graft. This brings a population of osteoblasts
membrane keeps the faster growing tissues like epithelium,
into the graft site
fibrous tissue or gingival connective tissue out of the defect
For the bone graft to be successful:2 allowing controlled regeneration to occur with vital bone for-
1. Osteoblasts must be present at the site mation.2 The application of bone graft material into the defect
2. Blood supply must be sufficient for nourishment prevents the collapse of the collagen membrane and it acts as
3. The graft must be stabilized during healing a place holder for new regenerating bone and an
4. The soft tissue must not be under tension osteoconductive scaffold for the in growth of blood vessels
Bone is in a constant process of renewal with formation and and osteoblasts.10
resorption. During the first year of life almost 100 percent of There are different types of bone grafts available, typically
the skeleton is replaced, while in adulthood the rate is closer classified by the source of the material used.
to 10 percent per year.9 Remodeling enables bone to adapt
Bone Graft Classification by Material Source
functionally to changes in loading.
The autogenous graft (where tissue is transferred from one
Osteoblasts – Only osteoblasts create new bone. For a graft
location to another in the same individual) is considered to be
to be successful, the graft matrix must contain or encourage
the gold standard. It is osteogenic, osteoinductive and osteo-
population by osteoblasts. If there is an insufficient number
conductive.3 There is biological activity due to vital cells and
of osteoblasts the graft will fail.2
growth factors. There is also no risk of disease transmission.
Blood supply – Bone grafting is regeneration not repair. The
However there is an increased risk of pain, infection, donor
term “repair” implies the regaining of lost tissue; regeneration
site morbidity, complexity in the surgical procedure, and a
is a biologic process where not only is the tissue regained, but
limited supply of bone3 (Fig. 2).
also its form and function. This requires a good blood supply
to the graft and surrounding tissue. Blood is needed for cell Bone substitute materials (BSM) were developed to coun-
viability and clot formation. The clot serves as the initial teract the difficulties of autogenous grafts. They can either
matrix where cells migrate and then serves as anchorage for replace autogenous bone entirely or expand the autogenous
graft. Materials need to be effective for procedures both before
insertion of the implants (time-delayed procedures) and for
on page 40
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38 oralhealth DECEMBER 2015
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 from page 38

3A. 3B. 3C.

Elevation of flap, extraction of teeth,

Periapical radiograph showing pathology curettage of granulation tissue and
CBCT 3D reconstruction showing
associated with central and lateral maintenance of remaining alveolar bone.
pathology in the same case.
incisors (#11 & #12).

optimization of the recipient site at the time of implant Allograft:

place- ment (simultaneous procedures).1 A graft between genetically dissimilar members of the
Grafts are classified as:11 same species i.e. human tissue
Autograft (autogenous graft): Xenograft:
Tissue transferred from one location to another within the A graft taken from a donor of another species i.e. bovine,
same individual porcine etc

40 oralhealth DECEMBER 2015

 —PROACTIVE INTERVENTION DENTISTRY—

3D. 3E. 3F.

Placement of particulate xenograft (MIS Tension free suturing with 4-0 black Labial view at two weeks.
4BONE™ XBM) to fill bone defect with par- silk sutures.
tial denture in-situ to retain the material.

Alloplast: factors. It has greater osteogenic potential than any other bone
Inorganic, synthetic or inert foreign material implanted into substitute as well as inherent biocompatibility.12
tissue The allograft can be derived from cadavers or living donors
The autograft is the patient’s own bone. It is chiefly (tissue harvested from hip replacement surgery). It has natural
har- vested intraorally or from the iliac crest. It is the bone composition and structure. This tissue is osteoinductive
ideal bone substitute since in contains living cells and as well as osteoconductive but lacks osteogenic properties
human growth

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—PROACTIVE INTERVENTION DENTISTRY—

3I.
3G. 3H.

Incisal view at two weeks showing Incisal view at five weeks with partial One month radiograph of grafted sites
presence of xenograft granules. epithelialization of the extraction sockets. at #11 & #12.

because of the absence of viable cells.12

immunologic response, but reduces the osteoinductive
A controversy exists as to the association of allogenic ma-
proper- ties. Frozen allografts induce stronger immune
terial and the risk of transmission of infections such as HIV, responses than freeze dried allografts, hence they are no
hepatitis B and C, prions, malignancies, systemic disorders or
longer used.12
toxins. Aggressive allograft processing gives it a less intense
The donor tissue is cleaned and then undergoes ultrasonics
to remove blood and tissue components and to eliminate fat

42 oralhealth DECEMBER 2015

 3J. 3K. 3L.

Labial view at three months with excellent Incisal view at three months with Labial view at five months.
soft tissue health. complete epithelialization and remaining
non- absorbed particulate xenograft.

from the cancellous bone structure; this improves penetration

potential antigenicity. Dehydration preserves the structural in-
of the surrounding tissues into the graft material.
tegrity of the material. Final sterilization by gamma radiation
Then chemical treatment denatures non-collagenic proteins,
ensures sterility.
inactivates viruses and destroys bacteria. Further oxidative
Allografts are available in different shapes from demin-
treatment denatures persisting soluble proteins and
eralized bone matrix granules to complete bone segments.
eliminates

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—PROACTIVE INTERVENTION DENTISTRY—

3M. 3N. 3O.

Incisal view at five months. Labial view of implant positioning/direc- Incisal view of implants with sculpted
tion indicators. surrounding gingiva.

3P. 4A. 4B.

After extraction implants are placed in the

Final periapical radiograph with implants in Preoperative panorex. Extraction of two proper esthetic position.
place. The above case is courtesy maxillary central incisors required.
Dr. Ifran Ahmad, The Ridgeway Dental
Surgery, UK and MIS implants.

4C. 4D. 4E.

Polylactide membrane acts as a wall. Resorption

Bovine xenograft particulate material (MIS
Healing abutments are used for additional is 1.5 years.
4BONE™ XBM) placed with a polylactide
membrane. space maintenance.

4F. 4G.
Panorex after implant placement.
4H.
Panorex with final crowns in place six months
after implant and graft surgery.

Resorbable collagen membrane is used to

cover the graft.

The above case is courtesy of Dr Henriette Lerner, Associate Professor University Iasi, HL-DENTCLINIC &
ACADEMY, Baden-Baden, Germany and MIS Implants. on page 46

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