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 One book, one tree: In support of reforestation worldwide
and to address the climate crisis, for every book sold
Quintessence Publishing will plant a tree
(https://onetreeplanted.org/).

A CIP record for this book is available from the British Library.
ISBN: 978-3-86867-619-8

Quintessenz Verlags-GmbH Quintessence Publishing Co Ltd

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12107 Berlin Surrey KT3 3AB
Germany United Kingdom
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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system,
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without prior written permission of the publisher.

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Reproduction: Quintessenz Verlags-GmbH, Berlin, Germany

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 Preface

Bone augmentation of the alveolar process is something special for

medicine. In addition to the dental prosthetic options, there is the possibility
here of true biologic regeneration of the alveolar bone, a restitutio ad
integrum. The new bone can be functionally preserved over the long term
thanks to dental implants. Bone augmentation is therefore in principle a
functionally based medical rehabilitation, the esthetic aspects of which must
not be disregarded. As my teacher Prof Dr Dr Franz Härle used to say, “If
you get the function right, the esthetics will fall into your lap.”
This book is aimed at dental colleagues as an introduction to the topic of
augmentation and is intended to provide experienced colleagues as well as
oral and maxillofacial surgeons with many practical tips. There is a
relatively wide range of information and training available in the new
media; it is even possible to receive surgical training on video portals. In
knowledge management, the task is to separate the wheat from the chaff
and to distill the relevant information from the mass of it. It takes a lot of
judgment to be able to better assess from the abundance of innovations
what will prove itself in the future and what is therefore already worth an
investment in clinical practice today. Therefore, even in the modern world
of technology, there is still a place for a classic scientific textbook. This
book aims to contribute to knowledge management and judgment within the
practical background of clinical care and practice.
The book includes the topics of basic biology, surgical techniques, and
clinical challenges and decision making. The biologic principles are
addressed to the extent that they have clinical consequences.
Fundamentally, classical dentistry has long been based relatively heavily on
material science, and consequently so has academic training. This was
consistent because classical conservative and prosthetic dentistry took place
outside the ectodermal barrier, essentially outside the body. Today, dental

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implants mean that dentists are increasingly working invasively inside the
body, so that the classical training content needs to be supplemented. Today,
among other things, the biology of wound healing, the body’s reaction to
antigens and foreign materials, and antibiotics and resistance are coming
more to the fore, alongside the medical management of an invasively
treated patient and the reaction to complications.
The operational techniques require surgery, unless one specializes in the
prosthetic restoration of dental implants. But even then, knowledge of the
surgical options is helpful in advising the patient. Even if one does little
augmentation oneself at first, one should know the augmentation
possibilities, along with their limitations in at-risk patients, in order to be
able to properly refer them to a specialist. In general, a certain restraint is
advised when teaching surgical techniques via drawings and animations
because paper is known to be uncomplaining, which is why this book relies
more on clarification through real clinical cases.
Experience and knowledge of the biologic background are essential for
overcoming clinical challenges and making decisions, because dentistry is a
science-based discipline. Differential indication means the risk-benefit
assessment of which procedure offers the highest safety and the best effect
for which situation and patient. This book attempts to facilitate this step in
the form of a treatment-planning concept based on indications. It is
therefore about decision making, preferably in consensus with the patient as
shared decision making.
I would like to thank Quintessenz Verlag, especially senior director Dr
h.c. Horst-Wolfgang Haase for the invitation and managing director
Christian Haase for the publishing realization despite coincidence with the
coronavirus crisis. I have been in close contact with Dr rer. biol. hum.
Alexander Ammann for years, among other things through his work in the
film and book series Visual Biology, and I am also indebted to him for this
book for numerous intellectual suggestions. I would like to thank Bryn
Grisham and her team, Anita Hattenbach and Viola Lewandowski for
editing the book, as well as my son, Immo Terheyden, DDS. The patience
and skill in translating my wishes into perfect drawings are worthy of
special thanks to Mrs. Christine Rose. For the production I could rely on
Mrs. Ina Steinbrück. Last but not least I would like to thank the numerous
colleagues in the scientific exchange internationally and nationally. In
particular, the participants in my courses and continuing education courses

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have always stimulated me to further thinking and practice in bone
augmentation by asking questions and reporting on the challenges of their
practice activities. In particular, I would like to mention the Implantology
Curriculum of the German Society for Implantology and the Academy for
Practice and Science of the German Society for Dental, Oral and
Maxillofacial Medicine, as well as the Master of Science course. Not the
least thanks are due to my wife, Dr med Eva Ulrike Terheyden Niemann for
her professional suggestions and corrections and support during the time-
consuming and not very family-friendly business of book writing. I would
like to address the last sentence to you, dear readers, with the request to
enter into an exchange with me and to discuss the contents—this is the only
way to move our field forward. Thank you very much for your time.

Prof Dr med Dr med dent Hendrik Terheyden, FEBOMFS

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 Author

Prof Dr med dent Hendrik Terheyden is head physician at the Department

of Oral and Maxillofacial Surgery, Helios Hospital in Kassel, Germany.
Hendrik Terheyden studied dentistry from 1983 to 1989 at the
University of Kiel. In 1989, he was a staff physician for the Navy in
Flensburg. From 1989-1992 he studied human medicine at the University of
Kiel. In 1993 he became a specialist in oral surgery and in 1997 a specialist
in oral and maxillofacial surgery with the additional title of plastic surgery
(1999). In 1999 he completed his PhD (Habilitation) at the University of

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Kiel. He received the Wassmund Prize of the German Society for Oral and
Maxillofacial Surgery (DGMKG). In 2004, he became an adjunct professor
at Kiel University. From 2009 to 2012, he was president of the German
Society for Implantology, and from 2017 to 2019, he was Chairman of the
Oral and Maxillofacial Surgery Working Group of the German Society for
Oral and Maxillofacial Surgery (DGZMK). Since 2006, Prof Terheyden has
been section editor of the International Journal of Oral & Maxillofacial
Surgery, and since 2012 he has been editor in chief of the International
Journal of Implant Dentistry. Since 2021, he has served on the board of the
Working Group of Senior Hospitalists of the German Society for Oral and
Maxillofacial Surgery

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 Table of Contents

A BIOLOGIC BASICS

1 General Principles of Augmentation Surgery

1.1 Bone as a Success Factor in Implantology
1.2 Aims of Bone Augmentation: Function – Esthetics – Prognosis
1.3 Atrophy of the Alveolar Process
1.4 Classifications of Alveolar Ridge Atrophy
1.5 Alternatives to Alveolar Ridge Augmentation
1.6 Prosthetic Versus Regenerative Approaches to Defects
1.7 Soft Tissue Augmentation and Management
1.8 Risk Management: SAC Classification
1.9 Teamwork
1.10 References

2 Biologic Basis of Bone Regeneration and Wound

Healing
2.1 Bone Tissue Structure
2.2 Wound Healing
2.3 Wound Balance: Proinflammatory and Anti-inflammatory Wound
Environment
2.4 Bone Remodeling
2.5 Resorption Protection of Bone Grafts
2.6 Osteoconduction and Osteoinduction

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2.7 Factors Influencing the Healing Potential of Bone Defects
2.8 Defect Classes and Augmentation Techniques
2.9 Mechanism of Impaired Wound Healing and Wound Dehiscence
2.10 Biofilm as a Triggering Factor of Impaired Wound Healing
2.11 The Race of Bacteria Against Angiogenesis
2.12 Clinical Consequences: Prevention of Wound Dehiscence
2.13 Open Wound Healing
2.14 Increasing Antibiotic Resistance
2.15 References

3 Bone Grafts
3.1 Biologic Effect of Bone Grafts
3.2 Graft Bed
3.3 The Gold Standard: The Autogenous Iliac Bone Graft
3.4 Donor Sites: Quality and Harvest Morbidity of Autogenous Bone
Grafts
3.5 References

4 Augmentation Surgery Materials

4.1 Properties of Foreign Materials
4.2 Bone Graft Substitutes
4.3 Dentin as a Bone Graft Substitute
4.4 Bone Products: Allogeneic and Xenogeneic Bone Grafts
4.5 Soft Tissue Replacement Materials
4.6 Clinical Differential Indication of Autogenous Materials Versus
Foreign Materials
4.7 Membranes
4.8 Bioactive Materials and Tissue Engineering
4.9 Conclusions on Bioactive Materials and Tissue Engineering
4.10 References

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B OPERATING TECHNIQUES

5 Patient Management and Surgery Preparation

5.1 Elective Surgery
5.2 Patient Selection According to Risk Factors
5.3 Informing the Patient
5.4 Realistic Patient Expectations
5.5 Shared Decision Making
5.6 Anti-infective Patient Preparation
5.7 Surgical Preparation, Anesthesia, and Sedation
5.8 Perioperative Medication Including Antibiotics
5.9 Provisional Prosthetic Restoration
5.10 References

6 Bone Grafting: Standards and Surgical Technique

6.1 Conditions for Bone Grafting
6.2 Mixed Bone Grafts
6.3 Resorption Protection of Bone Block Grafts
6.4 Instruments
6.5 Surgical Procedure
6.6 One- or Two-Stage Implant Placement with Bone Grafting
6.7 References

7 Soft Tissue Management and Augmentation

7.1 Dimensions of the Soft Tissue around the Dental Implant
7.2 Access Incision Guidelines
7.3 Flap Types
7.4 Vestibuloplasty and Other Soft Tissue Plastic Surgery
7.5 Flap Tension and Mobilization
7.6 Suture Technique and Material

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7.7 Implant Uncovering After Bone Augmentation
7.8 Soft Tissue Augmentation for Widening Keratinized Attached
Gingiva on Dental Implants
7.9 Soft Tissue Augmentation to Increase The Mucosal Thickness at
Dental Implants
7.10 Soft Tissue Augmentation in Conjunction with Immediate Implant
Placement
7.11 Soft Tissue Augmentation Instead of Guided Bone Regeneration
7.12 Soft Tissue Augmentation for Recession Coverage on Dental
Implants
7.13 Vascularized Connective Tissue Flap Coverage
7.14 Tunneling Techniques
7.15 Contraindications
7.16 References

8 Standard Surgical Techniques for Augmentation

8.1 Inlay Grafts
8.2 Interpositional Grafts
8.3 Appositional Bone Grafts (Horizontal Augmentation)
8.4 Onlay Bone Grafts (Vertical Augmentation)
8.5 References

9 Alternatives and Adjuncts to Standard

Augmentation
9.1 Titanium Mesh Technology
9.2 Partial Tooth Extractions
9.3 Implant Site Preparation by Condensation, Bone Expansion Screws,
Conical Implants, and Bone Spreaders
9.4 Vertical Distraction Osteogenesis of the Alveolar Process
9.5 Bone Ring Technique with Simultaneous Implant Placement
9.6 Extraoral Tent-Pole Technique in the Anterior Mandible and Lower
Border Augmentation

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9.7 Shell and Tent Techniques
9.8 Ridge Switch Graft for a Narrow Ridge
9.9 Apical U-Shape Splitting Technique
9.10 References

10 Extraction Socket Treatment

10.1 Gentle Tooth Extraction and Surgical Treatment of the Extraction
Wound
10.2 Goals of Ridge Preservation
10.3 Socket Grafting in Intact Alveoli
10.4 Socket Grafting with an Alveolar Defect
10.5 Primary Reconstruction of Extraction Socket Walls Using Bone
Blocks
10.6 Socket Seal Surgery
10.7 Augmented Immediate Implant Placement
10.8 Socket-Shield Technique
10.9 References

C CLINICAL CHALLENGES AND DECISION MAKING

11 Decision Making According to Defect Stage

11.1 Defect-Oriented Concept for the Differential Indication of
Augmentation Procedures
11.2 Defect Stage 1/4
11.3 Defect Stage 2/4
11.4 Defect Stage 3/4
11.5 Defect Stage 4/4
11.6 References

12 Decision Making in the Anterior Esthetic Region

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12.1 Special Anatomical Features of the Anterior Maxilla
12.2 Anatomical Features of the Anterior Mandible
12.3 Gingival Biotype
12.4 Gingival Height and Reverse Planning
12.5 Precise Augmentation by Avoiding Resorption
12.6 Implant Positioning
12.7 Augmentation for Dental Agenesis and Adolescents
12.8 Vertical Augmentation to Preserve Adjacent Teeth
12.9 Implant Treatment of Vertical Defects in Periodontally
Compromised Dentition
12.10 Treatment of Bone Defects in the Anterior Maxilla
12.11 Treatment of Bone Defects in the Anterior Mandible
12.12 References

13 The Posterior Regions: Free-End Situations

13.1 Clinical Considerations in Free-End Situations
13.2 Comparison of Soft Tissue Healing in Free-End Situations in the
Maxilla and Mandible
13.3 General Information on Short Versus Regular Implants
13.4 General Information on Narrow- Versus Regular-Diameter Implants
13.5 Pros and Cons of Vertical Augmentation in the Posterior Mandible
13.6 Pros and Cons of Sinus Elevation in the Posterior Maxilla
13.7 Conclusion on Differential Indication for Augmentation Versus
Modified Implants in the Posterior Region
13.8 Differential Indication for Bone Augmentation in the Posterior
Mandible
13.9 Differential Indication for Bone Augmentation in the Posterior
Maxilla
13.10 References

14 The Atrophic Edentulous Jaw

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14.1 Function (Mastication and Speech) and Alveolar Ridge Atrophy
14.2 Nutrition and Alveolar Ridge Atrophy
14.3 Dementia and Alveolar Ridge Atrophy
14.4 Quality of Life and Alveolar Ridge Atrophy
14.5 Facial Esthetics and Alveolar Ridge Atrophy
14.6 Dental Prosthetic Features in Severe Alveola Ridge Atrophy
14.7 Step 1: Differential Indication for Implant-Retained Overdenture
Versus Implant-Supported Denture
14.8 Step 2: Differential Indication for Fixed or Removable Implant-
Supported Dentures
14.9 Step 3: Differential Indication Based on Pros and Cons of Vertical
Augmentation
14.10 Extreme Atrophy
14.11 Differential Indication for Augmentation-Free Restoration and
Immediate Loading on Oblique Implants (All-on-Four Methods)
14.12 Differential Indication for Augmentation-Free Restoration of the
Maxilla with Zygoma Implants
14.13 Differential Indication for Augmentation-Free Restoration of
Cawood Class V to VI Atrophied Mandible with Short Implants
14.14 Differential Indication for Augmentation-Free Restoration with
Subperiosteal Implants
14.15 Recommendations for Augmentative Treatment of Atrophied
Edentulous Ridges
14.16 References

15 Reparative Surgery and Complication Management

15.1 Reparative Surgery and Implant Replacement
15.2 Augmentative Treatment of Peri-implantitis
15.3 Infectious Complications of Augmentations
15.4 Preoperative Measures to Prevent Wound Dehiscence in
Augmentation Sites
15.5 Intraoperative Measures to Prevent Wound Dehiscence in
Augmentation Sites

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15.6 Postoperative Measures to Prevent Wound Dehiscence in
Augmentation Sites
15.7 Complications and Their Avoidance During Sinus Elevation
15.8 General Complications of Augmentation Surgery
15.9 References

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A
BIOLOGIC BASICS

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 1
General Principles of Augmentation
Surgery

Information has never been as widely available as it is today. This is

especially true for dental implantology, which is still very much in flux
many decades after its establishment. In the dynamic interplay between
product developers and clinicians, new biomaterials and augmentation
procedures enter the practice almost daily. There are countless publications
and tempting continuing education courses on everything. The art of the
(dental) practitioner is to correctly classify the amount of innovations and
information for the benefit of the patient. What is good and what is bad for
my patient? What is risky and what is predictable? What is effective and
what is unnecessary? What pays off and what only costs? What is
fashionable and what is enduring? The basis of judgment is experience and
profound knowledge.
Dentistry has traditionally been strongly influenced by material
sciences, because until a few years ago it took place predominantly outside
the better ectodermal envelope of the body. Through implantology, among
other things, the spectrum of dental treatment has expanded into the interior
of our patients’ bodies. This requires better: a broadened theoretical basis
for dentistry, which is derived from biology and medicine. The performance
of the surgeon in augmentations depends not only of the correct technical
execution, but above all the correct therapeutic recommendations under
consideration of numerous influencing factors. This book is intended to
help the practitioner build self-confidence and critical judgment in making
good decisions and to provide some joy when the biology behind one’s
clinical observations becomes apparent and sustained success is achieved.

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1.1 Bone as a Success Factor in Implantology
The opportunity for functional and biological tissue regeneration is a
privilege of dentistry compared to most other branches of medicine. Today,
bone regeneration techniques allow dentists to accept almost no deviation in
the shape of the jaw bone as a given, whether acquired by accident, tumor,
or atrophy of the alveolar ridge after tooth loss or as the result of congenital
lack of dentition.
This also applies to corrections of the occlusal relation and vertical
dimension of the jaws. The foundations for surgical correction of the bone
and the overlying soft tissues in preparation for tooth replacement treatment
were largely laid by specialists in preprosthetic surgery in the 1970s and
1980s.1 Bone augmentation is a safe procedure in the long term. Data from
prospective 10-year studies exist today for major techniques.

Fig 1-1 The fate of the implant is decided by the first millimeter. Roughened implant parts
must not come into contact with the bacteria of the sulcus. Augmentation is required here.

The fate of the implant is decided on the first millimeter2 (Fig 1-1). A
circumferential ring of bone covering all roughened portions of the implant
on all sides can prevent downgrowth of the junctional epithelium and thus
pocket formation3 and supports a good long-term prognosis for lasting

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implant health.4 Circumferential bone of at least 1-mm but preferably 2-mm
thickness supports a good long-term prognosis and the basis for a soft tissue
sealing apparatus. Sufficiently thick bone creates a natural gingival color by
preventing a discoloration by the dark titanium of the dental implants (Fig
1-2). Bone is generally the basis of esthetics as it defines the height of the
gingiva (Fig 1-3) and anchors the facial soft tissues. The alveolar process
must be sufficiently wide to accommodate a stable implant with sufficient
material thickness that will not deform or even fracture under mastication.
In addition, the bone height should be sufficient to avoid long dental crowns
and interdental plaque retention. Bone should be present within the
prosthetic and functional loading axis of the restoration. This allows the
prosthesis to be more delicate and esthetic (Figs 1-4 to 1-6).

Fig 1-2 Photo superimposition. Replacement of the maxillary lateral incisors with titanium
implants. A gray discoloration by titanium should be prevented by sufficiently thick bone and
soft tissue.

1.2 Aims of Bone Augmentation: Function – Esthetics –

Prognosis

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The aforementioned guidelines result in the following goals of bone
augmentation:
Function
Esthetics
Prognosis

Implantology has masticatory rehabilitation as its primary medical goal.

With good function, good esthetics often results automatically. In addition,
esthetics is becoming more important as a therapeutic goal. The position of
the bone shoulder determines the position of the overlying soft tissue and
thus the gingival (pink) esthetics. These relationships are summarized in the
English rhyme:
The tissue is the issue,
but the bone sets the tone,
and the clue is the screw. (D. Garber, Atlanta)

Fig 1-3 The soft tissue height (biologic width) is composed of the following elements:
connective tissue attachment, junctional epithelium, and sulcus depth or free gingiva. It is
the same for teeth and implants, averaging about 3 mm. Because the soft tissue height is a
constant, it can be planned in advance by augmenting the bone height.

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Fig 1-4 In implant-retained prosthetic restoration of the maxilla, the implants can be placed
intersinusoidally in the anterior region, avoiding sinus floor augmentation. In this case,
however, the prosthesis must be an overdenture or otherwise made very solidly to avoid
fracture. With augmentation, the support polygon is large, allowing the placement of 6 to 8
implants and the use of a removable prosthesis that can be designed much more delicately
because the risk of breakage is low.

Fig 1-5 Maxillary restoration without augmentation. a. Overdenture for the maxilla with
intersinusoidally placed implants, avoiding augmentation. b. Lack of salivary irrigation
underneath the overdenture leads to reddening of the palate (ie, denture stomatitis,
candidiasis) and gingival hyperplasia at the implants with pseudo-pocket formation. The
masticatory load-bearing capacity is relatively low due to the lack of abutment spread.

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Fig 1-6 Maxillary restoration with augmentation. a. Sinus floor augmentation allowed the
placement of more implants, providing a greater number of abutments. b. Panoramic image
after sinus floor augmentation on both sides. c. Prosthetic restoration with a delicately
crafted removable and prosthesis that allows for irrigation and interdental cleaning (Prof. Dr.
M. Kern, Kiel). d. Galvano-telescopic copings. e. Intraoral frontal view of prosthesis. f.
Extraoral appearance of the lips with natural esthetics.

1.3 Atrophy of the Alveolar Process

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In contrast to the jaw base, the alveolar process in the maxilla and mandible
is not embryologically endochondrally preformed. The alveolar process
bone is formed via intramembranous ossification alongside the eruption of
teeth to the occlusal plane. Accordingly, this bone also disappears after the
teeth are lost. Alveolar ridge atrophy therefore is physiologic and not a
disease; however, the consequences, ie, loss of masticatory function and the
inability to wear dentures, can lead to disease, especially since the atrophy
progresses very rapidly in some patients. Resorption of alveolar bone
begins at the buccal bone lamella and later involves the oral bone lamella.
The resorption of the maxillary alveolar process is also explained by the
principle of bundle bone (Fig 1-7). This type of bone consists of the
calcified insertions of ligaments. In the alveolar process, these are the
insertions of Sharpey fibers (after William Sharpey, anatomist in London).
After tooth extraction, the periodontal ligament disappears as does,
inevitably, the bundle bone, which can make up the entire facial lamella of
the dental compartments. Loss of the alveolar process is accelerated by,
among other things, marginal periodontitis, traumatic tooth extraction,
unstable overdentures, and generalized osteoporosis. Particularly severe
atrophy with formation of a flappy ridge and irritation fibromas is seen in
combination syndrome (Fig 1-8) in the anterior maxilla when hard
mandibular residual dentition or mandibular dental implants occlude against
a maxillary full denture supported only by soft tissues. As atrophy occurs,
there is also decreased blood flow to the jaws, which can cause a reverse
flow in the mental artery. The risk of fracture increases due to the reduction
in the cross-section of the mandible.
Since the teeth and the alveolar process in the maxilla are
physiologically inclined buccally and there is a narrow apical base, height
reduction of the bone results in a shift of the ridge center inward, ie,
centripetal atrophy of the maxilla (Fig 1-9). With a wide apical base and
inwardly inclined teeth in the mandible, the opposite occurs in the
mandible. The ridge center moves outward with the height reduction of the
alveolar process, ie, centrifugal atrophy of the mandible. This effect can
lead to a change in the jaw relationship, causing pseudoprognathism and
crossbites in the posterior region. The pseudoprognathism is exacerbated
because the vertical occlusal dimension usually decreases over the course of
life due to tooth attrition, abrasion, tooth extractions, and periodontal tooth

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migration, among other factors. This causes the mandible to rotate forward
in the temporomandibular joint.

Fig 1-7 Bundle bone is the anchorage of tendons and ligaments in the skeleton. The
alveolar process consists almost entirely of bundle bone, especially in the maxilla. Alveolar
bone is carried alongside the teeth as they erupt to the occlusal plane. When the teeth are
lost, the bundle bone also disappears, initially buccally and later lingually and palatally. This
effect explains the rapid volume loss of extraction sockets and alveolar ridge atrophy as a
physiologic and unavoidable phenomenon unless the bone is physiologically loaded again
by dental implants (ie, the bone-protective effect of dental implants).

Due to the shrinkage of their attachment sites on the tooth-bearing

alveolar process, the perioral mimic muscles lose their tension. The lips curl
in and narrow. Because of the loss of support of the teeth and alveolar
processes, the cheeks and lips collapse. As a result of the loss of vertical
occlusal dimension, the corners of the mouths tend to turn downward, and
lip incontinence may occur, causing drooling and Candida infestation. The
mentalis muscle increasingly loses its attachment to the anterior alveolar
process, and the chin may droop. All in all, the stigmatizing typical lower
face of a toothless old person develops. The decreasing chewing ability
often causes a change of diet to diabetogenic food and is statistically
correlated with premature onset of dementia,6 without a causal relationship
being proven. Thus, severe alveolar ridge atrophy is not a simple sign of
aging but a pathological condition with consequences for the whole

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organism. Masticatory rehabilitation with dental implants becomes a
general medical goal.

Fig 1-8 Patient with combination syndrome. a. The panoramic view shows the isolated
alveolar ridge atrophy in the anterior maxilla. The hard occlusal force of the mandibular
residual dentition meets the soft tissue–supported maxillary full denture, which repeatedly
tilts forward, especially under protrusive contacts, thus accelerating the physiologic alveolar
ridge atrophy in a localized manner. b. Irritational fibromas in the anterior maxilla caused by
ill-fitting full dentures. These pathologies of the vestibular mucosa result particularly when
full dentures are advanced anteriorly well beyond the ridge. If they are overloaded anteriorly
due to a combination syndrome and the occlusion is not balanced, the prostheses can
increasingly tip forward during advancement. In parallel, the corner of the mouth shows
candidiasis.

1.4 Classifications of Alveolar Ridge Atrophy

The atrophy of edentulous jaws as a whole is best described by the
international classification according to Cawood and Howell (1991)7 (Fig 1-
10).
The resorption stage of the individual implant site can be classified by
the quarter rule according to Terheyden (2010)8,9 (Fig 1-11). This
classification is based on the typical pattern of resorption of the alveolar
process after tooth extraction and has the advantage that suitable treatment
methods can be assigned to the respective stages (see chapter 12).
Initially, the facial alveolar wall usually resorbs first. If its coronal
portion is atrophied, an implant can still be placed with primary stability,
but a vestibular dehiscence defect is present (first quarter). With further
atrophy, the entire facial wall is resorbed, resulting in a knife egde ridge
(second quarter), with the oral wall still standing (corresponding to Cawood
class IV). At this stage, there is usually insufficient bone to stabilize an

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implant, so a staged bone augmentation is necessary. The next stage is a
reduction in the height of the ridge as a whole, with the oral wall still
partially intact (third quarter), until finally the alveolar process is
completely resorbed (fourth quarter; (corresponding to Cawood class V).
This consideration of the cross-section of the individual implant site
should be supplemented by an occlusal view of the alveolar bone envelope
(Fig 1-12). The term alveolar bone envelope was originally established in
the orthodontic and periodontal literature10 and describes the buccal contour
line of the alveolar bone in the dental arch. If intact neighboring
periodontium is present in a singletooth gap, this is referred to as a
contained defect within the envelope (single- or double-tooth gap with
intact neighboring periodontium). The situation becomes more difficult
with larger gaps or gaps without neighboring periodontium with a poorly
defined envelope or in the edentulous jaw with an undefined envelope.

Fig 1-9 Effects on alveolar bone atrophy. a. Alveolar ridge atrophy has resulted in
maxillary retroposition due to the oblique position of the superior alveolar process and the
narrow apical base of the maxilla (left image). The reduced vertical occlusal dimension due
to alveolar ridge atrophy has resulted in counterclockwise rotation of the mandible at the
pivot point of the temporomandibular joint. This has caused pseudoprognathism. Alveolar
bone augmentation (eg, by LeFort I interposition in the maxilla and sandwich interposition in
the mandible) leads to forward and downward movement of the upper alveolar process in
the direction of the red arrows. The goal is to create the conditions present with a full

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dentition (right image) through dental implants. b. Due to alveolar ridge atrophy, the perioral
mimic muscles have lost their bony attachment point. The lips become narrower and
inverted, and especially the mentalis muscle loses its upper attachment point at the level of
the roots of the mandibular incisors. As a result, the chin sags. Passive relining of the lips by
a dental prosthesis does not improve the muscle attachments or traction. Bony regeneration
of the alveolar processes can restore a condition similar to that before tooth loss. c. In
contrast to conventional complete dentures, implant-supported dentures can achieve better
pretension of the facial muscles because they do not dislocate as easily as conventional
complete dentures when the lips are pulling back. If the alveolar processes are also
reconstructed by bone augmentation, the mimic muscles regain their correct attachment
points. In addition, stretching of the lower face and retraction of the chin can be achieved by
increasing the vertical occlusal dimension, so that the nasolabial and supramental folds are
smoothed. The goal is a relaxed and younger facial expression as a side effect of
masticatory rehabilitation. (Adapted from Cawood.5)

Fig 1-10 The classification of alveolar process atrophy of the edentulous maxilla according
to Cawood and Howell.7 (Adapted from Cawood.5)

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Fig 1-11 Classification of the implant site following the natural resorption stages in quarters,
according to Terheyden.8

Fig 1-12 a. The position within the envelope (contour line of the dental arch) is important for
the prospective success of a localized augmentation. Also, it is favorable for success if a
defect is enclosed by bony walls (ie, a contained defect). b. The chances of success of a
localized augmentation increase if the augmentation volume is within the envelope.
Therefore, the implant should usually be placed against the palatal/ lingual wall and should
not be too large in diameter.

1.5 Alternatives to Alveolar Ridge Augmentation

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Augmentation surgery always comes at a price, in terms of surgical burden,
discomfort, and cost for the patient; surgical complexity for dentists and
their teams; and increased possibility of complications. The risks and
benefits of augmentation surgery should always be well communicated and
weighed. Many efforts are underway to reduce the surgical burden of bone
augmentation through alternatives and minimally invasive techniques.
Overall, the development of implantology, supported by new materials,
is showing that good masticatory function can be achieved even without
augmentation measures. This is particularly relevant for patients undergoing
antiresorptive therapies, which do not allow bone augmentation surgery at
all. Furthermore, the success of therapy is made less dependent on the
individual skill of a clinician, which is a general trend in medicine.
Examples of augmentationfree implant surgery are zygoma implants or the
renaissance of the subperiosteal-implants in severe alveolar ridge atrophy
(see chapter 14).

1.6 Prosthetic Versus Regenerative Approaches to

Defects
According to Newton, every movement produces a countermovement
(Actio = Reactio). Many patients and dentists today are no longer satisfied
with the osseointegration of an implant at any position for the mere fixation
of an overdenture; the implant is expected to be placed in the ideal
functional and esthetic position. In implant dentistry, a prosthetic approach
to treating defects can be differentiated from a regenerative therapeutic
approach, describing two polarizations of a continuum of options (Fig 1-
13).
In the defect prosthetic approach, missing tissue and function is
replaced by foreign material, ie, a prosthesis made of plastic, ceramic, and
metal, similar to a prosthesis for missing limbs. In this therapeutic
approach, the dental implant is a retaining anchor for the prosthesis.
Because the implant is also a risk factor due to the risk of biologic
complications, as few implants as possible are planned, sometimes as few
as only one. The rationale is that the patient can concentrate their hygiene
efforts on a few posts, and that fewer implants equate to lower costs.

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Fig 1-13 Prosthetic versus regenerative approaches to defect treatment.

The replacement of missing body parts with a prosthesis is the

conventional procedure in many medical fields; the regenerative approach
of augmentation is seen as the future.11 This approach has broader goals
than mere prosthesis retention, including a functionally and biologically
complete regeneration of the missing tissue by the body’s own material and
a long-term, if not lifelong, prognosis of implants. In regenerative
replacement, the primary function of the implant is as a tooth root for the
introduction of masticatory forces into the jaw. Only the introduced
masticatory forces initiate the functional remodeling of the tissues, which
ensures their lifelong preservation. In the body, only what is functionally
defined is preserved. Therefore, with this approach, there is also more of a
tendency for a higher number of dental implants. This concept incorporates
delicate dentures reduced to single crowns with little metal or other foreign
materials, almost a conservative dentistry approach.

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 In practice, the decision between the two therapeutic approaches is
usually relativized by the age of the patients, in that younger and healthy
patients tend to be good candidates the regenerative approach, and older
and sick patients are better served by the defect prosthetic approach. This is
related to the physical resilience, the service life, the baseline situation of
the defects, the patient’s hygienic ability, and the desired masticatory
function.

1.7 Soft Tissue Augmentation and Management

For didactic reasons, bone augmentation and soft tissue augmentation are
often treated in separate lectures and textbooks. In clinical practice, this
separation is difficult. This book instead follows a common path for both,
because a good implant prognosis requires a mucosal thickness of 3 mm12
and keratinized tissue width of 2 mm,13 which corresponds to the
dimensions of the biologic width. Also, bone grafts heal better and undergo
less resorption under thick soft tissues than under thin ones. Some of the
goals of bone augmentation, such as preventing gray show-through of
titanium (Fig 1-14), can also be achieved with soft tissue grafts, but their
long-term stability is not as well documented scientifically, with 1- to 3-
year data available,14 while 10-year data are available for the same
indication in bone.15 However, the soft tissues must also not be too high or
overaugmented to avoid the formation of pseudopockets as a space for
pathogenic flora. Finally, bone augmentation will only heal without loss if
the soft tissue wound above it heals reliably. Good soft tissue management
is therefore an inseparable part and a basic requirement of augmentation
surgery (see chapter 7).

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Fig 1-14 Titanium shows through thin soft tissues.

1.8 Risk Management: SAC Classification

Augmentation surgeries usually have an increased degree of difficulty
compared to simple implant placement and belong to groups A and C of the
SAC classification16 (Fig 1-15). Augmentation operations place higher
demands on the surgeon’s training and equipment than S-level implant
procedures:
Straightforward: No augmentation. This corresponds to a standard
treatment without increased surgical anatomical risks and/or prosthetic
problems.
Advanced: One-stage augmentation. In this situation, there is still
enough residual bone for simultaneous implant placement. This refers
to a demanding treatment with increased surgical and/or prosthetic risk
potential and corresponding equipment and training requirements for
the team.
Complex: Two-stage augmentation. In this situation, there is not
enough bone for simultaneous implant placement. Complex implant
treatment at the specialist level with associated risks is required.

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Fig 1-15 The SAC classification of the International Team for Implantology (ITI)16 for the
surgical and prosthetic aspects of implant treatment.

1.9 Teamwork
Due to the stress and risks of surgical intervention, many patients and dental
practitioners decide against implant treatment in cases of bone deficiency,
although perhaps both sides would benefit from an osseointegrated
prosthesis. By collaborating with surgically specialized colleagues with
appropriate expertise, this threshold can be lowered. The discomfort
associated with wound healing can be temporarily outsourced to the
surgeon by a referring dentist. Subsequent prosthetic treatment is performed
back in the home practice. In such a team, the family dentist functions as
the architect of the overall treatment, coordinating the individual steps and
continuing the patient’s care thereafter.

1.10 References
1. Härle F. Atlas der präprothetischen Operationen. Munich: Hanser, 1989.
2. Schwarz F, Sahm N, Becker J. Impact of the outcome of guided bone regeneration in dehiscence-
type defects on the long-term stability of peri-implant health: Clinical observations at 4 years.

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 Clin Oral Implants Res 2012;23:191–196.
3. Iglhaut G, Schwarz F, Winter RR, Mihatovic I, Stimmelmayr M, Schliephake H. Epithelial
attachment and downgrowth on dental implant abutments—A comprehensive review. J Esthet
Restor Dent 2014;26:324–331.
4. Schwarz F, Giannobile WV, Jung RE. Groups of the 2nd Osteology Foundation Consensus
Meeting. Evidence-based knowledge on the aesthetics and maintenance of periimplant soft
tissues: Osteology Foundation Consensus Report Part 2-Effects of hard tissue augmentation
procedures on the maintenance of peri-implant tissues. Clin Oral Implants Res 2018;29(Suppl
15):11–13.
5. Cawood JI. Reconstructive Preprosthetic Surgery and Implantology. In: Härle F, Champy M,
Terry BC (eds). Atlas of Craniomaxillofacial Osteosynthesis: Miniplates, Microplates and
Screws. Stuttgart: Thieme, 1999:123–136.
6. Cardoso MG, Diniz-Freitas M, Vázquez P, Cerqueiro S, Diz P, Limeres J. Relationship between
functional masticatory units and cognitive impairment in elderly persons. J Oral Rehabil
2019;46:417–423.
7. Cawood JI, Howell RA. Reconstructive preprosthetic surgery. I. Anatomical considerations. Int J
Oral Maxillofac Surg 1991;20:75–82.
8. Terheyden H. Bone augmentations in implant dentistry. Dtsch Zahnärztl Z 2010;65:320.
9. Cordaro L, Terheyden H. ITI Treatment Guide 7. Ridge Augmentation Procedures in Implant
Patients. Berlin: Quintessenz, 2014.
10. Wennström JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to
orthodontic tooth movement in monkeys. J Clin Periodontol 1987;14:121–129.
11. Eckert SE. Time to bid adieu to removable dental prostheses. Int J Oral Maxillofac Implants
2014;29:535.
12. Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Linkeviciene L. Influence of vertical soft
tissue thickness on crestal bone changes around implants with platform switching: A comparative
clinical study. Clin Implant Dent Relat Res 2015;17:1228–1236.
13. Giannobile WV, Jung RE, Schwarz F. Groups of the 2nd Osteology Foundation Consensus
Meeting. Evidence-based knowledge on the aesthetics and maintenance of periimplant soft
tissues: Osteology Foundation Consensus Report Part 1-Effects of soft tissue augmentation
procedures on the maintenance of peri-implant soft tissue health. Clin Oral Implants Res
2018;29(Suppl 15):7–10.
14. Rotundo R, Pagliaro U, Bendinelli E, Esposito M, Buti J. Long-term outcomes of soft tissue
augmentation around dental implants on soft and hard tissue stability: A systematic review. Clin
Oral Implants Res 2015;26(Suppl 11): 123–138.
15. Chappuis V, Rahman L, Buser R, Janner SFM, Belser UC, Buser D. Effectiveness of contour
augmentation with guided bone regeneration: 10-year results. J Dent Res 2018;97: 266–274.
16. Dawson A, Chen S, Buser D, Cordaro L, Martin W, Belser U. The SAC Classification in Dental
Implantology. Berlin: Quintessenz, 2011: 19 ff.

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 2
Biologic Basis of Bone Regeneration
and Wound Healing

Unlike machines, the human body does not require space-demanding

storage of spare parts; rather, self-repair unfolds on demand from a few
pluripotent stem cells. These lie as space-saving pericytes in the walls of the
blood vessels, which is practical because neoangiogenesis is already a
prerequisite for tissue regeneration for nutritional reasons.

2.1 Bone Tissue Structure

Vascular supply and bone marrow

Bone consists of soft and hard tissue. The soft tissue includes the bone cells,
the marrow, and the vessels necessary to supply them. Compact bone is
nourished by the central vessels of the haversian system (named after
Clopton Havers, English anatomist, 1650–1702) (Fig 2-1). Only the
outermost layers are nourished by diffusion from the vessels of the
periosteum. After surgical detachment of the periosteum, this part of the
bone becomes insufficiently supplied. Among other things, this
phenomenon is used as an explanation for why after periosteal detachment,
a small surface resorption of the bone of about 0.5 mm is observed.
The maxilla has a rather spongy structure and a peripheral blood supply
type. The maxilla is largely peripherally perfused with periosteal vessels via
various arterial flow areas (greater palatine artery, anterior and posterior
alveolar arteries, nasopalatine artery) through a plexus (Fig 2-2). Thus, the
maxillary bone is still nourished via the periosteum even if parts of the

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internal vascular supply are interrupted, for example, by osteotomies or
bone segment formation.
The mandible, on the other hand, has a much more sensitive vascular
supply of the central type. Large parts of the horizontal branch are perfused
almost exclusively via the central vessel of the inferior alveolar artery. Only
the middle portion of the chin arch receives its perfusion through some
vessels from the floor of the mouth. The central artery is often occluded as a
result of arteriosclerosis, especially in older patients, in which case there is
a reversal of flow in the mental artery.1 In addition to the nourishing vessels,
the bone houses the hematopoietic tissue in the bone marrow, which is a
fluid tissue without inherent stability. Inside the bone, unlike other sites in
the body, the bone marrow is located in a place of mechanical rest and
external stability. This is also the location of mesenchymal stem cells,
which are the origin of bone healing.

Fig 2-1 a. Bone is one of the tissues with a strong blood supply. There are cross
connections between the central vessels of the osteons, to the periosteum and into the
bone marrow. b. In toluidine blue staining, a cross-section through cortical bone looks quite

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homogeneous (Laboratory MKG Kiel, hard ground section, pig, original magnification ×20).
c. A similar preparation to 2-1b after intravital labeling with fluorescent dyes appears much
more vivid. It shows the formation of osteons in compact bone. After illumination with UV
light, the growth bands are shown by xylenol orange (2 and 3 weeks), calcein green (4 and
5 weeks), and alizarin complexone red (6 and 7 weeks) (Laboratory MKG Kiel,
undecalcified hard ground section, pig, original magnification ×20).

Fig 2-2 a. Peripheral blood flow type in the maxilla via multiple periosteal vessels. b. Central
circulation type in the mandible via the central vessel of the inferior alveolar artery.

Bone cells
The bone building cells possess progenitor cells (pluripotent mesenchymal
stem cells, osteoprogenitor cells), which represent a regenerative reserve. In
addition to the bone marrow, it is now known that the pericytes or
perivascular cells of the blood vessels are the pluripotent mesenchymal
stem cells.2 This is practical because there can be no major bone
regeneration without a blood supply. When needed, these cells differentiate
into osteoprogenitor cells and finally, after adherence to a matrix, into
osteoblasts that build osteoid and then wall themselves into the matrix as
osteocytes. Some cover the entire bone surface toward the medullary cavity
without gaps as lining cells. If there are gaps in the lining cell layer, eg, due
to surgical trauma, this is a signal for osteoclast development. This also
explains the surface resorption after periosteal detachment.

Osteoclast function
Osteoclast function is under the influence of osteoblasts. Osteoblasts
possess receptors for a wide variety of hormones and messenger substances

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and can produce RANKL (receptor activator of nuclear factor kappa-beta
ligand) under the influence of parathyroid hormone. Together with M-CSF
(macrophage colonystimulating factor), they thus control the confluence of
monocytic progenitor cells into multinucleated osteoclasts. Osteoclasts are
immune cells and, like macrophages, are derived from bloodstream
monocytes, which in turn are derived from bone marrow hematopoietic
stem cells. At sites where the lining cells detach, osteoclasts attach to the
vacant bone sites. The attachment requires the protein osteopontin from the
bone matrix, which binds in a ring with integrins from the osteoclasts. This
creates a kind of suction cup for the osteoclasts, within which a very
strongly acidic environment can be generated by proton pumps without the
acid escaping into the rest of the tissue. The acid decalcifies the bone so that
its proteins are now exposed for attack by acidic enzymes such as cathepsin.
The Howship lacuna is formed (named after John Howship, surgeon and
pathological anatomist, London, 1781–1841). By endocytosis, materials in
solution in the lacuna are transported to the interior of the cell, where they
are further digested. If bacterial lipopolysaccharide is present among these
molecules, rapid inflammatory resorption can be initiated by Toll-like
receptors,3 which usually leads to very rapid removal of bone or tooth
tissue. In contrast to replacement resorption, inflammatory resorption does
not fill the bone during bone remodeling; it is incompatible with bone
formation due to the proinflammatory wound environment. It leaves defects
and sequestra, so the bone surgeon takes preventive measures to ensure a
low bacterial presence in the wound.

Basic bone substance

The hard tissue of the bone is a composite material consisting of fibers and
filler, with the fibers absorbing tensile loads and the filler absorbing
compressive loads. There are many examples of such composites in
engineering (eg, reinforced concrete or glass fiber–reinforced plastic in boat
building). The bone matrix consists mainly of collagen (fibers) and mineral
in the form of hydroxyapatite crystals (filler). This mineral is practically
insoluble in water at pH 7.4, but this changes rapidly at an acidic pH (as in
caries formation). The mineral can be released from the bone composite by
acid treatment to access the proteins of the bone. The bone mineral
hydroxyapatite is the model for many bone substitutes; the body accepts

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certain technologically produced materials as artificial bone matrices, or the
bone precursor cells cannot recognize them as foreign due to the lack of
protein structures.

Nonsoluble hard substance proteins

The proteins remaining after dissolution of the mineral are divided into
soluble and insoluble bone proteins. Collagen type I is the most important
representative of the insoluble proteins in terms of quantity. The stability of
bone is determined by its internal structure. This internal structure results
from the direction of the collagen fibers, which, like wires, provide internal
tensile strength to the bone. The internal direction of the collagen fibers can
be visualized in polarized light. The basic building block of the mature
cortical bone is the osteon with the central haversian canal. In the lamellar
bone, the collagen fibers are wound around the osteon in a parallel, helical
pattern in opposite directions, like circular plywood, which explains the
high mechanical stability of this bone type. In contrast, the immature woven
bone initially forms during wound healing. In woven bone, the collagen
fibers are not arranged in parallel but in a braid-like pattern and can thus
absorb forces evenly from all directions.

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Fig 2-3 Bone components as they can be extracted by stepwise treatment with acids and
solvents. On their own, bone morphogenetic protein (BMP) and bone matrix are inactive.
Only when the individual components are recombined does an osteoinductive bone
substitute material result. For example, recombinant BMP can be combined with bone
substitute material to obtain an active graft.

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Fig 2-4 The four temporally overlapping phases of wound healing in soft tissue.

Soluble hard substance proteins

The soluble bone proteins can be solubilized from the decalcified bone
matrix by the solvent guanidine hydrochloride. The collagenous bone
matrix then remains (Fig 2-3). The soluble protein fraction contains, among
other things, signal molecules (growth factors and differentiation factors)
and about 40 known bone-specific proteins, such as osteopontin, bone
sialoprotein, and osteocalcin. The soluble fraction also contains bone
morphogenetic proteins (BMPs; about 1 mg per kg bone). Allogeneic bone
grafts are sometimes partially decalcified during manufacture so that the
natural BMPs are more available in the wound. The material is called
demineralized freeze-dried bone allograft (DFDBA).

2.2 Wound Healing

For didactic purposes, wound healing can be divided into four phases:
exudative, inflammatory, proliferative, and remodeling. Every wound,
whether in bone or soft tissue, passes through these four phases, which
overlap in time (Fig 2-4).

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Exudative phase (coagulum)
The first phase of wound healing is the exudative phase, which lasts from a
few minutes to hours. It is characterized by hemostasis by platelets and
polymerization of fibrin, which forms a provisional extracellular matrix.
This is necessary for the storage of growth factors and as a scaffold
structure for the migration of the wound-healing cells. When the bone is
mechanically injured by an implant osteotomy, a defect is created. Bleeding
into this defect occurs from the bone marrow. The coagulum adheres to the
wound edges, and the wound is mechanically stabilized by coagulation and
proteins, eg, fibronectin, in the first hours. Dentists are familiar with the
importance of blood coagulum due to the clinical picture of painful
fibrinolytic alveolitis (ie, dry socket).

Inflammatory phase (purification)

This phase is initiated by the degranulation of platelets and lasts for hours to
days. The signal substances released, vasoactive substances such as
bradykinin, act on the blood vessels in the wound margin. The blood vessels
become permeable, and edema develops. The blood flow velocity slows
down so that granulocytes can more easily become adherent to the vessel
wall and ultimately leak through fine gaps between the endothelial cells into
the perivascular space (diapedesis). Here they begin the destruction and
phagocytosis of bacteria, chemotactically attracted by bacterial products
such as lipopolysaccharides and by complement signals (opsonization =
marking of bacteria by complement proteins). Chemotaxis means attraction
with specific directional indication for migrating cells by a concentration
gradient. The additional cell volume of the inflammatory cells is clinically
recognizable as swelling. Granulocytes generate a toxic wound environment
through free oxygen radicals when they occur in large numbers, for
example, because they continually encounter new bacterial antigens. By
disintegrating, granulocytes release tissue-dissolving enzymes from their
lysosomes until the tissue is liquid and pus forms. Pus is a physiologic
cleansing mechanism of the body in continuation of the work of
granulocytes.
The granulocytes are followed by the macrophages, which can survive
under the oxygen-deficient conditions of a wound margin and here can

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initiate new vessel formation and thus the next phase by secreting vascular
endothelial growth factor (VEGF).

Proliferative phase (healing)

When a wound is clean, macrophages can secrete growth factors such as
transforming growth factor-b (TGF-b), insulin-like growth factor (IGF), and
VEGF. These factors induce the formation of the granulation tissue that
replaces the provisional matrix of the coagulum. The proliferative phase
overlaps with the adjacent phases and lasts for days to weeks. Stimulated by
VEGF from macrophages, perivascular cells of the adjacent blood vessels
detach, divide, and assemble into infiltrates. They coalesce and form tubes
that connect to existing blood vessels. They can then be perfused,
improving oxygen supply to the defect area. Following the vessels,
fibroblasts migrate chemotactically. These encounter the stored growth
factors in the extracellular matrix of the blood coagulum and begin collagen
formation. Up to this point, wound healing is largely nonspecific and
similar in soft and hard tissue wounds. However, the phases that now follow
occur much faster in soft tissue than in bone.
BMPs are responsible for the difference between wounds in bone and
those in soft tissue. They are stored in the bone and are released when the
bone is injured by fracture or osteotomy. An important source is also bone
chips (eg, via a bone scraper) or the drill dust in an implant socket, which
should therefore preferably not be rinsed out before implant placement.
BMP leads to the differentiation of mesenchymal stem cells into bone
precursor cells. The resulting osteoblasts can only exist on a firm
foundation and anchor themselves to bone structures in their environment,
mediated by integrins and osteopontin. When these anchorages signal
mechanical quiescence to the cells (mechanoreceptors), they begin
expressing bone-specific matrix proteins (osteoid), starting from the injured
bone surface.
If the proliferative phase proceeds undisturbed, the matrix mineralizes,
and woven bone is formed within a few weeks (Fig 2-5). Bone formation
can also proceed on osteoconductive surfaces within reach of osteoblasts.
Osteoconductive surfaces are dental implants or bone substitutes (Fig 2-6),
which must first be covered with a protein film. The fibronectin contained
in this layer is used by osteoblasts for mechanical anchorage. An

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intermediate stage of cartilage (endochondral ossification), as in the
extremities, does not occur in the jawbone, where intramembranous
ossification predominates.

Fig 2-5 Initial woven bone formation in the course of a sinus elevation with bone substitute
mixture after 6 weeks. Preosteoblasts condense and accumulate around an osteoid matrix,
which is already increasingly mineralized in the direction of the right margin of the image
(Laboratory MKG Kiel, undecalcified hard section, toluidine blue, pig, original magnification
×200).

Remodeling phase (conversion)

This phase lasts weeks to years in bone. It involves the load-dependent
remodeling of immature woven bone (collagen fibers disordered in random
direction) into mature lamellar bone (collagen fibers parallel in tensile
direction). Freely grafted bone and, within limits, some bone graft
substitutes are completely degraded over time and replaced by new bone.
This remodeling is also load-dependent because it has been observed that
bone is retained on occlusally loaded teeth and dental implants, whereas in
unloaded areas of the jaw it is usually quickly degraded again.

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Fig 2-6 Particles of xenogeneic bone substitute material (pink) are covered by blue woven
bone during healing following sinus elevation and are bonded together and integrated into
the bone. The foreign material is osteoconductive; it covers itself with fibronectin, on which
osteoblasts attach (Laboratory MKG Kiel, undecalcified hard section, toluidine blue, pig,
original magnification ×200).

2.3 Wound Balance: Proinflammatory and Anti-

inflammatory Wound Environment
The image of a scale (Fig 2-7) helps the physician to understand wound
healing as a quantitative problem, for example, the quantitative depletion of
defense cells when bacterial inoculation becomes too high or the
quantitative consumption of antibodies when antigens become prevalent.
In the wound environment, a distinction must be made between
proinflammatory polarization and anti-inflammatory polarization as the two
sides of the scale. Regeneration and tissue formation only occur in the anti-
inflammatory milieu, while the proinflammatory milieu ensures degradation
of the extracellular matrix of the tissue. The amount of collagen currently
present in the tissue is the equilibrium of constant formation and
degradation of collagen. When degradative enzymes are secreted by
granulocytes, the balance is shifted in the direction of degradation, because
the granulocytes make room for themselves in order to be able to move
through the tissue more easily. The clinical effect is the bleeding tendency

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of the inflamed gingiva, which bleeds on probing because collagen has been
degraded. The proinflammatory milieu (Fig 2-8) is accompanied by matrix
metalloproteinases and other matrix-degrading enzymes and consequently a
low content of extracellular matrix and growth factors. Furthermore,
proinflammatory cytokines, free radicals, and an acidic environment are
found. Acid belongs to inflammation and is part of the bacterial defense
mechanism of inflammation. The proinflammatory milieu also includes the
urokinase plasminogen activator (uPA), which leads to dissolution of the
coagulum and can cause fibrinolytic alveolitis (dry socket). Other examples
of non-healing wounds that chronically persist in the proinflammatory
mode are leg ulcers or gastric ulcers. Chronic secreting wounds remain in
the proinflammatory state.
The anti-inflammatory environment includes the opposite, ie, much
extracellular matrix and many growth factors. Important components of the
extracellular matrix are fibronectin and proteoglycans. Important tissue
growth factors include fibroblast growth factor (FGF), IGF, and TGF. High
levels of tissue inhibitors of metalloproteinases (TIMPs) inactivate
proteolytic enzymes. The anti-inflammatory environment is slightly basic
with the natural tissue pH of 7.4. A basic pH is part of regeneration. Such a
wound no longer secretes and heals dry.
The scales of wound healing can therefore tilt in both directions (see Fig
2-8). In both environments, macrophages play the leading role; they can
determine the further fate of the wound with their polarization (M1 or M2).
M1 polarization promotes the inflammatory milieu by secretion of
proinflammatory cytokines.4 The M2 polarized macrophages promote
angiogenesis, oxygenation, and extracellular matrix assembly through
secretion of growth factors.5
From what has been said, it is clear that tissue regeneration and thus
alveolar ridge augmentation and osseointegration of an implant are tied to
an antiinflammatory environment. Anything that lowers the pH (eg, decay
products of polylactide materials), stimulates the release of
proinflammatory cytokines such as IL-1b or tumor necrosis factor-α (TNF-
α) (eg, macrophages upon antigen contact), or degrades extracellular matrix
(eg, fibrinolysis) stands in the way of bone formation. So the physician
should try to shift the wound balance to the anti-inflammatory side. An
example of weighing the balance on the anti-inflammatory side is the
introduction of extracellular matrix into the wound in the form of collagen

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membranes, collagen fleece, or collagen powder.6 This acts like a magnet
on the hypervalent proteases of the inflammatory environment and causes a
substrate inhibition of this enzyme so that the endogenous collagens of the
connective tissue are spared.7 This is an additional explanation for the
effectiveness of the collagen membrane in guided bone regeneration (see
chapter 6).

Fig 2-7 Diagram of wound equilibrium intended to illustrate wound healing as a quantitative
process. A non-healing wound contains M1 polarized macrophages of the proinflammatory
environment; a healing wound contains M2 polarized macrophages of the anti-inflammatory
wound environment. The macrophages are the switch point of the transition from the
inflammatory to the regenerative phase. IL-1, interleukin-1; TNF-α, tumor necrosis factor-α.

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Fig 2-8 a. The anti-inflammatory wound environment of a healing wound is characterized by
a high content of extracellular matrix (fibrin, collagen, fibronectin) and growth factors
(VEGF; TGF; FGF, fibroblast growth factor; KGF, keratinocyte growth factor; PDGF, platelet-
derived growth factor) and by neoangiogenesis. Tissue inhibitors of metalloproteinases
(TIMPs) prevent collagen degradation by inhibiting proteases. b. The proinflammatory or
toxic wound environment of a non-healing wound contains cytokines such as TNF-α, many
granulocytes, and a weak extracellular matrix with few blood vessels. In the marginal area,
hyperemia is present; centrally there is a lack of blood vessels. The toxic wound
environment contains oxygen radicals that kill bacteria and somatic cells. Aggressive
proteases are also found, which break down collagen and ultimately liquefy the tissue to
form pus.

2.4 Bone Remodeling

In the body of young healthy patients there is usually no bone older than 3
to 4 years; later in life the renewal period extends to about 10 years.8 Bone
tissue is continuously and abundantly rebuilt. The continuous remodeling
explains how, some time after a bone injury, the bone can regain its
anatomically correct shape without a visible scar; how bone grafts heal; and
how the bone can functionally adapt to the occlusal forces of a dental
implant.
The balance between the responsible cells, the osteoclasts and the
osteoblasts, is ensured by their molecular coupling, among other things, via
the BMPs stored and chemically bound in the bone matrix. The cell
complex consisting of degrading and remodeling cells is referred to as the

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bone multicellular unit (BMU) (Fig 2-9) and is the biologic basis of the
equilibrium that keeps bone mass constant despite constant remodeling. At
any given time, about 1 to 2 million BMUs are active in the body under
healthy conditions.8
In the healing process of a bone block for augmentation, a distinction
must be made between resorption from the surface, which costs
augmentation height and volume, and internal resorption. Sometimes too
much surface resorption of the bone is undesirable, eg, over the facial
implant surface or after bone grafting. In contrast, rapid internal resorption
with rapid graft remodeling is desirable. The resorption phase in the BMU
lasts about 30 to 40 days, followed by reconstruction over approximately
150 days.9 After the bone is degraded by osteoclasts, a rest period of several
days occurs during the reversal phase.10 The growth and differentiation
factors (BMPs) bound in the bone are exposed on the surface. So-called
reversal cells11 clean the cavity and line it with a protein film. This cement
line serves as an attachment point for the osteoblasts that subsequently
move in. The reversal cells can enzymatically detach the superficial fringe-
like proteins protruding from the bone, including the growth factors, by
serine proteases.12 The coupling of osteoclasts and osteoblasts, ie, the
balance of degradation and attachment, is thought to be regulated by the
matrix-bound cytokines such as IGF and BMP, among others.13,14 According
to this theory, BMP goes into solution and can now stimulate the receptors
of osteoprogenitor cells, which initiates differentiation of the cells into
osteoblasts. This differentiation only goes on for so long, as fresh BMP is
found and limits itself when the Howship lacuna is replenished. Ideally,
osteoclasts and osteoblasts are so precisely balanced by this molecular
coupling that neither osteoporosis nor osteopetrosis develops. Similarly,
BMPs are also released from the matrix by the dentist crushing autogenous
grafts (eg, using a scraper). Thus, bone chips differentiate stem cells into
osteoblasts that build new bone.

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Fig 2-9 The BMU is the model of coupling osteoclasts (OCl) and osteoblasts (OBs) so that
bone volume remains in balance and osteoporosis does not develop. Through parathyroid
hormone (PTH) and other signals or signaling by osteocytes (OCy) from within the bone,
the osteoblasts and lining cells detach from the bone surface and form a canopy. Under this
canopy, blood monocytes (blue, center) fuse into osteoclasts after stimulation with
granulocyte colony-stimulating factor (GCSF) and RANKL and degrade bone in the
resorption lacuna. This exposes BMPs at the bone surface, which in turn stimulate bone
progenitor cells derived from pericytes (green) of the blood vessels and from mesenchymal
stem cells (MSCs) to fill the resorption lacuna. Thus, BMPs play a physiologioc role in
keeping bone resorption and bone rebuilding in balance. Therapeutically, BMP can also be
exposed by milling the bone or creating bone chips. PGs, prostaglandins.

Cutting cones in compact bone

Remodeling, which occurs in numerous isolated Howship lacunae in
trabecular bone and woven bone, is more concentrated in compact bone.
Here, assemblies of many osteoclasts are found at the tip of a vascular loop
of artery and vein. Together, they form a bone cutting cone (Fig 2-10) that
can bore a tunnel into cortical bone at an astonishing rate of 1 mm per day
(Fig 2-11). Coupling to reconstruction by osteoblasts occurs just as in the
Howship lacuna by BMP, but concentrically around the entire tunnel wall.
Here, the osteoblasts build up new bone layer by layer in opposing turns of
the collagen fibers, which continue to line the tunnel from the inside. This
creates a new osteon. This remodeling process is particularly important for
the incorporation of cortical block grafts. According to a somewhat

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mechanistic idea of the author, but confirmed in the clinic, block grafts
should be joined as closely as possible to the existing bone so that the bone
cores from the supporting bone can penetrate into the graft.

Fig 2-10 The bone cutting cone is a multiple-resorption lacuna as it occurs due to the
cooperation of countless osteoclasts in the cortical bone. The tunnel of the bone drill core
fills up again with concentrically deposited lamellar bone as drilling progresses posteriorly.
Thus, a new osteon is formed. Through this process, cortical bone grafts are repositioned
and incorporated.

Creeping substitution
It is now possible to introduce bone grafts into this remodeling process;
grafts are also completely remodeled into host bone after 3 to 4 years. These
can be free avascular autogenous grafts, but also gently processed
allogeneic grafts, which then also contain BMPs. Even gently processed
xenogeneic bone grafts still have an osteoinductive effect because BMPs
show little variation across species and are active across species at human
receptors. Even purely mineral xenogeneic and alloplastic bone substitutes
are remodeled as long as they are integrated in bone and can be reached by
cutting cones, and as long as they are dissolved by osteoclasts through acid,
which is only true for certain mineral materials (Fig 2-12).

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Fig 2-11 Intravital fluorescence labeling (see Fig 2-1c) shows two cutting cones with two
osteons in the process of formation over several weeks. The dark material on the left is the
defect wall of cortical bone. The defect lumen in the right two-thirds of the image has initially
filled with layers aligned parallel to the wall. The load-oriented remodeling is perpendicular
to it (mandibular defect treated with BMP-7, Laboratory MKG Kiel, undecalcified hard
ground section, pig, original magnification ×20).

A free (nonvascularized) bone graft is thus attacked by osteoclasts from

the recipient bone tissue of the bone defect, degraded, and replaced by new
vital bone as part of the remodeling process. This process of internal
resorption takes 3 to 4 years and is called creeping substitution. Due to the
proportion of new bone, the graft takes on functional forces over time and is
subsequently not degraded. This effect is seen in follow-up examinations
for remodeling of dental implants placed in bone block grafts15 (Fig 2-13).
The functional adaptation of the bone structure is called Wolff’s law (“Law
of the Transformation of Bones” by Julius Wolff, 1892, Orthopedist,
Berlin).

2.5 Resorption Protection of Bone Grafts

Internal resorption in the interest of rapid vascularization of the graft is
desired and should be promoted by tightly joining the bone graft to the bone

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surface and by opening up the bone marrow cavity through perforation of
the recipient bone surface (see Fig 2-13).
Surface resorption, on the other hand, is undesirable because it leads to
loss of augmentation height, loss of planned contour and, in the case of
dental implants, exposure of the roughened implant surface with recession
of the gingiva, visible exposure of crown margins, and risk of peri-
implantitis.

Fig 2-12 The high magnification shows that Bio-Oss (Geistlich) is also degraded by
osteoclasts during the remodeling of a bone regenerate if it stands in the way of the load-
oriented remodeling of the spongiosa (Laboratory MKG Kiel, undecalcified hard section
Toluidine blue, pig, original magnification ×400).

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Fig 2-13 Placement of a cortical bone block graft on the mandible of a patient. a. Bone
defect (3/4 according to the Terheyden quarter rule; see Fig 1-11) in the lateral mandible,
prepared by grinding and perforation of the cortical bone. b. A block from the external
oblique ridge of the mandible on the same side is fixed in vertical overlap for vertical
augmentation by three osteosynthesis screws. c. The contour gaps and the space to the
lingual are filled with a mixed particulate bone graft (25% autogenous bone chips, 75%
xenogeneic bone substitute material). d. The graft is covered by a collagen membrane (Bio-
Gide, Geistlich).

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Fig 2-13 e. After flap mobilization, the wound is closed by single interrupted sutures that are
not too tightly placed. The incision exactly in the middle of the remaining attached gingiva
facilitates tight suturing. f. When reopening the wound 4 months later, integration of the
block and the particulate grafts is well advanced. Such a re-entry operation is usually not
necessary with the block graft, as the screws can also be removed via stab incisions, thus
avoiding renewed surface resorption. g. The newly built up and partly vertically augmented
bone is sufficiently wide to circumferentially surround the dental implants. Together with the
osseointegration of the dental implants, the bone block has another 3 months to remodel. h.
A radiographic study after bone block grafting with simultaneous placement of dental
implants showed that remodeling under masticatory loading takes about 2 to 3 years before
a plateau occurs. (Fig 2-13h modified from Michalczik and Terheyden.15)

Because resorption of bone grafts is always by osteoclasts, these cells

should be inhibited to minimize surface resorption. Three principles should
be mentioned here: highly mineralized bone grafts, shielding of the surface
by membranes, and overlaying with bone substitute materials. Because
osteoclasts degrade bone through acid, a highly mineralized bone graft,
such as from the cranium or the external oblique ridge of the mandible,
resists acid attack longer or buffers the acids.16 Because osteoclasts
originate from bloodstream progenitor cells, a membrane should separate
the blood vessels of the covering soft tissue flap from the bone graft
surface,17 thus blocking the pathway for osteoclasts (Fig 2-14). These cells

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only gain access to the bone surface after a few weeks, when blood vessels
have overgrown from the depths. Overlaying with a slightly basic calcium
phosphate–based bone substitute has both effects, shielding the bone and
buffering the acids or depleting the osteoclast capacity.18 The resorption
inhibition can be done selectively with bisphosphonates, which are also
used clinically in orthopedic surgery for hip joint prostheses.19 In dental
implantology, these approaches are still in the experimental stage.20

Fig 2-14 Resorption protection by a membrane. a. Single case observation of a patient

with an edentulous gap from the right canine to the left lateral incisor sites and horizontal
alveolar ridge atrophy with a Terheyden 1/2 defect. The implants placed at the same time
show extensive vestibular dehiscence defects. b. The exposed implant portions are covered

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by trimmed autogenous block grafts from the external oblique ridge of the mandible, fixed
by micro lag screws with two screws per block. c. The contour gaps are filled with
autogenous bone chips. d. Only the right maxilla is protected by a collagen membrane (Bio-
Gide). e. Reentry 4 months later shows complete coverage of the implants on the right side
but a new dehiscence defect of 1 to 2 mm due to surface resorption of the bone graft at the
left central incisor implant, which had not been covered by the membrane.

Fig 2-15 Osteoconduction. Six weeks after Onlay osteoplasty on the lateral mandible.
Particles of bone substitute material (tricalcium phosphate) lying close to the bone base are
already incorporated by bone. Distant particles are located in the soft tissue (Laboratory
MKG Kiel, rat, original magnification ×20).

2.6 Osteoconduction and Osteoinduction

Osteoconduction refers to the formation of new bone tissue by appositional
growth from the walls of a graft recipient site (Fig 2-15). Osteoconduction
is based on differentiated cells of the bone bed. Because of this prerequisite,
osteoconduction proceeds very slowly. It may take months for a sinus
elevation graft, for example, to ossify by this process (Fig 2-16), and this
ossification occurs in the form of a gradient only from the bony defect walls
(Fig 2-17), taking a longer period of time to reach the dental implants.
Osteoconductive bone substitutes improve appositional bone growth
potential and allow critical-size defects, defined by a lifetime of failure to

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heal spontaneously, to heal. The bone substitute acts as an artificial bone
matrix and serves as a scaffold for existing osteoblasts. Osteoconduction is
often competing with scar healing of a defect by fibroblasts, which quickly
gain the upper hand because they grow faster.

Fig 2-16 Osteoconduction. The image shows a gradient of bone formation over 12 weeks
in the direction of the arrow after sinus floor augmentation with xenogeneic bone substitute.
The sinus floor, as the starting point of bone formation, is at the bottom. No bone formation
has yet occurred in the area of the arrowhead (Laboratory MKG Kiel, toluidine blue, pig,
original magnification ×200).

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 Osteoinduction is new bone formation by differentiation of bone cells
by BMPs from connective tissue precursor cells (stem cells), which are
ubiquitously present in the body as pericytes of blood vessels (Fig 2-18).
Therefore, osteoinduction also functions in a non-bony (ectopic) bed, for
example in the musculature, independent of the presence of osteogenically
differentiated cells. In a sinus elevation with osteoinductive materials,
ossification occurs abruptly at many sites simultaneously without gradients,
wherever blood vessels with their pericytes are present. The implant surface
is also engaged at an early stage (Fig 2-19).21 Only some BMPs, such as
BMP-2, -7, and -9, induce the differentiation of bone progenitor cells.
Materials can only be osteoinductive if they contain BMPs: first and
foremost autogenous bone grafts, but also allogeneic grafts and even
xenogeneic grafts if they are prepared in a protein-conserving manner or
used fresh, as well as native and recombinantly produced bone
morphogenetic proteins.

Fig 2-17 Contact microradiography matching Fig 2-16 shows the gradient of
osteoconduction starting from the sinus floor in the direction of the arrow. Increased
magnification of the same toluidine blue–stained hard section shows that the dental implant
is still not osseointegrated 12 weeks postoperatively. In this respect, osteoconduction by
bone augmentation material alone is an ineffective process (Laboratory MKG Kiel, pig).

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Fig 2-18 Osteoinduction. Mesenchymal stem cells, which are ubiquitously present in blood
vessels, are induced into bony differentiation by BMP. When growth factors act on the
differentiated cells, they divide and form new bone in a multicentric manner without a
gradient.

Fig 2-19 Osteoinduction. In contrast to Fig 2-17, gapless osseointegration of the implant
can be observed 12 weeks after sinus floor augmentation by BMP-7 with xenogeneic bone
substitute as a carrier substance (left, toluidine blue, original magnification ×4).
Osteoinduction has a simultaneous multicentric effect as soon as blood vessels have
penetrated the defect by neoangiogenesis, which takes about 2 weeks under favorable

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conditions. Fluorochrome labeling (right, original magnification ×100) showed main bone
growth between the 3rd and 6th week (Laboratory MKG Kiel, pig).

2.7 Factors Influencing the Healing Potential of Bone

Defects

Prerequisites for undisturbed bone healing

Osteoblasts exist only if they can anchor themselves to a substrate via

integrins. If the substrate has too much mechanical instability, these cells
dedifferentiate, fibrous tissue is formed as, for example, in pseudoarthrosis.
Mechanical stability is thus the first important basic prerequisite for bone
healing, along with the coagulum, a phenomenon that is well known from
fracture treatment. The third prerequisite is a bony bed or BMP from bone
grafts, because bone does not usually form in free tissue without the
possibility of apposition.
Mechanical stability
Stable coagulum
Bony bed (or BMP from bone grafts)

Defect shape and size

Whether a jawbone defect heals completely as bone or
partially/predominantly as connective tissue is primarily a question of the
shape of the defect. This is due to the access to the BMPs in the bony defect
walls. Second, bony healing is size-dependent, because neoangiogenesis
can usually bridge only a few millimeters in the tissue. Soft tissue wounds
therefore reduce larger distances by scar shrinkage, which bone cannot.
Shaft-like deep narrow bone defects of a few millimeters’ width, for
example, a fracture or an extraction socket with high bony walls, fill up
better with bone than bowl-shaped superficial defects. In terms of shape, the
interfaces of the defect with the adjacent bone are significant. The less bone
contiguity, the less likely spontaneous bony healing will occur.

Local and general factors influencing the organism

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Local factors influencing bone healing are, for example, the intactness of
the periosteum in the covering flap, and generally the quality of the
surrounding defect bed, which is also referred to as a weak or strong
replacement bed. This classification mainly refers to soft tissue scarring and
the condition after trauma or previous surgery. Other local factors
influencing intraoral bone healing are mechanical stability, eg, lack of
interference by tongue pressure or chewing movements in unfavorable
defect locations, especially when using soft tissue–supported removable
provisional prostheses, which should therefore be avoided as much as
possible during augmentation.
General factors influencing the organism include the smoking habits of
the patient. Nutrition also plays a role in the healing potential of bone
defects. For example, collagen formation in any bone healing process
requires vitamin C to hydroxylate the amino acids proline and lysine. The
enzyme protocollagen hydroxylase produces the amino acids
hydroxyproline and hydroxylysine in the protein chain of collagen. The
enzyme requires vitamin C22 as a cofactor, which has also been shown
clinically in substitution experiments in bone grafting.23 Free sugars in the
diet, on the other hand, promote inflammation.24 A corresponding change in
diet could, for example, mitigate chronic periodontitis.25

2.8 Defect Classes and Augmentation Techniques

The following defect types in dental surgery are classified according to their
clinical healing tendency (Fig 2-20). As the degree of difficulty increases, a
distinction is made between inlay, interpositional, attachment, and onlay
grafts. However, it is not only the degree of surgical difficulty that
increases, but also the requirements for the healing potential (cell content,
BMP content) of the bone graft. This is because the number of bony defect
walls decreases with each stage, and the contact surfaces to the existing
bone are the origin of osteoconductive growth. The fewer contact surfaces
there are, the more healing must be based on osteoinduction of the bone
graft.

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Fig 2-20 Defect classes.

Angiogenesis in bone defects

In unfavorable defect shapes and locations or in the case of mechanical
instability, bony regeneration may only include the basal particles of the
bone substitute material, because angiogenesis at the alveolar ridge does not
penetrate further than 3 to 4 mm into a foreign material. A meta-analysis of
all relevant published results on alveolar ridge augmentation revealed a
maximum horizontal and vertical buildup height of 3.7 mm for particulate
materials.26 Onlay grafts with particles of bone substitute material that
extend beyond this distance are only integrated into connective tissue; the
bony buildup of the regeneration volume is incomplete (Fig 2-21).
Frequently, particles that are not incorporated are then rejected. According
to the results of this meta-analysis, significantly more bone (5.8 mm) could
be built up vertically with bone blocks, which is due to the placement of the
blocks over bone cutting cones that can penetrate far into the graft via
creeping substitution (Fig 2-22).

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Fig 2-21 The results of the meta-analysis by Troeltzsch et al26 show a threshold of 3.7 mm
for augmentation with particulate material. Only with bone blocks is a greater augmentation
dimension possible since these are not vascularized by neoangiogenesis but rather by
creeping substitution from cutting cones.

Internal bone defects

Inlay grafting, interposition (sandwich), and bone-splitting augmentation
techniques create internal bone defects. In these cases, if performed
correctly, the augmentation material lies between two or more bone walls
with blood supply, so that it can be vascularized from multiple sides. In the
case of appositional grafts and onlays under barrier membranes,
vascularization starts from only one wall at the defect base. Normally, as
mentioned above, the potency of neoangiogenesis of the jaw is only
sufficient to vascularize about 3.7 mm of an overlying bone substitute.
Bone substitute material lying further away from the bone then only
heals fibrously into a scar and no longer forms new bone. However, if
angiogenesis occurs from two sides, the distance is doubled (Fig 2-23).
Because of the good healing tendency, internal defects can usually be
treated with osteoconductive bone graft substitutes and do not require such
high-quality autogenous grafts, eg, from the iliac crest. For inlay defects
such as in the case of sinus elevations, where more than two walls are
composed of bone, filling with a material is not mandatory at all, shown by

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the concept of graftless sinus floor augmentation, where only a blood
coagulum fills the subantral space.

Fig 2-22 Schematic drawing of bone augmentation by bone substitute (BS) material with a
height greater than 3.7 mm, covered by a collagen membrane. Up to the threshold of 3.7
mm, the BS particles are integrated by vessels from the bone surface. Beyond 3.7 mm, the
particles become vascularly integrated only when the membrane degrades and allows
transmembrane angiogenesis. The associated stem cells are no longer osteogenically
differentiated; therefore, only a fibrous regenerate arises in this area.

2.9 Mechanism of Impaired Wound Healing and Wound

Dehiscence
In a problem wound, for example, with persistent bacterial contamination
by a biofilm, the granulocytes retain dominance and create a toxic wound
environment. They release aggressive enzymes (collagenases) that dissolve
the collagen of the tissue. In addition, toxic radicals, which are supposed to
kill bacteria, can also kill healthy cells as collateral damage. As a result, the
tissue of the wound margin loses stability and vitality, looks irritated, and
becomes tender, ie, mechanically unstable. In the case of wound tension, eg,
due to insufficiently mobilized flaps, there is also a disturbance of the blood
supply to the flap. Similarly, sutures that are too tight or stitches that are too

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dense have a negative effect by reducing the blood supply to the wound
margins. Due to collagen degradation, the sutures tear out, and wound
margin dehiscence becomes clinically visible because the flap retracts (Fig
2-24). This all happens well in advance of any visible suppuration. Because
there is no purulent infection initially, it is usually still worthwhile to
perform a secondary suture after debridement of the wound during the
initial dehiscence. This removes the biofilm and tissue debris as a
proinflammatory stimulus for the granulocytes.

Fig 2-23 In this adaptation of schematic drawing of the Terheyden implant defect classes
(see Fig 1-11), the circles symbolize the distance that a blood vessel must travel from the
bone surface by neoangiogenesis in order to reach the most distant particles of the bone
substitute material during augmentation. It can be seen that actually only the 1/4 defect is
suitable for augmentation by particulate materials because in the higher defect classes the
distance exceeds 3.7 mm. Only the surgical conversion of the 4/4 defect by sandwich
osteotomy allows treatment with particulate bone substitute material, since the graft is now
in an intermediate position between two vascularized bone surfaces and can therefore be
accessed from two sides.

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Fig 2-24 a. Onset of dehiscence 8 days after bone block grafting. b. With continued
observation without intervention, wound dehiscence increased 14 days postoperatively. Still
no purulent wound infection is present. This block graft was later lost via sequestration.
Rapid intervention by secondary suturing would have been simple and much more
successful.

Fig 2-25 The threads of the suture with bacterial deposits after 1 week. Twined sutures in
particular are a good interface for bacteria to form a biofilm. The bacteria can use the
sutures as an intermediate base to invade the wound.

2.10 Biofilm as a Triggering Factor of Impaired Wound

Healing

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In medicine, the problem of biofilm-related infections has been recognized
relatively recently.27 Probably all nonobligate intracellular human
pathogenic bacteria and fungi can form biofilms.28 Biofilm-related
infections are therefore problematic because the biofilm protects the
bacteria from antibiotics both mechanically and through biologic resistance
mechanisms.29 Wound infections,30 periprosthetic joint infections, and
osteomyelitis are also known to occur in orthopedic surgery due to the
biofilm problem.31
In the jaw and in intraoral surgery, most infections or wound
dehiscences in augmentation surgery occur clinically 4 to 10 days
postoperatively because bacteria first need a certain amount of time to build
up a biofilm. Without this, they cannot survive in the host. It can be
assumed that these biofilms advance per continuitatem from the adjacent
teeth, across the suture gaps, and through the channels of the suture
materials into the depths of the wound (Fig 2-25). In the case of onlay grafts
in particular, the materials are located close to the surface, in contrast to
graft placement in internal bone defects. It is illusory to assume that, for
example, a microscope can be used to suture the wound so tightly that
bacteria cannot penetrate through the gaps in the suture into the deeper
layers of the wound.
Suturing techniques cannot adequately address the problem of wound
dehiscence.
As soon as the bacteria in the wound encounter hard material and thus
an interface from solid to liquid, they can adhere and begin to build up a
biofilm. Such biofilms always form at solid-liquid interfaces. The bacteria
attach to the solid side and can thus benefit from the shear motion of the
surrounding liquid. They also need this because otherwise the surrounding
solution would be free of substrate in a short time but full of metabolic
products, which would suffocate the bacteria. The shear movements of the
liquid are the reason why corals build up supporting scaffolds and why
biofilms can establish on boat hulls, which painting with antifouling can
hardly stop. The tooth surface is also an example of a solid-liquid interface
and is known to accumulate plaque. Solid-liquid interfaces allow bacterial
growth and are the reason why polytetrafluoroethylene (ePTFE) membranes
produce more dehiscence compared to soft collagen materials. Collagen is
water soluble, so it is present in the wound in the form of a soft gel that
does not allow shear movement but rather floats in the fluid stream. A bone

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block graft provides a solid-liquid interface. The softness of leukocyte- and
platelet-rich fibrin (L-PRF) and platelet-rich plasma (PRP) gels may be a
very obvious reason why these materials promote intraoral soft tissue
healing. They cannot establish interfaces with shear movements against the
wound fluid.

2.11 The Race of Bacteria Against Angiogenesis

It can be assumed that the augmentation materials are usually placed
sterilely in the wound after preoperative bactericidal single-shot antibiosis.
But especially with onlay bone substitute grafts, the materials lie close to
the surface under the suture gaps. It is probably too mechanistic to think
that a suture will permanently prevent bacteria from penetrating into the
deeper layers of the wound.
Transplanted foreign or autologous material is avascular and initially
has no defense of its own. It takes about 14 days for blood vessels to grow
into the material.32 Until then, secondary biofilms can also form on a
primarily sterile material. Only after 14 days, when the foreign material is
integrated into perfused tissue, can the defense cells penetrate to the
material and henceforth keep it free of bacteria. The concept of successful
wound care is based on impeding the advance of bacteria to the biomaterial
as long as possible during the sensitive first 14 days, so that the advancing
blood vessels win the race against the advancing bacteria (Fig 2-26).

2.12 Clinical Consequences: Prevention of Wound

Dehiscence
To avoid wound dehiscence over bone grafts or over the surface of hard
foreign materials, it makes sense to obstruct bacteria (see chapter 15).
This obstruction of bacteria occurs clinically by simply lengthening the
pathway by deep placement of the bone substitute using inlay and
interpositional rather than onlay grafts. Therefore, onlay grafts are more
risky than interpositional grafts. Vestibular incisions are safer than
midcrestal incisions for onlay grafts, but vestibular incisions are
nonphysiologic for soft tissue perfusion and should be avoided; therefore it

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is the augmentation procedure rather than the incision pattern that should be
modified.
The migration of bacteria can be hindered by the suture technique. Even
if it is impossible to achieve a bacteria-proof suture until healing is
complete, gently sutured vital tissue with a good blood supply can
counteract the bacteria with its innate immune defense. The goal of suturing
is therefore a macroscopically firm adaptation of well-perfused wound
margins, which is most likely to succeed with incisions within the attached
gingiva, ie, in the center of the alveolar ridge and gingival sulcus.

Fig 2-26 Guided bone regeneration wound: race between neoangiogenesis and the
biofilm. In the left image, the blood vessels manage to vascularize the bone substitute
particles (BS; blue) before the biofilm has grown in per continuitatem through the wound
gaps. In the right image, the bacteria (red dots) were faster and able to establish a biofilm
on the interface of the BS with the wound fluid, shielding them from immune defense. This
toxin-laden part of the particles is later purulent and rejected, failing to osseointegrate (see
Fig 2-8).

Once the suture has been overcome by bacteria, it is necessary to block

their further access. This is done intraoperatively by inserting a barrier
membrane. Collagen membranes block the path of the bacteria for some
time until they have been digested by bacterial enzymes. This takes only
hours with an exposed collagen membrane. Placing other soft materials,
such as PRF membranes and collagen fleece, beneath the collagen
membrane is also beneficial because these materials are hydrophilic and
form a type of gel that does not build up an interface with the body fluid.
Two-layer coverings or soft tissue flaps that are as thick as possible (ie, soft

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tissue augmentation) also extend the distance that bacteria must travel.
There are clinical examples of all of these methods.
It is also very effective to prevent bacteria from growing in the first
place by limiting solid-liquid interfaces. In other words, the less foreign
material you introduce into the wound, the more likely you are to avoid
infection. A good example is distraction osteogenesis, which requires no
foreign material other than the distractor and virtually never results in
clinical infection.
If a biofilm has formed inside the wound, the bacteria that have
migrated in should be transported out again or killed. Therefore, according
to the logic of the biofilm theory, it makes sense to regularly follow up with
patients after augmentation surgery from the third day onward to rinse the
suture gaps locally with disinfectant and to clean the neighboring teeth or
treat them with chlorhexidine gel.
The channels between the threads of a suture are a weak point. One
should find a good clinical compromise between creating a bridge for
bacteria and keeping the wound edges together. In normal intraoral surgery,
this means suture removal after 7 days; in augmentation surgery, it is more
common to wait 10 days before removing the suture.

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Fig 2-27 Increasing development of bacterial resistance to common antibiotics over time.
(Adapted from Boyanova et al.36)

2.13 Open Wound Healing

If the suture does not provide reliable protection against bacteria anyway
and the barrier functions of PRF and membranes are sufficient, one can
generally consider dispensing with tight wound closure over certain
materials and defects, eg, in guided bone regeneration (GBR; see chapter
6), and favoring open wound treatment from the outset.33 This saves soft
tissue mobilization, which is responsible for much of the postoperative
swelling and hematoma. This is already standard practice in ridge
preservation (see chapter 10).

2.14 Increasing Antibiotic Resistance

According to the holobiont theory, higher life is possible only under the
tolerance of the bacteria, because these existed far before us and have
important functions in the human body since time immemorial. These
functions are above all the defense of pathogenic agents by eubiosis, ie, a
state of equilibrium between the bacterial species.34 Thus, one can only
work with the bacteria, not against them. The potential damage to the
intestinal flora from long-term antibiosis35 is largely ignored in dentistry.
However, massive prolonged antibiosis with reserve antibiotics in elective
augmentation surgery in dentistry is the wrong way to go. Prophylactic
single-shot antibiotics may not be as critical in terms of intestinal flora
damage and resistance development. Augmentation procedures should be
improved and applied in such a way that single-shot antibiotics are
sufficient.

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Fig 2-28 Geographic gradient in methicillin-resistant Staphylococcus aureus. (Source:
European Centre for Disease Prevention and Control website.37)

A comparison between recent time periods shows an increasing

resistance of bacteria to the antibiotics commonly used in dentistry36 (Fig 2-
27). Bacterial resistance is not evenly distributed geographically, as can be
seen on the surveillance atlas of the European Centre for Disease
Prevention and Control website37 (Fig 2-28). Bacterial resistance to
penicillin antibiotics affects southeastern Europe and Asia much more than
northwestern Europe. Contributing to this geographic imbalance is a free
sale of antibiotics in some health care systems, the massive use of
antibiotics in animal husbandry, and the outsourcing of antibiotic
production with corresponding production effluents in Asia in the context of
globalization. There, the contamination of surface waters with antibiotic
residues has occurred.38 This induces the spread of antibiotic-resistant
germs in the wild,39 which similarly occurs in German hospital
wastewater.40
Many patients who have undergone long-term antibiotics develop
resistant germs in their body. In particular, this affects patients following
tumor diseases, but under certain circumstances also patients with implants
who have received treatment for repeated implant complications. In the
author’s experience, this may be one reason why revision surgeries often

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have a worse prognosis than initial surgeries. With regard to previous long-
term antibiotics, a thorough medical history is therefore advisable.
Bacterial resistance is often countered clinically by switching to more
potent classes of antibiotics. However, it is unlikely that new classes of
active ingredients will be added to the classic modes of action of antibiotics,
or that new ones will be developed, because the relevant molecular
metabolic processes of the bacteria have already been exploited. It makes
little sense from a global health policy perspective to wear out the last
reserve antibiotics for indications that do not pose a vital threat.41
Appositional and onlay grafts require soft tissue mobilization to cover
the additional volume. They are therefore more susceptible to dehiscence
and infection than inlay and interpositional grafts, which are usually only
sutured in an adaptive manner or are even completely left open to the oral
cavity (eg, for ridge preservation). Onlay grafts often only function in a
contaminated environment under long-term antibiotic protection. The more
alloplastic, allogeneic, or even proteinaceous xenogeneic foreign material is
used, the more the required potency and duration of antibiotics increases.
So, as a clinician, one should reconsider some of the material-driven
treatment strategies in implant dentistry in recent years.
Inlay grafts (eg, sinus elevation) and interpositional grafts (eg, ridge
splits, sandwich) are increasingly replacing appositional and onlay grafts.
They offer better healing conditions due to the bone-lined defects, and
single-shot antibiotic prophylaxis is sufficient. The latter does not have
great potential to promote resistance development. Augmentation using
interpositional and inlay techniques is a possible strategy against the
resistance problem in augmentation surgery.
In the author’s experience, it is sometimes better to treat patients with a
history of use of multiple antibiotics with the distraction osteogenesis
procedure. Because almost no foreign material is deposited, distraction
osteogenesis does not usually require antibiotic protection at all.

2.15 References
1. McGregor AD, MacDonald DG. Age changes in the human inferior alveolar artery—A
histological study. Br J Oral Maxillofac Surg 1989;27:371–374.
2. Davidoff MS. The pluripotent microvascular pericytes. Are the adult stem cells even in the testis.
Adv Exp Med Biol 2019;1122:235–267.

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3. AlQranei MS, Chellaiah MA. Osteoclastogenesis in periodontal diseases: Possible mediators and
mechanisms. J Oral Biosci 2020;62:123–130.
4. Fretwurst T, Garaicoa-Pazmino C, Nelson K, et al. Characterization of macrophages infiltrating
peri-implantitis lesions. Clin Oral Implants Res 2020;31:274–281.
5. Horwood NJ. Macrophage polarization and bone formation: A review. Clin Rev Allergy
Immunol 2016;51:79–86.
6. Kallis PJ, Friedman AJ. Collagen powder in wound healing. J Drugs Dermatol 2018;17:403–408.
7. Fleck CA, Simman R. Modern collagen wound dressings: Function and purpose. J Am Col Certif
Wound Spec 2011;2(3):50–54.
8. Myneni VD, Mezey E. Regulation of bone remodeling by vitamin K2. Oral Dis 2017;23:1021–
1028.
9. Eriksen EF. Cellular mechanisms of bone remodeling. Rev Endocr Metab Disord 2010;11:219–
227.
10. Raggatt LJ, Partridge NC. Cellular and molecular mechanisms of bone remodeling. J Biol Chem
2010;285: 25103–25108.
11. Delaisse JM. The reversal phase of the bone-remodeling cycle: Cellular prerequisites for
coupling resorption and formation. Bonekey Rep 2014;3:561.
12. Everts V, Delaissé JM, Korper W, et al. The bone lining cell: Its role in cleaning Howship’s
lacunae and initiating bone formation. J Bone Miner Res 2002;17:77–90.
13. Mohan S, Baylink DJ. Insulin-like growth factor system components and the coupling of bone
formation to resorption. Horm Res 1996;45(Suppl 1):59–62.
14. Henriksen K, Karsdal MA, Martin TJ. Osteoclast-derived coupling factors in bone remodeling.
Calcif Tissue Int 2014; 94:88–97.
15. Michalczikb V, Terheyden H. Stability of bone level at implants after augmentation with
mandibular block grafts. Zeitschr Zahnärztl Implantol 2007;23:266–279.
16. Mertens C, Decker C, Seeberger R, Hoffmann J, Sander A, Freier K. Early bone resorption after
vertical bone augmentation—A comparison of calvarial and iliac grafts. Clin Oral Implants Res
2013;24:820–825.
17. Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing two
techniques of bone augmentation: Onlay graft alone or associated with a membrane. Clin Oral
Implants Res 2001;12:632–639.
18. Wiltfang J, Jätschmann N, Hedderich J, Neukam FW, Schlegel KA, Gierloff M. Effect of
deproteinized bovine bone matrix coverage on the resorption of iliac cortico-spongeous bone
grafts—A prospective study of two cohorts. Clin Oral Implants Res 2014;25:e127–e132.
19. Wang M, Wang L, Ye R. Risedronate reduces postoperative bone resorption after cementless total
hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2018;52:189–200.
20. Möller B, Wiltfang J, Acil Y, Gierloff M, Lippross S, Terheyden H. Prevention of the surface
resorption of bone grafts by topical application of bisphosphonate on different carrier materials.
Clin Oral Investig 2014;18:2203–2211.
21. Terheyden H, Jepsen S, Möller B, Tucker MM, Rueger DC. Sinus floor augmentation with
simultaneous placement of dental implants using a combination of deproteinized bone xenografts
and recombinant human osteogenic protein-1. A histometric study in miniature pigs. Clin Oral
Implants Res 1999;10:510–521.
22. Açil Y, Ghoniem AA, Wiltfang J, Gierloff M. Optimizing the osteogenic differentiation of human
mesenchymal stromal cells by the synergistic action of growth factors. J Craniomaxillofac Surg
2014;42:2002–2009.

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23. Li X, Tang L, Lin YF, Xie GF. Role of vitamin C in wound healing after dental implant surgery
in patients treated with bone grafts and patients with chronic periodontitis. Clin Implant Dent
Relat Res 2018;20:793–798.
24. Dror E, Dalmas E, Meier DT, et al. Postprandial macrophagederived IL-1β stimulates insulin,
and both synergistically promote glucose disposal and inflammation. Nat Immunol 2017;18:283–
292.
25. Woelber JP, Bremer K, Vach K, et al. An oral health optimized diet can reduce gingival and
periodontal inflammation in humans—A randomized controlled pilot study. BMC Oral Health
2016;17:28.
26. Troeltzsch M, Troeltzsch M, Kauffmann P, et al. Clinical efficacy of grafting materials in
alveolar ridge augmentation: A systematic review. J Craniomaxillofac Surg 2016;44:1618–1629.
27. Høiby N. A short history of microbial biofilms and biofilm infections. APMIS 2017;125:272–
275.
28. Moser C, Pedersen HT, Lerche CJ, et al. Biofilms and host response—Helpful or harmful.
APMIS 2017;125:320–338.
29. Ciofu O, Rojo-Molinero E, Macià MD, Oliver A. Antibiotic treatment of biofilm infections.
APMIS 2017;125:304–319.
30. Bottagisio M, Coman C, Lovati AB. Animal models of orthopaedic infections. A review of rabbit
models used to induce long bone bacterial infections. J Med Microbiol 2019;68:506–537.
31. Zimmerli W, Sendi P. Orthopaedic biofilm infections. APMIS 2017;125:353–364.
32. Zimmermann CE, Gierloff M, Hedderich J, Açil Y, Wiltfang J, Terheyden H. Survival of
transplanted rat bone marrowderived osteogenic stem cells in vivo. Tissue Eng Part A
2011;17:1147–1156.
33. Ghanaati S, Al-Maawi S, Conrad T, Lorenz J, Rössler R, Sader R. Biomaterial-based bone
regeneration and soft tissue management of the individualized 3D-titanium mesh: An alternative
concept to autologous transplantation and flap mobilization. J Craniomaxillofac Surg
2019;47:1633–1644.
34. Esser D, Lange J, Marinos G, et al. Functions of the microbiota for the physiology of animal
metaorganisms. J Innate Immun 2019;11:393–404.
35. Pilmis B, Le Monnier A, Zahar JR. Gut microbiota, antibiotic therapy and antimicrobial
resistance: A narrative review. Microorganisms 2020;8:269.
36. Boyanova L, Kolarov R, Mitov I. Recent evolution of antibiotic resistance in the anaerobes as
compared to previous decades. Anaerobe 2015;31:4–10.
37. Data from the ECDC Surveillance Atlas–Antimicrobial resistance. European Centre for Disease
Prevention and Control website. Available at: https://www.ecdc.europa.eu/en/antimicrobial-
resistance/surveillance-and-disease-data/data-ecdc. Accessed 4 August 2021.
38. Liu X, Lu S, Guo W, Xi B, Wang W. Antibiotics in the aquatic environments: A review of lakes,
China. Sci Total Environ 2018;627:1195–1208.
39. Paths to binding environmental standards in antibiotics production in Asia [in German]. VFA
website. Available at: https://www.vfa.de/en/arzneimittel-forschung/articles-arzneimittel-
forschung/wege-zu-verbindlichen-umweltstandards-in-der-antibiotika-produktion-in-asien.html.
Accessed 4 August 2021.
40. Treatment of waste water from hospitals [in German]. Denewa website. Available at:
http://www.denewa.eu/denewa/werkpakketten/behandeling-van-ziekenhuisafvalwater?lang=10.
Accessed 4 August 2021.
41. Abu Sin M, Nahrgang S, Ziegelmann A, et al. Global and national strategies against antibiotic
resistance [in German]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz

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2018;61:507–514.

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 3
Bone Grafts

Bone has a pronounced healing potential, which is still present even if the
bone is temporarily cut off from the blood supply, ie, avascular grafting.
This is due to the bone morphogenetic proteins (BMPs) and growth factors
stored in bone and the principle of slow remodeling of bone from the inside
out. Because the bone structure is constantly being functionally remodeled
throughout life, grafts can be remodeled into patients own bone, and bone
injuries heal over time without scarring.

3.1 Biologic Effect of Bone Grafts

Autogenous bone grafts bring three factors necessary for tissue
regeneration: cells, matrix, and growth factors (Fig 3-1).

Cells
Vital, human, divisible, and osteogenically differentiated bone cells survive
various forms of processing in cell culture experiments (Figs 3-2 and 3-3),
with laboratory studies showing that the autologous iliac crest graft offered
by far the highest yield of vital osteogenic cells, setting the gold standard
for others to follow as a reference1 (Fig 3-4). Among the osteotomy
methods, the bone scraper and bone mill yielded higher counts of culturable
vital cells than piezoelectric devices and drills.2 It is still relatively unclear
how long these detected vital cells survive after bone grafting. The
surviving cells have relevance to the osteoinductive effect of autogenous
bone, as studies in goats have shown that bone grafts containing vital cells
showed a faster and 30% higher yield of regenerated bone than the same
grafts containing nonvital cells.3

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Fig 3-1 Three factors necessary for tissue regeneration.

Fig 3-2 a. Bull bone mill (Mondeal). b. Interior view with scraped bone chips. c. R. Quétin
bone mill.

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Fig 3-3 a. Reusable bone filter for insertion into the suction hose (Schlumbohm). b. Opened
filter.

Growth factors
Even cell-poor compact bone can also be grafted because an important part
of the osteoinductive effect of the autogenous bone graft is due to its
content of bone growth and differentiation proteins such as BMPs. BMPs
are relatively stable proteins that are produced from fresh bone in active
form and can be extracted with a yield of about 1 mg per kg bone.4 They
can be exposed and made bioavailable from the bone by opening the matrix
(eg, via a scraper or mill).

Matrix
The third part of the graft effect is based on the osteoconductive effect of
the autogenous bone matrix. When osteoprogenitor cells differentiate, they
require a solid substrate to attach to in order to become osteoblasts. The
cells grow on the matrix as if on a scaffold. But osteoclasts are also
activated, which resorb the matrix and release BMP.

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Fig 3-4 a. Human bone chips with different origin and processing were placed in cell culture
medium. b. The growth of osteogenically differentiated cells was best in native iliac
cancellous bone, but even intraoral bone ground with a steel bur with subsequent collection
in the bone filter still yielded vital and divisible bone cells. (Adapted from Springer et al.1)

A bone substitute material that only fulfills the matrix function can
acquire osteoinductive properties and be improved in its efficiency by
mixing it with autogenous bone chips as a mixed graft (Fig 3-5). Bone
scrapers and bone filters are suitable for this purpose. The speed of healing
depends on whether all three properties are present. A hydroxyapatite-based
bone substitute lacks the cellular component and growth factors, and a pure
cortical graft also lacks the cellular component. Accordingly, the healing of
these materials is slower and less predictable compared to autogenous
pelvic bone blocks. In challenging defects, eg, vertical augmentation for
implant placement, vital autogenous grafts with all three properties should
be used if possible.

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Fig 3-5 Use of autogenous bone chips. a. Fenestration defect on an implant in a maxillary
left central incisor site. b. Harvesting of bone with a scraper in the defect area. c. The
SafeScraper Twist (Geistlich) is a disposable instrument. d. Opened collection container
with bone chips in the form of flakes, which occupy a large volume. e. Bone particles
obtained during implant osteotomy in the bone filter. f. Bone substitute material is mixed
with sterile autologous blood. g. After all particles are soaked with the sterile blood, the filter
bone is added. This will induce blood clotting. h. The titanium surface is covered with the
bone chips from the scraper as the innermost layer of the construct. i. Trimming of the
collagen membrane (Bio-Gide, Geistlich). The middle section forms a tongue that is
clamped under the palatal flap. The right section serves as a double layer. j. The membrane
has been fixed under the palatal flap. After coagulation, the bone substitute material mixture
is placed in a 4-mm-thick layer; the contour should flow out harmoniously to the sides. The
coronal portion is overcorrected. k. The second membrane section is placed transversely as
a double layer and is intended to increase the durability of the barrier and cushion the soft
tissue flap from sharp particles. The membrane is moistened with saline after placement. l.

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The flap is held in place with a single hook, and the 15c scalpel is used to slit the
periosteum for flap mobilization. m. Suture closure is performed in a coronally overcorrected
position using interdental sutures and single interrupted sutures (Supramid 4-0 and 5-0,
Resorba).

3.2 Graft Bed

If an augmentation material lacks one or two of the three properties of the
autologous graft, the graft bed must compensate for them. Conversely, the
poorer the graft bed, the more complete the augmentation material must be.
The probability of success decreases if the graft bed is weakened by soft
tissue scarring or general disease. In patients with risk factors, the use of
vital autogenous material may be a safer option than bone graft substitute.
The success of bone grafting depends largely on the quality of the tissue at
the recipient site. It is critical whether the site has good bony support (eg, a
cyst cavity) that provides bone cells and BMP, or rather poor support
limited to soft tissues (eg, a mandibular continuity defect with minimal
connection to the residual jaw). A well-perfused graft bed is referred to as a
strong graft bed. The more scarring and circulatory disturbances are present,
the weaker a graft bed is in terms of replacement. Full irradiation of tumor
site leads to a graft bed that is no longer capable of taking the graft.
The choice of material in a bone defect depends critically on the defect
wall thickness of the graft site, as shown by the sequence of inlay,
interpositional, appositional, and onlay grafts in chapter 2.

3.3 The Gold Standard: The Autogenous Iliac Bone Graft

The autogenous monocortical iliac crest block graft is referred to as the
gold standard of bone grafting in the international literature across
disciplines5–9 in terms of its clinical predictability and healing potency
compared with materials from other sources. The autogenous iliac bone
graft has cells, growth factors, and interconnecting porosity of the matrix in
physiologic proportion. Autogenous bone grafting is associated with a high
degree of predictability of graft take with minimal complications in the
shortest possible time. Note that the term gold standard comes from
economics, with gold being a reference point for currency but not
necessarily the most valuable material. Likewise, in this case, calling the

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autogenous iliac bone graft the gold standard means it is a reference point
for biologic potency, and does not necessarily indicate that it is the best
material of its group. For example, recombinant BMPs have been shown in
some studies to have a higher regenerative performance than the iliac bone
graft.6

3.4 Donor Sites: Quality and Harvest Morbidity of

Autogenous Bone Grafts
A variety of autogenous bone grafts from different intraoral donor sites are
available for bone regeneration (Fig 3-6). If larger quantities are required,
bone can be harvested from the cranium and the anterior and posterior iliac
crests (Fig 3-7). The various sites of origin and harvesting techniques differ
in their invasiveness and patient burden and in their biologic effectiveness.
Because cancellous bone grafts contain vital osteogenic cells, they are
suitable for treating critical defects even in poor graft beds. Cortical blocks,
on the other hand, better resist the surface resorption of the healing phase
than particulate grafts. However, they place higher demands on the graft
bed and on the patient’s behavior. Because of the higher risk of dehiscence
compared to particulate grafts, soft tissue coverage should be ideal and the
patient should not chew food in that area, for example. On the other hand,
using bone mills or drills reduces the cellularity in the grafts.1

Chips from scrapers, mills, and piezoelectric devices

Scraper chips are often the best alternative for restoring the smallest bone
defects and as fillers. Scraper chips are easy to obtain, have a high surface
area with exposed BMPs, and have a high volume. According to an in vitro
study, chip extraction with the piezoelectric device versus the manual
scraper showed minimal, nonsignificant differences in terms of cell
viability.7 Milled chips can be obtained relatively atraumatically with
implant systems that use low-speed twist drills (Fig 3-8). With each drilling,
the chips can be collected between the drill flukes, from which they can be
flushed out with saline solution and temporarily stored in a moist container.
In cancellous bone, it may even be justifiable to work at a very slow speed

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with fresh sharp drills without water cooling in order to recover as many
chips as possible.

Fig 3-6 Intraoral harvesting of autologous bone.

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Fig 3-7 Extraoral versus intraoral harvesting of autologous bone.

Fig 3-8 The grooves of this twist drill (Camlog) have filled during low-speed drilling with
retromolar block graft, which can be collected and stored.

Bone collectors

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Milling chips from a bone collector, which is a sieve integrated into the
suction hose, have the risk of higher bacterial contamination than scraper
chips but contain osteogenically differentiated vital cells capable of
division.1 To minimize contamination by salivary bacteria, it is
recommended that the collector be switched on only briefly during implant
drilling or during other bone work. There are various approaches to
disinfecting the filter bone particles. However, due to the toxic effect of the
disinfectants, this is associated with an increased necrosis rate of the bone
cells and inactivation of the growth and differentiation factors,8 which is
why this method has not yet become established and is still under
development. Currently, 1-minute exposure to 0.2% chlorhexidine solution
is the gentlest procedure based on study data9; however, this method is not
used by the author.

Fig 3-9 Harvesting of trephine cylinders from the chin.

Trephine chips
With trephine drills, overheating problems easily arise due to the high
rotational speed and the large surface area, so that reduced pressure and
plenty of saline solution should be used for flushing. There are trephine
drills with internal cutting edges that simultaneously grind the bone into
particles and collect them in a reservoir. A 2.5-mm bone punch can be
obtained with a 3.5-mm trephine drill, to be used instead of the pilot

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implant osteotomy. The cores are secured in the recipient site with
microscrews.10 Trephine bone cylinders are usually obtained from the chin
(Fig 3-9).

Fig 3-10 a. Exposure of the external oblique ridge and marking of the graft position with a
pencil. b. Strictly monocortical osteotomy lateral to the nerve with the Lindemann bur in
alignment parallel to the outer surface for the anterior and posterior cut, with a connecting
cut in a longitudinal direction. Shown is a protected minicircular saw according to Khoury
(Dentsply Sirona). c. Fitting of the bone block as a vestibular shell technique. d.
Osteosynthesis by lag screw (1.5-mm system, KLS Martin). e. External oblique ridge and
position of graft harvesting (dashed line shows maximum possible extension). To avoid
fractures, the graft should not be taken in the highly loaded ascending ramus of the
mandible (marked with an X).

Particulate grafts via bone mills

Bone grafts can be comminuted by a bone mill. The grinding of compact
pieces brings the enclosed growth factors and osteoinductive proteins to the
surface and increases the volume of the bone graft quite considerably.
However, the number of vital bone cells decreases. Such bone particles can
be used as fillers next to larger grafts or for sinus floor augmentation.

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Intraoral block grafts from the external oblique ridge, zygomatic
alveolar crest, maxillary tuberosity, and chin
The retromolar block graft from the Linea obliqua (Fig 3-10) has a better
benefit-risk profile than the chin bone block (Fig 3-11). According to a
prospective study of 45 patients, six times as many sensory disturbances
occurred in the chin group (40% of cases) compared with the retromolar
group, of which permanent residual conditions remained after 1 year in two
patients in the chin group versus no patients in the external oblique ridge
group. Patient acceptance was equal between chin and retromolar, but
significantly higher when block harvesting was combined with third molar
removal.11 A retrospective comparative study indicated the risk of residual
permanent damage to the buccal nerve with impaired sensitivity of the
vestibule and inner cheek.12 This complication is avoided if the distal relief
incision on the ascending mandibular branch is no longer than 1 cm.
The chin bone has some significant disadvantages. To obtain it, the
mentalis muscle is detached. In a prospective study, this resulted in labial
ptosis with a measurable postoperative mean 1.65-mm increase in exposure
of the mandibular incisors,13 a complication to be aware of; however, true to
Goethe’s observation: “You only see what you know.” The author therefore
harvests chin bone grafts only when no other bone sources are possible, and
then via a longitudinal cut in the labial frenulum without detachment of the
mentalis muscle. The block graft from the chin should also not be used as a
rule because one can unintentionally create a defect that perforates lingually
and does not heal completely. In the case of large chin bone grafts,
impairments of the external soft tissue contour is possible. The main
complication of chin bone harvesting is about 30% devitalized mandibular
anterior teeth,14 because the incisive nerve lies on average only 3 mm below
the compact buccal bone.15 According to a systematic review, patients even
preferred the iliac crest block to the chin block.16 The chin should be a
second-choice harvest site if other sites have already been utilized.

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Fig 3-11 a. Harvesting of a monocortical autogenous bone block from the chin. b.
Osteosynthesis for lateral augmentation in the mandibular left lateral incisor and canine
region. c. Cortical perforation of the block was performed for faster integration. The bone
chips were extracted through the bone filter.

Fig 3-12 a. Extraction of the maxillary left central incisor with loss of the buccal alveolar
wall. b. Ridge preservation with simultaneous wall reconstruction using a three-layer soft
tissue–connective tissue–bone graft from the maxillary tuberosity.

Cohesive bone chips suitable for horizontal or vertical ridge

augmentation can also be obtained from the maxillary tuberosity. The chips
from the maxillary tuberosity are quite spongy in structure and have a
higher resorption tendency than chips from the external oblique ridge. They
have only about half the bone density of chips from the external oblique
ridge.17 Composite bone–soft tissue punches for ridge preservation with
simultaneous wall reconstruction can also be obtained on the maxillary
tuberosity18 (Fig 3-12). However, the maxillary sinus should not be opened
in this case.

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Fig 3-13 Follow-up examination of augmentation height after onlay grafting. The
autogenous cranial bone grafts show hardly any height loss due to resorption (dotted lines),
whereas the autogenous iliac crest grafts (solid lines) lost a few millimeters of height within
the first months. (Adapted from Mertens et al.20)

An intraoral block graft can also be obtained from the zygomatic

alveolar crest using a piezoelectric device while sparing the maxillary sinus
mucosa with minimal morbidity.19

Block grafts from the calvarium

Calvarial bone is one of the most mineralized bones in the body, ten times
higher than the iliac crest. It resists resorption for a very long time
compared to iliac bone and is therefore occasionally preferred for
augmentations. In a retrospective study of the maxilla, 33% height
resorption was reported for iliac bone versus 11% for cranial bone20 (Fig 3-
13). However, removal is relatively challenging surgically (Fig 3-14). The
cranial roof consists of two parietal panels on both sides of the midline, the
outer portion of which can be used as graft harvest site. The difficulty and

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the risk of complications are higher compared to harvesting iliac bone
chips; however, immediate postoperative pain was significantly lower in a
prospective study.21 Nevertheless, the same authors also reported in a
previous study22 that exposure of the dura had occurred in 11% of cases and
that harvest defects had to be covered with bone cement to avoid creating
dents in the contour of the skull. These are, after all, considerable
disadvantages.

Fig 3-14 a. Exposure of the tabula externa of the skull by paramedian longitudinal incision
in the scalp. Opening of the diploic layer by a ball bur in a rectangular shape. The chips are
obtained in the filter. b. Because of the skull convexity, the oscillating saw can be used flat
in the diploic layer. c. Last separation of the cancellous bone layer of the diploe with the
blade chisel. d. Removal of an approximately 6 × 4–cm cortical graft with internally adhering
cancellous bone.

Cancellous bone punching (pelvis, tibial head)

Large amounts of cancellous bone can be obtained gently from the anterior
or posterior iliac crest. The most gentle technique, which can also be used
under local anesthesia, is the trephine punch at the iliac crest (Fig 3-15).
About 2-cm-long trephine punches are obtained manually via a 1-cm skin

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incision. If one does not perforate the inner and outer cortical bone of the
ilium during this procedure, only minimal trauma and postoperative
discomfort can be expected. However, major hemorrhage can be caused by
inexperienced handling. An analogous procedure is used on the head of the
tibia to obtain cancellous bone punches with significantly lower initial pain
levels than on the iliac crest.23

Monocortical iliac crest bone chips

The iliac bone crest has been rated too negatively in the reporting of the last
20 years in view of the emerging alternatives in tissue engineering.
However, tissue engineering has not yet been able to meet expectations, so
that the iliac crest is still the standard when intraoral grafts or bone
substitutes are not sufficient. The studies with high harvesting morbidities
were largely from orthopedics and neurosurgery. In these fields, very large
amounts of bone are often harvested bicortically with corresponding defects
(Fig 3-16). With a proper monocortical harvesting technique of smaller
amounts for implantology from the inner aspect of the crest, the
complication rate is very low (Fig 3-17). In a randomized prospective study,
there were no complications at the iliac crest. On a visual analog scale (VAS
0 to 100), postoperative pain was 40 and decreased to 4 within 14 days,
with concomitant high patient satisfaction of 93 points on the VAS.5 An idea
of the degree of distress caused by iliac bone harvesting for implantology
purposes is given by the following study24: Only 38% of the patients
experienced any pain at the hip, which disappeared after an average of 18.1
days. In-patient stay was 4.3 days, and 20.2 days of sick leave were taken,
with 90.5% overall patient satisfaction.

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Fig 3-15 a. Trephine punches with cross handle (bottom) for turning in manual mode. b.
Obtained autogenous cancellous bone punches from the iliac crest.

Fig 3-16 Large horseshoe-shaped monocortical iliac block graft were grafted for building up
a severly atrophic mandible, which was directly restored with dental implants at the same
time.

Fig 3-17 Gentle removal of the pelvic bone via a 2.5-cm skin incision medial to the iliac
crest, with avoidance of the iliac spine (marking) and protection of the associated cutaneous
femoral nerve. Bone harvesting was performed only from the inner aspect of the crest to
protect the outer muscle insertions and avoid pain.

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 The tendency to resorption that has been attributed to the iliac bone is
also a matter of surgical technique, because secure fixation, avoidance of
pure block grafts, and good timing of occlusal loading of teeth or dental
implants prevent resorption. In a large study on block grafts in the atrophic
interforaminal mandible, long-term resorption at 16-mm graft height was
only 2 mm after 5 years, which incidentally is also an example of the bone-
protective effect of dental implants.25

Fig 3-18 a. Complete loss of the maxilla after injury by a sledgehammer in a 43-year-old
patient. Here, replacement of the orbital floor with a patient-specific ceramic implant. b.
Intraoral view of the maxillary defect with fistula to the nose. c. Shaping of a new maxilla by
osteotomy of the fibula twice, with the skin of the fibula in between to replace the palate. On
the upper portion of the graft is the vascular pedicle of the fibular vein and artery. d.
Maxillary reconstruction under microsurgical anastomosis of the fibula vessels with the
fibular artery and vein.

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Microsurgically anastomosed bone grafts
Microsurgically anastomosed, vascularized bone chips (eg, from the fibula,
pelvis, and scapula) are a good choice for large tumor and trauma defects.
In preprosthetic surgery, it is a rare situation and reserved, for example, for
the most severe jaw atrophies after failure of other procedures (Figs 3-18
and 3-19).

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Fig 3-18 e. Lateral cephalometric image before reconstruction with defect. f. Lateral
cephalometric image after reconstruction with improved soft tissue projection. g. Placement

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of dental implants in the fibula bone. h. Dental implants (mirror image) in the reconstructed
maxilla. i. Prosthetic restoration. (Prosthetics: Dr Szyczewski, Poznan, Poland.)

Fig 3-19 a. Ameloblastoma in the left mandible of a 24-year-old patient. b. Jaw

reconstruction by double-barrel fibula graft, anastomosed microsurgically. c. Healed fibula
harvesting defect without functional limitations. d. Insertion of dental implants into the fibula
bone. e. Prosthetic restoration with metal-ceramic single crowns with restitutio ad integrum.

3.5 References
1. Springer IN, Terheyden H, Geiss S, Härle F, Hedderich J, Açil Y. Particulated bone grafts—
Effectiveness of bone cell supply. Clin Oral Implants Res 2004;15:205–212.

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2. Miron RJ, Gruber R, Hedbom E, et al. Impact of bone harvesting techniques on cell viability and
the release of growth factors of autografts. Clin Implant Dent Relat Res 2013;15:481–489.
3. Kruyt MC, Delawi D, Habibovic P, Oner FC, van Blitterswijk CA, Dhert WJ. Relevance of bone
graft viability in a goat transverse process model. J Orthop Res 2009;27:1055–1059.
4. Urist MR, Sato K, Brownell AG, et al. Human bone morphogenetic protein (hBMP). Proc Soc
Exp Biol Med 1983; 173: 194–199.
5. Putters TF, Wortmann DE, Schortinghuis J, et al. Morbidity of anterior iliac crest and calvarial
bone donor graft sites: A 1-year randomized controlled trial. Int J Oral Maxillofac Surg
2018;47:1474–1480.
6. Kim HJ, Buchowski JM, Zebala LP, Dickson DD, Koester L, Bridwell KH. rhBMP-2 is superior
to iliac crest bone graft for long fusions to the sacrum in adult spinal deformity: 4 to 14-year
follow-up. Spine (Phila Pa 1976) 2013;38:1209–1215.
7. Pekovits K, Wildburger A, Payer M, Hutter H, Jakse N, Dohr G. Evaluation of graft cell
viability-efficacy of piezoelectric versus manual bone scraper technique. J Oral Maxillofac Surg
2012;70:154–162.
8. Sawada K, Fujioka-Kobayashi M, Kobayashi E, Schaller B, Miron RJ. Effects of antiseptic
solutions commonly used in dentistry on bone viability, bone morphology, and release of growth
factors. J Oral Maxillofac Surg 2016;74:247–254.
9. Sawada K, Nakahara K, Haga-Tsujimura M, FujiokaKobayashi M, Iizuka T, Miron RJ. Effect of
irrigation time of antiseptic solutions on bone cell viability and growth factor release. J Craniofac
Surg 2018;29:376–381.
10. Khoury F, Doliveux R. The bone core technique for the augmentation of limited bony defects:
Five-year prospective study with a new minimally invasive technique. Int J Periodontics
Restorative Dent 2018;38:199–207.
11. Raghoebar GM, Meijndert L, Kalk WW, Vissink A. Morbidity of mandibular bone harvesting: A
comparative study. Int J Oral Maxillofac Implants 2007;2:359–365.
12. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay
augmentation: Comparison of donor site morbidity and complications. Clin Implant Dent Relat
Res 2003;5:154–160.
13. Nóia CF, Rodríguez-Chessa JG, Ortega-Lopes R, Cabral-Andrade V, Barbeiro RH, Mazzonetto
R. Prospective study of soft tissue contour changes following chin bone graft harvesting. Int J
Oral Maxillofac Surg 2012;41:176–179.
14. Nóia CF, Ortega-Lopes R, Fernandes Moreira RW, Mazzonetto R. Prospective clinical
assessment of pulp sensitivity after chin bone harvesting. Implant Dent 2013;22:199–202.
15. Vu DD, Brockhoff HC 2nd, Yates DM, Finn R, Phillips C. Course of the mandibular incisive
canal and its impact on harvesting symphysis bone grafts. J Oral Maxillofac Surg
2015;73:258.e1–258.e12.
16. Nkenke E, Neukam FW. Autogenous bone harvesting and grafting in advanced jaw resorption:
Morbidity, resorption and implant survival. Eur J Oral Implantol 2014;7(Suppl 2): S203–S217.
17. Kamal M, Gremse F, Rosenhain S, Bartella AK, Hölzle F, Kessler P, Lethaus B. Comparison of
bone grafts from various donor sites in human bone specimens. J Craniofac Surg 2018;29:1661–
1665.
18. Raghoebar GM, Meijer HJA, van Minnen B, Vissink A. Immediate reconstruction of failed
implants in the esthetic zone using a flapless technique and autogenous composite tuberosity
graft. J Oral Maxillofac Surg 2018;76:528–533.
19. Sakkas A, Schramm A, Karsten W, Gellrich NC, Wilde F. A clinical study of the outcomes and
complications associated with zygomatic buttress block bone graft for limited preimplant

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 augmentation procedures. J Craniomaxillofac Surg 2016;44:249–256.
20. Mertens C, Decker C, Seeberger R, Hoffmann J, Sander A, Freier K. Early bone resorption after
vertical bone augmentation—A comparison of calvarial and iliac grafts. Clin Oral Implants Res
2013;24:820–825.
21. Wortmann DE, Boven CG, Schortinghuis J, Vissink A, Raghoebar GM. Patients’ appreciation of
pre-implant augmentation of the severely resorbed maxilla with calvarial or anterior iliac crest
bone: A randomized controlled trial. Int J Implant Dent 2019;5:36.
22. Kuik K, Putters TF, Schortinghuis J, van Minnen B, Vissink A, Raghoebar GM. Donor site
morbidity of anterior iliac crest and calvarium bone grafts: A comparative case-control study. J
Craniomaxillofac Surg 2016;44:364–368.
23. Huang YC, Chen CY, Lin KC, et al. Comparing morbidities of bone graft harvesting from the
anterior iliac crest and proximal tibia: A retrospective study. J Orthop Surg Res 2018;13:115.
24. Gjerde CG, Shanbhag S, Neppelberg E, Mustafa K, Gjengedal H. Patient experience following
iliac crest-derived alveolar bone grafting and implant placement. Int J Implant Dent 2020;6:4.
25. Boven GC, Meijer HJ, Vissink A, Raghoebar GM. Reconstruction of the extremely atrophied
mandible with iliac crest onlay grafts followed by two endosteal implants: A retrospective study
with long-term follow-up. Int J Oral Maxillofac Surg 2014;43:626–632.

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 4
Augmentation Surgery Materials

The first successful cranioplasty in humans employed a piece of dog bone

on an injured soldier and was published by van Meekeren in 1668.1
Transplantation of bones and soft tissues thus has a history of more than
300 years, with foreign materials from other humans, animals, or artificial
materials being used from the beginning to reduce the trauma of graft
harvest. Trauma related to graft harvest is highly dependent on the amount
needed, with mostly small volumes needed in dentistry compared to most
indications in orthopedic surgery. Therefore, in dentistry, one is not forced
to take risks with foreign materials in dentistry.2

4.1 Properties of Foreign Materials

First of all, foreign materials should be biocompatible, ie, not enter into
harmful chemical reactions with body molecules, eg, have a neutral pH, and
not corrode to a significant extent. Furthermore, depending on the
indication, it is important to be able to control the degradation and
remodeling process, which can occur through solubility in water,
chemically (eg, hydrolytically or enzymatically), and cellularly.
According to immunologic aspects, biomaterials are divided into
autogenous (from the patient), isogenic (from identical twins), allogenic
(from other people), xenogeneic (from other organisms), or alloplastic
(technologically produced).

Chemistry and pH value

Some materials, such as bioglasses, release OH– ions and generate a
strongly alkaline pH.3 Other materials, such as polylactides (polylactic

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acid), which are contained in some barrier membranes, resorbable films, or
adhesives in bone graft substitutes, hydrolyze spontaneously in the body
and release lactic acid. Acids are part of the proinflammatory tissue
environment and trigger bone resorption rather than regeneration.
Magnesium products corrode in the body and form hydrogen gas bubbles in
the tissues. Even tissue-stable and normally corrosion-resistant materials,
such as titanium, can corrode in the microenvironment of body cells or
bacteria due to acid exposure,4 which is referred to as biocorrosion. On an
even smaller scale, biomolecules such as albumin can create a corrosive
nano-environment under the molecular body.5

Interface formation
Solid foreign materials that are not water soluble form permanent interfaces
in the body. This is a problem with metallic implants such as hip
replacements, which often have a limited life span and can become loose as
a soft tissue layer develops between the bone and metal. Solid-liquid
interfaces are also always susceptible to biofilm formation by bacteria if
they are positioned close to the surfaces, because foreign materials have no
defense of their own. One example is Teflon membranes for guided bone
regeneration (GBR), which are prone to dehiscence or extrusion due to
biofilms.

Particle-related sterile inflammation

Inorganic particles of tissue debris are removed in the body by patrolling
macrophages by phagocytosis and digested intracellularly. These cells
remove the material, break it down into smaller molecules in lysosomes,
migrate to the lymph nodes, and present it in the lymph node to dendritic
cells, which may prepare an immune response. Nondigestible metal
particles migrate with the macrophages throughout the body. For example,
titanium particles have been found in the liver after experimental
implantation in the jaw.6 For these non-intracellularly digestible substances,
particle size plays an important role.
Larger particles are not transportable at all and are encapsulated in
place. In contrast, very small nanoparticles can pass through cell and cell
nucleus membranes, in some cases without barriers, and cause changes in

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the cell nucleus. Therefore, caution is generally advised when using
nanomaterials in wounds and defects.7 Medium-sized particles are
problematic if they do not trigger encapsulation or clearance but frustrate
phagocytosis. If the macrophage fails to internalize8 the particle, it can
trigger sterile inflammation. For example, asbestos is dangerous not
because of the chemistry but because of the size of the particles, because
particle-induced inflammation can promote pulmonary fibrosis and
eventually even tumors in the lungs. Substitute materials that contain or
produce nonabsorbable particles of critical size in large quantities should be
avoided.

Antigen structures through proteins

The organism distinguishes foreign from self on the basis of antigens that
bind to receptors of immune cells. Full antigens are bound to structures of
proteins and other organic molecules. Therefore, foreign materials
containing organic materials should be considered with increased caution as
transplants for tissue engineering. For example, an equine bone graft
substitute (from horses) was known to cause a high rate of complications
because the bone had not been deproteinized to reduce the brittleness of the
material and improve its mechanical properties.9 Collagen is the main
component of proteinaceous bone and soft tissue substitutes. The amino
acid sequence of collagen is species specific and differs in pigs (porcine
material), cattle (bovine material), horses (equine material), and humans.10
Our immune system reacts to molecules that were not in the body in the
neonatal period when immune tolerance developed. In this respect, it is
surprising that, in view of the mass use of proteinaceous foreign materials
in dentistry, clinical adverse reactions are not greater.

Antigenic effect through haptens

Small organic molecules or certain metal ions (eg, nickel ions) alone cannot
form a full antigen to trigger foreign recognition. They can, however,
modify the tertiary structure of body proteins in such a way that they are
interpreted as foreign by the immune system. Such substances are referred
to as haptens or semi-antigens. Bone and soft tissue substitute materials

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should therefore not release any haptenic organic molecules (eg, plastic
monomers) or metal ions into the tissue.

Cell-bound transplant antigens

Higher organisms had to defend themselves against parasites and tumors
throughout their evolution. A foreign or degenerated cell is recognized by
foreign antigens on its surface, which are presented by special proteins that
are specific to a human. These are called human leukocyte antigens (HLAs)
in humans and the major histocompatibility complex (MHC) in general.
MHC class I presents intracellular antigens to the immune system and is
used by all body cells except erythrocytes. MHC class II presents
extracellular antigens and is produced only by certain cells, such as
dendritic cells of the immune system. A foreign allogeneic cell (from
another human) is recognized as foreign if it carries foreign MHC proteins,
even if it has identical amino acid sequences at the protein level. This
foreign recognition pathway leads to organ rejection in organ
transplantation and is responsible for the necessary immunosuppressive
medication of these patients. For this reason, manufacturers of allogeneic
bone graft substitutes attempt to mitigate the cellular antigenicity of their
products through purification processes, but this is not completely
successful with block-shaped materials because residual foreign human
cells remain in the marrow spaces and osteocyte cavities. Manufacturers of
allogeneic soft tissue substitutes (eg, acellular dermal matrix) also try to
banish cell-bound antigenicity from their materials.11

4.2 Bone Graft Substitutes

Certain biomaterials can replace the autologous bone graft and be
incorporated by the bone without irritation, thus acting as passive defect
fillers or active bone augmentation materials. In appropriate cases of well-
healing bone defect types, the use of bone graft substitutes saves the patient
from autogenous bone donation or reduces the need for autogenous or other
bone grafts. The addition of bone graft substitutes can slow the uncontrolled
resorption of autogenous grafts that sometimes occurs and reduce the
amount of graft removed. Osteoblasts from the medullary cavity of the

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recipient bone grow appositionally along the surfaces of the bone
substitutes (artificial extracellular matrix) into the defect. This process is
called osteoconduction.
Bone substitute materials are usually passive fillers. The gradual
appositional colonization of the bone substitute material with bone cells
(osteoconduction) takes many months depending on the regeneration
volume.

Micro- and nano-porosity

Successful bone graft substitutes exhibit micro- and macro-porosity and
sometimes nano-porosity. Micro- and nano-porosity facilitates the
attachment of matrix proteins such as fibronectin from the recipient wound,
which in turn serve as a mediating layer to the bone cells.

Interconnecting macro-porosity
Macro-porosity of a bone graft substitute of about 200 to 600 µm12 is
required to allow blood vessels to grow through an augmentation volume so
that the necessary oxygen supply is still achieved even in the center of a
large-volume defect. However, the pores must not be too large either,
approximately 200 to 300 µm13; otherwise bone will not form on the
surfaces of the bone graft substitute. The osteon with a diameter of 200 μm
can serve as a model, the canal of which, starting from the central blood
vessel, was circularly lined by bone at the time it was formed. No oxygen-
dependent body cell such as osteoblasts can exist much further than 100 µm
from the blood vessel.14 Tissue regeneration, especially bone regeneration,
is always angiogenic. This means that bone formation is initially preceded
by the formation of new blood vessels in the defect (Fig 4-1). To allow
blood vessels to grow in, a bone graft substitute should have
interconnecting porosity in addition to the above properties so that blood
vessels not only find their way in but also find their way out as veins.
Otherwise, there will be no blood flow. The requirement of interconnecting
porosity is fulfilled by materials of natural origin (animals, algae, corals),
while it is very difficult to produce artificially. If a material has already
proven itself in the cancellous bone of an animal, then it can be assumed

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that, as a protein-free mineral framework, it has a macro-porosity that is
favorable for the blood vessels.

Fig 4-1 Osteoinduction. A scaffold material (Bio-Oss Block, Geistlich) and recombinant
human bone morphogenetic protein (rhBMP)-7 were implanted in a muscle. Macro-
angiography with barium contrast on the left shows the connection of the graft to the blood
supply. Micro-angiography on the upper right at ×50 magnification shows a newly formed
blood vessel entering the block in longitudinal section from the left and many vessel cross-
sections (white). It is striking that newly formed bone always appears at a constant distance
from the vessels and only in the vicinity of a vessel. The image at bottom right shows the
layer-by-layer deposition of new bone on a bone substitute surface within 6 weeks
(Laboratory MKG Kiel, polychrome sequence labeling, pig, original magnification×100).

Degradability
A bone graft substitute should be as chemically inert as possible and
produce a slightly basic pH in solution (blood = pH 7.4). Depending on the
indication, resorption within months by spontaneous solubility (tricalcium
phosphate [TCP]) or exclusive cellular degradation by acid (hydroxyapatite

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[HA]) with a correspondingly long service life is advantageous. There are
also combinations of TCP and HA (biphasic calcium phosphate [BCP]).
According to the German Society for Implantology (DGI) guidelines,15 a
bone substitute material should be able to be degraded by the body in the
long term, meaning that titanium metal particles and nondegradable
polymers do not appear to be very suitable as biomaterials in implantology.
For materials that are not water or acid soluble, the body generally has no
degradation mechanism and its only response is encapsulation as a foreign
body. Consider, in the case of peri-implant inflammation, that these
encapsulated materials can come into contact with oral bacteria in the
vicinity of dental implants and become infected.

4.3 Dentin as a Bone Graft Substitute

Dentin has a different structure than bone, but a very similar molecular
composition. It also contains BMPs stored in the dentin matrix. It is
therefore not surprising that dentin can be used to build bone. The
observation already goes back to the Norwegian Gisle Bang, who published
a study showing ectopic osteoinduction in guinea pig muscle by
demineralized allogeneic dentin chips in a controlled experiment in 1972.16
In Korea, the method of using crushed allogeneic wisdom teeth was
further developed into a commercial product and published in 1999.17 A first
clinical study on 37 patients comparing this product to an alloplastic
material was published in Korea in 2014,18 followed by a prospective
randomized study on ridge preservation with autogenous demineralized
dentin chips in comparison to xenogeneic bone mineral in 2017.19
In 2009, the first study on the use of human teeth as block grafts in bone
defects was documented by Lars Andersson in Malmö.20 In Germany, Frank
Schwarz and co-workers have addressed the issue and have already
published a prospective controlled study on tooth block grafts compared to
bone block grafts for alveolar ridge augmentation.21
Both methods, grinding the teeth and using them as block grafts, are
still in the clinical experimental stage; severe complications have not been
published so far.

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4.4 Bone Products: Allogeneic and Xenogeneic Bone
Grafts
Human (allogeneic) or animal (xenogeneic) bone can be used to produce
bone regeneration products. Rejections of human allografts can occur due to
the cell-bound MHC antigens, which in humans are also called HLAs and
are commonly referred to as transplant antigens. Rejections of animal
products can be based on both the cell-bound MHC antigens and
additionally on the antigenicity of the foreign proteins.
The advantage of allogeneic and xenogeneic grafts in implant surgery is
the avoidance of bone harvesting surgery, so that the patient does not have
to endure the donor morbidity of bone harvesting, and so that even those
surgeons who do not have the option of iliac bone harvesting can treat
complex cases. It is even possible to order prefabricated allogeneic block
grafts tailored to the patient’s individual defect via CAD/CAM using
individual computed tomography (CT) data.
However, there is some evidence of healing problems with allograft
blocks. A study from Germany on onlay allogeneic block grafts was
terminated prematurely because healing complications occurred in over
80% of cases.22 A recent study from Israel on allogeneic block grafts
showed dehiscence in 80% of cases and 25% block exposure as well as
infections that required surgery and long-term antibiotics for resolution in
21% of cases.23
Allogeneic grafts are more commonly used as mineral bone substitutes
in the United States, mainly in the form of demineralized freeze-dried bone
allograft (DFDBA). In this case, freeze-drying serves to preserve the
material, and partial decalcification breaks down the matrix so that the
BMPs become more readily available for wound healing. In a direct
comparison, allogeneic grafts performed worse than autogenous bone in
various augmentation studies. For example, in a direct comparison of block
bone grafts in humans, Spin-Neto and coworkers24 found 27.6% vital bone
for the autogenous bone graft versus 8.6% for the allogeneic graft. In sinus
floor augmentation, in a human study, the allogeneic graft was
approximately halfway between autogenous bone and bone substitute in
terms of bone density at 5-month biopsy.25

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Microbiologic decontamination
Cadaver and animal products should be disinfected and preserved prior to
sale, which competes with the attempt to preserve the activity of BMPs.
Bacterial contamination of cadaver donations should not be underestimated.
Before J. Choukroun became famous on the topic of L-PRF, he was known
for his observations of gas-forming infections during sinus elevations with
allogeneic grafts,26 which occurred because spore-forming germs had
survived the disinfection process of the bone graft. A retrospective study
showed 60% infections in the healing process after allogeneic graft
transplantation in orthopedic indications, which healed without
consequences in 92% of cases with antibiotic treatment.27 In a recent study,
for example, 51% of allogeneic grafts from cadaver donors were
contaminated with Klebsiella pneumoniae.28

Fig 4-2 Preparation classes of human bone allografts.

Preparation of human allografts

In addition to collagen, the protein fraction in bone also contains growth
factors and BMPs. The art of industrial preparation of allografts is to
remove the antigenic proteins and cellular components while preserving the

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desired BMP proteins (Fig 4-2). Bone contains the mineral scaffold, which
can be rendered pure and used therapeutically by removing all proteins.
However, such grafts should not be presented as osteoinductive. Allogeneic
(human) bone products can be divided into three classes according to their
preparation:
I. Fresh frozen human bone grafts: osteoinductive by BMP, MHC
antigenicity, possibility of disease transmission from donor, only
available through local bone banks at hospitals.
II. Gently disinfected human grafts: osteoinductive by BMP, limited MHC
antigenicity, statistically low disease-transmission risk, durable
commercially available industrial product.
III. Sterilized human grafts: only osteoconductive, no active BMPs but
collagen proteins preserved, thus not osteoinductive; screwable, durable
industrial product.

Fresh frozen allografts or xenografts (fresh frozen bone) of class I are

critical because of their immunogenicity, risk of disease transmission, and
lack of sterility (bacteria of deceased) and therefore should be viewed
critically for dental indications (Fig 4-3). Most documented cases of HIV
and hepatitis transmission to recipients through bone grafts fall into this
category.29 In a prospective study of ridge augmentation in the maxilla,
wound dehiscence and loss occurred with fresh frozen bone in 68% of
patients,30 probably due to antigenicity.

Block versus particulate human allografts

A distinction should be made between block grafts and particulate grafts. In
block grafts, it is not possible to completely remove the donor’s cells,
leaving residual antigenicity of the MHC system. In particulate grafts,
removal of cells and MHC antigenicity is technically possible according to
a recent study.31 However, one of the particulate allograft products tested
was pooled from different donor collectives. Unlike block allografts, these
products lose traceability to a single body donor in the event of a problem.

Living, multi-organ, and cadaveric donors for human allografts

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A distinction can be made between living donors and cadaveric donors
according to the source of the allogeneic bone grafts. Living donor tissue
comes from hospitals in cases of, eg, resected femoral heads during the
insertion of hip joint prostheses. Living donors have the theoretical
advantage that the window between viral infection (eg, with HIV) and
seroconversion can be excluded by retesting 6 weeks after bone donation.
Multi-organ donors are patients who are explanted within the organ
transplant program in hospitals under sterile conditions and are tested
multiple times. Cadaver bone also comes from distant countries. The extent
to which these donors are tested should be clarified with the supplier of
these products. It was reported in 1996 that HIV infection was established
in 4 of 12 patients who had been treated with fresh bone grafts from an
HIV-positive multi-organ donor.32 However, this occurred at a time when
HIV testing could not be done routinely.

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Fig 4-3 Transplantation of cryopreserved autogenous bone. a. Head of femur obtained
during joint replacement surgery, cryopreserved for 2 years. b. Sinus floor defect and lateral
ridge deficit. c. Cancellous bone and block material separated from the femoral head. d.
Sinus lift and lateral ridge grafting. e. Osteosynthesis of the block material. f. Four months
later implant placement into the successfully healed bone graft.

Preparation of animal xenografts

Xenogeneic bone products are commercially available in the following
preparation levels:
I. Gently disinfected animal grafts: osteoinductive by BMP, protein
antigenicity, HLA antigenicity, disease transmission risk from animal,

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 durable commercially available industrial product.
II. Sterilized animal transplants: not osteoinductive (no active BMPs),
protein antigenicity, limited HLA antigenicity, disease transmission risk
from animal unlikely, shelf-stable commercially available industrial
product.
III. Protein-free animal transplants: brittle and not screwable, durable
industrial product, osteoconductive, no antigenicity and disease
transmission.

Class I and II animal products are debatable because they can trigger
immune reactions due to the foreign protein. For example, an equine block
material, although very convenient to use with screws because of its
collagen content, was withdrawn from the market because of antigenicity
and high rates of wound healing disorders. In a prospective human study,
wound dehiscence was observed in one-third of the patients and implant
loss in another third.33 Antigenicity occurs in principle in all protein-
containing animal products and is not linked to cells but to species-specific
amino acid sequences, eg, of collagen. However, with minor species-
specific differences in protein structure, this may often remain clinically
inapparent.

Deproteinized xenogeneic bone chips

In the 1960s to 1990s, Kiel bone chip was known worldwide as “Kiel
Graft.” It was the first industrially produced bone graft material,
manufactured and distributed by the Braun Company (Melsungen,
Germany).34 Through R. Maatz and A. Bauermeister, a method was
developed at the University of Kiel in the 1950s to remove proteins from
calf cancellous bone, thereby depriving the material of its antigenicity.35 In
fact, however, the scaffold collagen was still present in the chip material,
which gave the Kiel bone chip a certain strength but, according to
experimental studies, nevertheless triggered considerable immunologic
foreign body reactions. This was probably the reason why the “Kiel bone
chip” was relatively rarely used, and autogenous bone material is preferred
in many countries.34 The material looked like its market successor Bio-Oss
(Geistlich, in collaboration with P.J. Boyne of Loma Linda University,
California), in which it was possible for the first time to remove the protein

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completely. The exact preparation process remains a company secret to this
day.
In 1980, J.F. Osborn then took an alternative successful path to bone
replacement with synthetically produced hydroxyapatite.36

The problem of HLA sensitization by cell-containing human allografts

HLA sensitization can be induced by HLA antigens from cell surfaces of
bone allografts, soft tissue substitutes, and platelet transfusions, as shown,
for example, in a small case series of six patients from Brazil with sinus
lifts using an allogeneic graft not approved in Europe and Germany.37 A
meta-analysis found HLA sensitization in 48% of patients after bone
allografts.38
This HLA sensitization may become problematic when a donor organ is
needed later in life. However, it is still unclear whether this also applies to
the rather small antigen quantities present in grafts for dental applications.
Manufacturers of allogeneic bone substitute materials try to reduce the cell-
bound antigen content of their products by purification processes. In the
case of block-shaped bone pieces, however, this is not completely
successful because residual foreign human cells remain in the marrow
spaces and osteocyte cavities. According to a comparative study,39 the
content of human MHC class I antigens (determined by enzyme-linked
immunosorbent assay [ELISA]) in commercially available allogeneic grafts
amounted to 0.037 to 0.04 ng per mg bone mass, compared to 0.084 ng in
autogenous bone and 0 ng in protein-free xenogeneic materials. MHC class
I is expressed by almost all nucleated cells. MHC class II molecules,
normally expressed only by dendritic cells, were measured (using ELISA)
at low levels of 0.004 ng per mg bone mass in the allograft osteograft, 0.189
ng per mg bone mass in autograft, and 0 µg each in allogeneic graft from a
femoral head and protein-free xenogeneic materials, as expected.
HLA sensitization is one of the major organ rejection risks in kidney
transplantation if antibodies against MHC class I or II are already present in
the recipient’s blood before contact with the foreign organ.40 Allogeneic
grafts and especially allogeneic foreign blood transfusions are seen by
transplant physicians as the main risk for such immunization of organ
recipients. Certain HLA genes are also associated with the development of

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autoimmune diseases, such as ankylosing spondylitis, lupus erythematosus,
and insulin-dependent diabetes mellitus, among others.
In subjects such as orthopedics, indications for musculoskeletal
allogeneic grafts are made in life-threatening or life-decisive situations
because autogenous grafts are not available in the required quantity. In
implant surgery, alternatives exist for the much smaller amounts of bone
required. For the use of bone allogeneic grafts in dentistry, doubts remain in
the synopsis of molecular findings and clinical study results.

4.5 Soft Tissue Replacement Materials

The standard for soft tissue augmentation in the oral cavity is the
autogenous free mucosa graft for epithelial coverage of wounds and for
widening of the attached gingiva, as well as the autogenous subepithelial
connective tissue graft from the hard palate for thickening of the attached
gingiva also in the context of recession coverage.
Soft tissue substitutes were originally developed for burn surgery, where
the coverage of enormous body surfaces and life-saving indications are
involved. Such quantities often cannot be obtained autogenously. The
dentist usually has only very small areas to cover in situations of elective
surgery, and therefore, analogous to bone graft substitutes, there is
essentially little reason to take risks with foreign materials.

Allogeneic soft tissue substitutes

Analogous to allogeneic bone substitutes, allogeneic connective tissue
grafts from body donors have been developed. One example is the acellular
dermal matrix. Here, the cell bodies are removed to eliminate the graft
antigens.

Xenogeneic soft tissue substitutes

In a further step, the preparation procedures of the acellular dermal human
matrix were also transferred to porcine skin (Fig 4-4). For non-human
products, ie, xenogeneic dermal matrix, in addition to the transplantation
antigens, the antigenicity of the foreign proteins has to be considered.

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Basically, amino acid sequences of proteins are species-specific and vary to
different extents. Thus, foreign proteins can become antigens. For any
protein that was not present in the newborn’s body in the days after birth,
the human body does not develop immune tolerance and recognizes it as
foreign. This strategy of the immune system was necessary for survival for
millions of years.
A plethora of membranes and soft tissue thickening matrices are
available from bovine, porcine, or equine sources. Little is known about
immune responses to these substances because regulatory procedures in
Europe and the United States do not require such studies. However, as part
of the registration studies for recombinant BMP-2 using a bovine collagen
fleece as carrier, antibodies against bovine collagen were found.41 However,
these antibodies present in the blood of patients did not lead to clinical
disease or visible changes in the studies and were not part of the BMP
approval process. Nevertheless, the finding is interesting because such
antibody formations to foreign proteins are also to be expected for the
numerous other animal soft tissue substitutes. In view of the unexplained
genesis of many autoimmune diseases, antibody formations against
collagens should not be stimulated unnecessarily, if possible. Particularly
severe autoimmune diseases involve the connective tissues, such as
scleroderma and lupus erythematosus. Given the abundance of animal
products used in dentistry, it is surprising that more side effects and
allergies do not occur.

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Fig 4-4 Soft tissue augmentation with xenogeneic material – recession coverage. a.
Gingival recession on the maxillary left canine. b. Epiperiosteal preparation of a coronal
shift flap. c. Soft tissue relining with porcine xenogeneic matrix (Mucoderm, Botiss). d.
Coronal flap displacement by gingival sutures. e. Partial coverage of recession 4 months
later.

Allergic defense reactions were a problem in the past with repeated anti-
wrinkle injections with bovine collagen. Over time, some patients
developed a type IV allergy to the foreign protein with corresponding
consequences for the facial skin.42 Therefore, the collagen filler has now
been phased out and replaced by other substances. In dentistry, collagen
products are usually not used repeatedly on the same patient in the short

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term, so that the threshold for a visible defense reaction may not be
exceeded as quickly.
Animal collagen products otherwise have many advantages. They are
enzymatically degradable by human proteases as part of normal connective
tissue remodeling and are thus absorbable in the body. Collagen products
are hydrophilic and do not form solid- liquid interfaces. On contact with
water, they behave in a similarly absorbent manner to a chamois cloth and
adhere to the substrate due to the surface tension of the water. This makes
them very easy to handle clinically and, as a matrix scaffold, they also bind
soluble tissue growth factors.

Hemostatic effect of collagen

Collagen is a trigger of extrinsic blood coagulation, so collagen fleece has a
hemostatic effect, eg, during tooth extraction, and can also stabilize a
coagulum, eg, during cyst filling.

4.6 Clinical Differential Indication of Autogenous Materials

Versus Foreign Materials
Autogenous materials, unlike foreign materials, have no lobby. Developers
of foreign material–based technologies are more likely to enjoy financial
support than traditional autogenous techniques. Funders hope for increased
economic power supported by marketing as well as congress and speaker
sponsorship, none of which exist for autogenous materials. Economically,
autogenous material is a fee item in the physician’s treatment bill as
opposed to a third-party material, which is a pass-through item that
increases the physician’s bill. Cost-reimbursing agencies scrutinize material
costs much less than fee items, under which the autogenous materials fall.
Opening a box of foreign material is more convenient and less
techniquesensitive for treatment teams than obtaining and processing
autogenous grafts.
The above list of risks may suggest that autogenous material, which is
always free of these deleterious effects, is to be preferred as a matter of
principle. However, a good balance must be found, because an ethical
principle of surgery is Primum non nocere, so that a surgeon should use

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foreign material if this causes less overall harm than obtaining autogenous
materials.
In the end, the informed patient chooses a material together with the
physician in a participatory decision (see chapter 5). However, the patient
should also be correctly informed about the origin and the pros and cons of
the materials.

4.7 Membranes
The observation that different tissues sometimes compete in wound healing
was initially noticed in periodontology in particular on the basis of the long
junctional epithelium. After root planing, regeneration with a new
desmodontal attachment may occur to a lesser extent. However, repair by a
long junctional epithelial occurs more rapidly because epithelium cells
grow faster than the cementum. Membranes have been used to interfere
with this competitive wound healing by preventing epithelial cells from
deep growth by using the membrane as a barrier (guided tissue regeneration
[GTR]). The principle of the barrier membrane was transferred to bone as
GBR. Here, according to the original mechanistic concept, the aim was to
intervene in the competitive healing between the slow-growing bone cells
and the fast-growing connective tissue cells. Why the membrane really
works is the subject of numerous theories, including resorption inhibition
by keeping osteoclasts from the soft tissue, the concentration of growth
factors in the bone defect, and the inhibition of neoangiogenesis from the
soft tissue. It has never been proven whether a membrane must be
cellocclusive or may have pores, because even a metal grid (mesh) can act
like a barrier membrane. All that is known is that with membrane,
approximately 2-mm greater bone thickness compared to bone formation
without membrane was achieved in a randomized clinical trial.43

Membranes made from native xenogeneic collagen

A native collagen membrane becomes soft and flexible after contact with
water and has a tendency to adhere to bone without gaps because the
collagen molecule is hydrophilic and, in principle, water soluble. The
collagen membrane does not create a solid-liquid interface and bonds with

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the blood coagulum, which is also a polymer in aqueous solution. The cells
of the organism apparently do not recognize any difference between their
own connective tissue and the foreign material, which, after implantation,
participates in the remodeling of the tissue collagen by proteases in the
same way as their own tissue.
Due to the hydrogen bonds of water, the native collagen membrane
sticks to hydrophilic surfaces like a piece of blotting paper. Additional
fixation by tacks is therefore not usually necessary for native collagen
membranes, so that the subsequent removal of the tacks is also unnecessary.
Collagen membranes are less prone to soft tissue dehiscence than Teflon
membranes, so that physiologic incisions such as the gingival margin
incision and midline incision can be used. Unproblematic handling and
posttreatment is a major advantage of collagen membranes.
A disadvantage of collagen membranes is their animal origin and
possible sensitization to foreign proteins depending on the manufacturing
process. Because of the foreign proteins and species-specific immune
responses, collagen membranes are not easily interchangeable, and close
attention should be paid to generic products and alternatives to established
products.

Membranes made from chemically modified xenogeneic collagen

In the case of natural collagen membranes, the barrier function in the tissue
is relatively short-lived, lasting only a few weeks. There has been no lack of
attempts and products to modify collagen, eg, by chemical crosslinking, and
make it more stable. In a human study of GBR for dental implants, the
collagen of a natural porcine membrane was made more crosslinked by
chemical treatment with formalin and used in comparison with the native
collagen membrane. This chemical treatment impedes attack by tissue
proteases and thus increases the durability of the barrier function. The study
was terminated prematurely due to high wound dehiscence rates in the
modified membrane group, and the product did not reach market.44 Another
chemical modification of natural collagen by ribose sugar molecules aimed
to increase the mechanical stiffness of the membrane. So far, it generally
has been confirmed that chemical modifications cause the tissue
friendliness to suffer and the dehiscence rate to approach that of Teflon
membranes.

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 A practical suggestion for increasing the barrier function time of
collagen membranes is to double or triple layer them or use thicker
versions.

Teflon membranes
Early membranes were made of expanded polytetrafluoroethylene (ePTFE,
Teflon). This material tends to form soft tissue dehiscences in the oral
cavity and requires very safe soft tissue management. The Teflon membrane
should not be placed directly under an incision if possible, so incision
techniques away from the ridge were recommended. Teflon membranes are
hydrophobic and rigid and form a solid-liquid interface in the tissue. They
should always be carefully adapted to the bony defect margins with small
tacks. After healing, a second surgical procedure is required to remove the
membrane and tacks. An alternative nonabsorbable membrane type consists
of thin rolled titanium foils.

Resorbable plastic membranes

Resorbable plastic membranes consist of polymers of hydroxy acids (lactic
acid, glycolic acid), which decompose in the body environment over time
by hydrolysis in a chemically non-cell-bound manner. The resulting acids
are buffered by tissue fluids, but can still inhibit bone formation by local pH
shifts into the acidic range. Decay particles are phagocytosed by
macrophages, which cause an inflammatory reaction and also inhibit bone
formation. Particles of a certain size allow sterile inflammation without
bacterial influence. Such membranes are similar to Teflon membranes in
terms of processing technology. Clinically, resorbable plastic membranes
have not proven successful in oral bone regeneration.

Other membrane types

The idea of applying a membrane material in liquid form to the wound,
which then hardens, eliminates the need for the surgeon to adjust the shape
of the membrane. This idea was pursued in the Membragel concept
(Straumann), which is made of polyethylene glycol. The material is

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resorbable in the tissue but produced worse results than the conventional
technique in a randomized clinical trial.45

4.8 Bioactive Materials and Tissue Engineering

Current knowledge of the biology of wound healing, especially the
discovery of the principle of tissue differentiation by BMP, opens up new
therapeutic possibilities. Building on experience with bone marrow extracts
from World War I wartime surgery, S. Annersten of Sweden was able to use
bone protein extracts to produce ectopic bone in muscle in animal
experiments in 1940. P. Lacroix from France created the term osteogenin
for this bone growth substance in 1945. This work was known to M.R. Urist
of the United States, who in 1965 extracted the responsible proteins from
bone in pure form and named them bone morphogenetic proteins. Despite
this long history, and despite the fact that genetic engineering now makes it
possible to recombine and produce almost any protein on a large scale, the
autogenous bone graft is still the basis of clinical work. So progress is slow.
On the other hand, the direction toward tissue engineering is
undisputed. After a phase of defect healing in the 19th century, the 20th
century was the era of regeneration by autogenous grafts (Fig 4-5). In the
21st century, there are indications that tissue engineering will stimulate the
body’s own regenerative powers and use them to heal defects. The
molecular signals for this are the growth and differentiation proteins already
known from developmental research. Nature is the model; consider, for
example, the enormous amounts of bone that are formed in the antlers of
deer every year (Fig 4-6). To do this, one must properly loosen the genetic
brakes and stimulate the right molecular switches. In humans, many
principles already found in lower organisms are confirmed. Embryogenesis
repeats the development of living beings, as the basic biogenetic rule states:
ontogeny recapitulates phylogeny (E. Haeckel, 1834–1919, anatomist, Jena,
Germany). Wound healing corresponds to a repetition of embryogenesis;
the genetic equipment for this has lain dormant in the cells of our body
since the earliest history of development.
Possible goals of the use of tissue engineering (Fig 4-7) in implantology
are:

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 Support and replacement of autogenous bone grafts in augmentation
procedures
Acceleration of bone healing
Improving the osseointegration of implants
Accelerating the osseointegration of implants
Improvement of peri-implant bone quality

Tissue engineering is the targeted manipulation of wound healing in vivo

and in vitro for the purpose of regenerating tissue components or entire
organs.
In order to regenerate tissue using tissue engineering, three factors are
required: cells, matrix, and signal molecules and, in addition to time, a
blood supply (Fig 4-8). The bone substitute materials discussed above are
regarded as the matrix. Cells in associated tissue communicate with each
other. Signaling proteins (cytokines) secreted into the interstitium are
responsible for the closer cell environment in the tissue. These are protein
molecules that cooperate with specific receptors on the cell surface. These
so-called transmembrane receptors trigger phosphorylation reactions of
messenger molecules (second messengers) inside the cell. Second
messengers control the expression of certain genes and thus certain cellular
reactions (Fig 4-9).

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Fig 4-5 Medical history of tissue engineering.

Differentiation factors have a morphogenic effect. They stimulate the

differentiation of a stem cell into a bone cell. They are osteoinductive
proteins.
Growth factors have a mitogenic effect in tissue. They stimulate the
proliferation of tissues through cell division.

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Fig 4-6 Example of massive bone formation in nature due to osteoinduction.

Growth factors and morphogenic factors also regulate the development and
growth of organs during embryonic development. The embryonic cells also
remain in post-fetal life as stem cells. Tissue regeneration during wound
healing repeats embryonic development in this aspect.

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Fig 4-7 Classification and development status of various bone growth-promoting principles
in oral bone regeneration. The lowest three rows show the respective test stage. rhGDF,
recombinant human growth and differentiation factor; rhPDGF, recombinant human platelet
derived growth factor; PRP, platelet-rich plasma; L-PRF, leukocyte- and platelet-rich fibrin;
BMAC, bone marrow aspirate concentrate; BioSeed, BioTissue.

Fig 4-8 Principles for reconstitution of a bone graft (see chapter 2). Therapeutic assembly of
matrix, BMPs, and stem cells from tissue produces bone regeneration.

Recombinant human BMPs

Recombinant human BMP-2 (rhBMP-2) is approved for oral surgery and
dentistry in the United States and other countries (but not in Europe). The
price of a single dose of BMP for therapeutic use is between one to several
thousand dollars in the United States, depending on the size of the package
(Infuse Bone Graft, Medtronic). This product is supplied together with a
xenogeneic collagen sponge as a carrier, which is easily compressed in the
defect and has no significant inherent stability compared to bone grafting
materials and is therefore often combined with titanium meshes in alveolar
augmentation.46

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Fig 4-9 Circulation of natural BMPs in bone tissue. BMPs are incorporated in the bone
ground substance on the right and are exposed by osteoclasts, trauma, or surgery. From
the surface they are released by membranous serine proteases from their binding. By
diffusion, they migrate to the transmembrane receptors of the bone precursor cells. There
they cause differentiation into osteoblasts. These produce BMP again and incorporate it into
the bone ground substance.

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Fig 4-10 Example of osteoinduction by rhBMP-7 (rhOP-1) for sinus elevation in the mini pig.
There was a significant superiority of rhOP-1 over the control materials. COIR, Clin Oral
Implants Res.

The approval of recombinant human osteogenic protein-1 (rhOP-1 or

rhBMP-7) as Osigraft (Stryker) as a drug for the field of orthopedics has
meanwhile been withdrawn in Europe, so that only rhBMP-2 is currently
approved in Europe for orthopedic indications such as tibial non-unions and
vertebral body fusions. rhBMP-2 is produced at a relatively high cost in
mammalian cell cultures such as hamster ovary cells, which explains its
commercially high price. BMP-2 can also be produced more cheaply in
bacterial cell cultures. It is then not glycosylated and three-dimensionally
folded as in eukaryotic cells, but it is still effective. Since chemically exact
copies of human proteins, when produced in bacteria like BMP-2, also have
antigenic activity due to different protein folding, an immune response to
BMP has been demonstrated.47 An antibody response has also been
demonstrated to the carrier materials for BMP-2 (collagen sponge) as a
foreign protein in some patients. The use of rhBMP is not recommended in
patients with autoimmune diseases or hypersensitivity to foreign collagen,

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women with potential for pregnancy, or individuals who are still growing. It
is feared that induced antibodies to BMP affect skeletal development in
fetuses and children.
Among all tissue-engineering techniques, BMP research has reached the
highest level of experimental verification through numerous successful
randomized clinical trials (RCTs) in humans. For BMP-2 and rhOP-1
(BMP-7), a large amount of animal experimental data is available,
unanimously demonstrating the therapeutic effect of topically applied BMP
on the induction of new bone48 (Fig 4-10). rhOP-1 has only been used in
orthopedics, neurosurgery, and facial reconstructive surgery for mandibular
reconstruction49 (Fig 4-11). In contrast, numerous randomized studies with
significant evidence of efficacy are available for rhBMP-2 for mandibular
gap osteoplasty, alveolar restoration, lateral and vertical ridge
augmentation, ridge preservation, and sinus floor augmentation. The latter
studies are noteworthy in that the control groups were often the autogenous
iliac bone graft, which heals very quickly and is therefore a challenging
control. rhBMP-2 was equivalent to autogenous pelvic bone according to a
meta-analysis of six RCTs.50 A recent meta-analysis of human studies in
implant dentistry even showed a slight superiority to autogenous bone graft
for ridge augmentation, but not for sinus floor augmentation, which healed
better spontaneously or with bone graft substitute than with BMP.51

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Fig 4-11 Example of osteoinduction by rhBMP-7: prefabrication of a mandible in the dorsal
muscle.

Native autologous growth factors: PRP, PRF

Platelets contain many substances, including growth factors that act on bone
cells. In particular, the protein platelet derived growth factor (PDGF) has a
mitogenic effect on bone progenitor cells. These factors are not
osteoinductive and can therefore only act on bone regeneration in the bony
bed or in combination with bone grafts. Different fractions containing
platelets can be extracted from whole blood by centrifugation, commonly
referred to as platelet-rich plasma (PRP). This includes many different
special designations with different growth factor contents. Depending on
the procedure, increases in the concentration of growth factors compared to
whole blood of up to one power of 10 can be achieved. A whole series of
scientific studies, including several randomized clinical trials, have been
published on autologous platelet concentrates since it was first described in
the late 1990s in maxillofacial surgery. These have been summarized as

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meta-analyses for the field of sinus floor augmentation and implant therapy,
which repeatedly showed that for the parameters of implant survival and
bone regeneration there is no evidence of improved bone regeneration for
PRP and relatives.52,53
Platelet-rich fibrin (PRF) refers to autologous fibrin membranes with
increased growth factor content prepared by slow centrifugation, clotting,
and flattening (Fig 4-12), also known as the J. Choukroun method.54 The
material has recently been repeatedly used successfully in clinical studies.
The corresponding meta-analyses speak of moderate evidence for
leukocyte- and platelet-rich fibrin (L-PRF)55,56 for bone formation in ridge
preservation and wound healing.

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Fig 4-12 PRF membranes. a. Centrifuge distributed by Mectron. b. Edentulous maxillary
right central incisor site with horizontal and vertical atrophy. c. Intrasurgical view of the
palatal bone wall. d. Fixation of an autogenous bone block from the external oblique ridge
on the firm supporting bone at the edentulous site. The block was perforated for faster
healing, and chips were collected. e. Bio-Gide (Geistlich) membrane clamped under the
palatal flap. f. Bone scraper chips are filled behind the shell-like block. g. Mixture of filter
bone and fine-grain Bio-Oss added as contour filling and resorption protection. h. A section
of collagen membrane is placed as a double layer. i. After centrifugation of whole blood, the
red coagulum is stripped from the PRF. j. PRF coagulum on the draining sieve. k. The PRF
clot is turned into a membrane by flattening and squeezing it. l. Place the PRF membrane
on the collagen membrane. m. The flap is mobilized (periosteal slitting) with a single hook
and 15c scalpel. n. Wound closure with interdental sutures and interrupted sutures.

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Fig 4-13 Two approaches to gene therapy with BMPs for bone regeneration.

Recombinant growth factors

As with BMPs, it is also possible to recombinantly produce an almost exact
copy of a human growth factor, eg, rhPDGF. Preclinical animal research on
recombinant growth factors in implant dentistry dates back to the early
1990s, as with BMPs. Recent animal and human studies also confirm the
efficiency of PDGF for bone regeneration in implantology. In the United
States, a bone graft substitute based on rhPDGF-BB has been approved as
Gem21 (Lynch Biologics), but randomized prospective clinical studies have
not yet been published in implantology, only in periodontology. There are
only single case reports on PDGF-BB in implantology. In Europe, PDGF-
BB has so far been approved for the treatment of chronic foot wounds in
diabetics (Regranex, Janssen-Cilag) and documented on the basis of
multiple RCTs.

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 The recombinant growth factor studied in implant dentistry at the
highest level of RCT evidence is rhGDF-5. rhGDF-5 is a hybrid of growth
factors and BMP and is also called BMP-15. It showed efficacy in
augmentation in animal experiments. GDF-5 was shown to be equivalent to
autologous bone graft in a randomized clinical trial for sinus floor
augmentation.57

Gene therapies
Instead of producing BMPs in a complex technical process, the coding
genes can also be introduced into body cells in vectors, and these cells can
be genetically modified as gene therapy (Fig 4-13). This introduction is
called transfection. Henceforth, the cells of the wound produce BMP. Thus
one has also solved the problem of carrier material and delivery kinetics,
because these cells continuously produce physiologic amounts of BMP.
Gene therapy exists in two varieties. With in vivo transfection, vectors are
delivered directly into the wound. In ex vivo transfection, body cells are
harvested and transfected in a test tube and then returned. There have been
numerous successful experimental studies of bone regeneration with both
approaches. Approval in humans is not expected in the near future because
of the risks associated with genetically modified cells. One approved gene
therapy with genetically modified body cells to date is currently chimeric
antigen receptor-modified T (CAR-T) cell therapy for leukemia.

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Fig 4-14 Technique for Harvest BMAC system (Harvest/ Terumo BCT) using a Jamshidi
needle with a T-handle, shown here taken from the posterior iliac crest in a prone position.
The cells in the aspirate are enriched by centrifugation prior to transplantation.

Small molecules
Small molecules of drugs are much cheaper to produce than complicated
recombinant proteins. In fact, it is possible to intervene in many metabolic
processes of bone formation. For example, statins, which are actually lipid-
lowering agents, promote osseointegration of dental implants58 and
periodontal defects.59 Also, via hormone-like analogues of parathyroid
hormone, strontium ranelate, prostaglandin EP4 receptor antagonists, and
vitamin D have been reported to promote bone growth. All of these studies
have so far failed to show clear and consistent success equivalent to that of
BMP.

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Native autologous cell preparations
Mesenchymal osteogenically differentiated stem cells can be obtained from
the patient by sharp puncture of the iliac crest with a Jamshidi needle,
processed, and then transplanted. Instead of a cell culture step, the stem
cells are enriched in these procedures by centrifugation of the aspirated
fluid (bone marrow aspirate concentrate, BMAC; Figs 4-14 to 4-16). In the
literature, there is one controlled prospective study on sinus floor
augmentation with BMAC. The latter showed equivalent results for cell
aspirates as for autologous bone grafts.60 In orthopedic applications, a
positive conclusion was drawn.61 However, the number of recoverable
mesenchymal stem cells from a marrow aspirate is limited. A larger amount
of mesenchymal stem cells can be obtained by ultrasound aspiration during
liposuction and enriched by an automated purification process (adipose-
derived stem cells, ADSCs, Celution System, Cytori). This material can also
be cryopreserved.

Cultured autologous cells

The starting point of tissue regeneration is stem cells, mesenchymal stem
cells in the case of bone regeneration. Pluripotent stem cells can be
cultivated and expanded relatively well in vitro. In this way, part of the
wound healing process is temporarily relocated to the well-protected and
controllable environment of the laboratory in order to relocate them back to
the defect after the proliferation and, if necessary, differentiation step. The
relocation back to the defect is apparently the problematic part of this
procedure. In an animal experiment on sinus floor augmentation, cultured
cells were not effective.62 It has been shown that the transplanted cells do
not survive long in the wound63 (Fig 4-17). Reasons may be a lack of blood
supply due to large defects or dedifferentiation due to a lack of growth
factors. Therefore, attempts have been made to precondition the stem cells
prior to transplantation. Cultured cells may also be rejected for
immunologic reasons because cell cultures contain foreign proteins from
fetal calf serum. A randomized controlled trial of sinus elevation with
cultured cells showed no effect for cell therapy compared to the control
group.64

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Fig 4-15 a. Patient with atrophied maxilla. b. Section of lateral cephalometric image
showing apical ridge atrophy (Cawood class IV). c. Panoramic radiograph after LeFort
interpositional osteoplasty. d. Section of lateral cephalometric image after LeFort
interpositional osteoplasty. e. Panoramic radiograph after placement of dental implants 4
months after augmentation. f. Osseointegrated dental implants.

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Fig 4-15 g. Telescopic prosthesis. h. Intraoperative view of the LeFort interpositional gap,
which will soon be impregnated with the BMAC cell concentrate. i. Bio-Oss blocks are used
for lateral riodge augmentation and secured in place with screws. BMAC is soaked into the
blocks. j. Covering with collagen membrane (Bio-Gide). k. Two trephine biopsies from the
former Bio-Oss blocks staining of the newly formed bone. l. Sections from the biopsy. Bio-
Oss trabecular bone on the left with empty osteocyte cavities is covered by newly formed
bone (dark red, osteocyte cavities filled), with bone marrow next to it.

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Fig 4-16 Vicryl Mesh Bag (Ethicon) technique. a. Panoramic showing extreme atrophy of
the lateral mandible. b. Section of lateral cephalometric image showing atrophy of
mandibular base and replacement with neo-mandible as well as an exposed inferior
alveolar nerve with corresponding pain syndrome. c. Postoperative panoramic with Vicryl
Mesh Bag in situ. d. Prosthetic restoration with removable dentures using ball-head anchors
on the lateral mandibular implants. e. Four months after placement of dental implants. f.
Section of lateral cephalometric image after bone augmentation.

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Fig 4-16 Vicryl Mesh Bag (Ethicon) technique. g. Vicryl Mesh Bag filled with bone substitute
material (Bio-Oss) and BMAC cells. h. Intraoperative image with minimally invasive tunnel
preparation through a vertical incision in canine region. i. Intraoperative image with insertion
of Vicryl Mesh Bags into the tunnel. j. Prosthetic restoration. (Prosthetics: Dr Schlatmann,
Nuremberg.)

4.9 Conclusions on Bioactive Materials and Tissue

Engineering
Autogenous bone remains the therapeutic standard for bone regeneration in
dental surgery. Through the many studies on tissue engineering, the
mechanism of action of the autogenous bone graft has been discovered and
newly appreciated. The role of bone graft substitutes as an artificial matrix
(scaffold) has also been well defined by tissue engineering research. Cell-
based therapies, the actual tissue engineering, did not fulfill the set
expectations in the field of bone regeneration. Of all the varieties of tissue
engineering, only recombinant BMP was able to achieve market maturity in
some countries and produce a consistently significant effect on bone healing
in almost all studies. However, among other things, the high price speaks
against widespread use in dentistry. In Europe, recombinant growth factors

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and BMP are not yet approved for use in dentistry, but they are generally
promising.

Fig 4-17 Problem of survival of cultured cells in the wound. (top left) Bio-Oss blocks are
incubated with cultured osteogenic stem cells. (top center) Confluent field of stem cells at
the bottom of the Petri dish. (top right) Scanning electron micrograph of confluent cells on
the Bio-Oss blocks just prior to transplantation. (bottom left) Cells transfected with green
fluorescent protein (GFP) and genetically modified so that cells fluoresce as long as they
are vital. (bottom center) Transplantation of the artificial bone grafts into the subcutaneous
tissue. (bottom right) hardly any fluorescence 1 week after transplantation; only about 3 out
of 1000 cells survived the transplantation (rat).

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 (Basel) 2018;11(12):2530.
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22. Draenert FG, Kämmerer PW, Berthold M, Neff A. Complications with allogeneic, cancellous
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64. Hermund NU, Stavropoulos A, Donatsky O, et al. Reimplantation of cultivated human bone cells
from the posterior maxilla for sinus floor augmentation. Histological results from a randomized
controlled clinical trial. Clin Oral Implants Res 2012;23:1031–1037.

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B
OPERATING TECHNIQUES

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 5
Patient Management and Surgery
Preparation

A surgical procedure usually means extraordinary physical stress and

anxiety as well as lost working hours and time for the patient. The result of
a procedure performed intraorally cannot be 100% predicted due to the
contaminated surgical field and cannot be guaranteed by the physician. The
principle of participatory decision making ensures that patients recognize
the necessity and the benefit for themselves and take joint responsibility for
the result.

5.1 Elective Surgery

A dental implant procedure is usually elective. This means that, in contrast
to vital indications, the patient and the doctor are free to choose the scope,
procedure, timing, materials, and surgical environment to suit them. For
both, this also means minimizing or avoiding unnecessary risks. Elective
surgery offers the opportunity to carefully weigh and discuss the advantages
and disadvantages in advance. The patient and the surgeon are free to
choose the date. The procedure can be prepared in terms of materials,
assistance, methods, etc. An implant procedure can be scheduled in reserved
practice times, during which the team can concentrate on it without
interruption. This calmness in the team is then also transferred to the patient
and is a quality feature of the surgery performed.

5.2 Patient Selection According to Risk Factors

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Preparation for an elective procedure also includes risk management based
on the patient’s preexisting conditions. For example, in the case of an
elective procedure, there is time to have high blood pressure checked again
by the patient’s general practitioner before the procedure. If risk factors are
present, referral to specialized centers is an option for difficult implant
procedures.
Today, there are few real contraindications to augmentation surgery. The
following should be mentioned here: simultaneous cytostatic treatments as
part of tumor therapies as well as antiresorptive therapy such as the use of
bisphosphonates or denosumab, an antibody against receptor activator of
nuclear factor kappa-beta ligand (RANKL).
The former contraindications have largely become risk factors. This
means that, if the case is severe enough and necessary, limited
augmentation of soft tissue or bone can be indicated with the acceptance of
an increased complication rate on both sides. There are hardly any risk
calculations for complications associated with bone or soft tissue
augmentations, only for dental implant placement, and here also only for
early loss of dental implants. As an example of such risk calculations, a
meta-analysis on implants placed in the irradiated jaw found a risk ratio of
2.18 for implant loss in the irradiated versus the healthy jaw.1 In this study,
the risk of implant loss was 4.6% in the healthy jaw group and 4.6% x 2.18
= 10.1% in the irradiated jaws. Approximately every tenth implant was lost
in the irradiated jaw according to this meta-analysis, and one can use this
handy figure in the patient education discussion. Further complications such
as osteoradionecrosis must of course be taken into account in the
indications and information (Fig 5-1). In the case of implant placement,
however, attention should still be paid to the further risk-increasing
combination of individual risk factors.

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Fig 5-1 Wound-healing disorder after implant restoration with exposed bone in the mandible
after radiation therapy.

In addition, the risk for wound-healing disorders is higher when bone

and soft tissue augmentations are performed along with dental implant
placement compared with dental implant placement alone. In this group of
procedures, if risk factors are present, the indications should be particularly
critical. In the case of all risk factors, the degree of suffering and the
severity of the indication for the procedure must always be weighed on a
patient-by-patient basis. For example, in the case of an unstable mandibular
full denture, the severity is usually higher than in the case of replacement of
an anterior tooth, which might also be possible with an adhesive bridge. The
benefit must always be weighed against the risk of damage and an
alternative selected if necessary. Primum non nocere, ie, first do no harm, is
a basic rule in surgery.
Risk factors for augmentation surgery include poorly controlled diabetes
mellitus with a glycohemoglobin fraction (HbA1c) greater than 7.5%.
Smoking is a risk factor for early survival of dental implants depending on
the amount of cigarettes and increases very strongly with more than 20
cigarettes per day.2 For dental implant placement in combination with sinus
floor augmentation in heavy smokers, the implant loss rate even increases
to five times that of nonsmokers.3 A history of periodontitis increases risk
for early implant loss,4 but this is negated for patients who have undergone
periodontal rehabilitation and are receiving supportive periodontal therapy.5

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Autoimmune diseases such as rheumatoid arthritis are risk factors mainly
due to immunosuppressive medication. Especially with the
immunosuppressive drug methotrexate, which is a cytostatic drug by folic
acid antagonism, severe wound healing disorders are seen. Glucocorticoids
are detrimental to wound healing, but one study showed no effect on early
implant loss rate.6 Prostaglandins have a positive effect on bone healing, so
antagonization by nonsteroidal anti-inflammatory drugs (NSAIDs) is
always suspected of causing bone-healing disorders. However, there is a
lack of studies on implantology and augmentation surgery.7 Newly coming
into focus are proton pump inhibitors for the reduction of gastric acid and
selective serotonin uptake inhibitors (antidepressants), which, based on the
evidence level of retrospective studies, triggered an increased rate of early
implant loss.8,9 Vitamin D deficiency is common in the population, and a
negative influence on the osseointegration of dental implants is suspected
but could not be proven in studies so far.10 Malnutrition or undernutrition
leads to wound-healing disorders11; however, an age higher than 65 years
does not increase the risk of implant loss.12

Fig 5-2 a. Hematoma in the floor of the mouth with respiratory obstruction due to swollen
and elevated tongue after placement of a central mandibular dental implant in a patient
without anticoagulant medication. b. Panoramic radiograph of the same patient. Such
hematomas occur due to injury of oral floor arteries, especially during implant placement in
the interforaminal region of the mandible with accidental lingual bone perforation.

Congenital or acquired coagulopathies represent a special risk group for

augmentation surgery (Figs 5-2 and 5-3). The latter can be classified as
thrombocytic (eg, acetylsalicylic acid [ASA] medication), plasmatic (eg,
phenprocoumon therapy), or vascular (eg, Osler disease). As a rule,
thrombocytic disorders are characterized by a prolonged intraoperative
bleeding time, whereas plasmatic disorders are prone to extensive

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hemorrhage and hematoma even days later because no stable fibrin polymer
(coagulum) is formed. Phenprocoumon and ASA are both characterized by
long effect duration after discontinuation, so that short-term discontinuation
of therapy does not provide any advantage for the frequency of re-bleeding.
As a result, the strategy here is usually to reduce the invasiveness of the
procedure and provide precise topical surgical hemostasis. New direct oral
anticoagulants can be well controlled when taken orally; eg, after a waiting
period of 12 hours after discontinuation of dabigatran, no increased
bleeding complications occurred compared to the normal group.13 However,
the possible discontinuation of anticoagulants should be discussed with
primary care physicians and depends on the severity of the underlying
disease. Implant placement alone is less critical than when combined with
bone and soft tissue augmentations with regard to the risk of postoperative
bleeding.

Fig 5-3 Facial hematomas with an ultimately mild course after implant surgery in a patient
under anticoagulation treatment with phenprocoumon.

See Table 5-1 for a summary of the relative risk for dental implant loss
associated with various medical and dental preexisting conditions.

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Table 5-1 Relative risk (risk ratio) corresponding to the increased clinical risk for dental
implant loss due to certain general medical and dental preexisting conditions compared with
patients without this risk factor, calculated from meta-analyses and study data. Such data
are not available for augmentation surgeries.

Risk Factor Relative Risk

Smoking < 10 cigarettes2 Risk ratio: 1.28

Smoking < 20 cigarettes2 Risk ratio: 1.46

Smoking > 20 cigarettes2 Risk ratio: 2.51

Smoking in combination with sinus floor augmentation3 Risk ratio: 4.8

History of periodontitis4 Risk ratio: 1.69

Jaw irradiation1 Risk ratio: 2.18

Therapy with antidepressants (selective serotonin uptake Risk ratio: 3.1 to 6.3
inhibitors)9
Therapy with proton pump inhibitors9 Risk ratio: 2.3 to 2.8
Rheumatoid arthritis Too few studies
Methotrexate therapy No studies
NSAID therapy Too few studies
Neurologic diseases (eg, Parkinson disease) Too few studies
HIV virus detection Too few studies
Age over 65 years Does not increase risk
Periodontitis after rehabilitation and supportive therapy5 Does not increase risk
(risk ratio: 1.04)
Diabetes mellitus Does not increase risk
Osteoporosis without antiresorptive medication Does not increase risk
Vitamin D deficiency Does not increase risk
Hypothyroidism Does not increase risk
Cardiovascular disease and hypertension Does not increase risk

Implants and augmentations in osteoporosis

Osteopenia and osteoporosis can be prevented if one succeeds in
developing peak bone mass early in life and in delaying the inevitable age-
related decrease in bone mass thereafter as long as possible, so that one

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does not fall below the critical limit of fracture risk (Figs 5-4 and 5-5).
According to a metaanalysis there was no significantly increased implant
loss rate for patients with osteoporosis in almost 30,000 dental implants
analyzed, only an increased marginal bone loss of 0.18 mm compared to
patients with healthy bone mass.14 Dental implants are therefore possible in
patients with osteoporosis. Nevertheless, osteoporosis should not be
underestimated, because bone may have already lost 70% of its mineral
content and stability before changes become visible as a warning sign on a
conventional radiograph. As a result, drilling resistance when placing the
implants can be unexpectedly low, and it is very difficult to achieve primary
stability (Fig 5-6). In patients with osteoporosis there is a special indication
for augmentation, with the aim of achieving firmer bone or a mechanically
more favorable implant distribution, for example, by sinus elevation.

Fig 5-4 Representation of osteopenia and osteoporosis as an age-related deviation from

the statistical normal distribution of bone mass.

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Fig 5-5 Paramedian fracture of the right mandible during implant treatment in a 75-year-old
female patient with osteoporosis. Delayed secondary fracture healing with formation of a
callus zone and bone distention (elephant foot) can be seen. The suspicion of osteoporosis
arises from this panoramic in view of the relatively thin basal cortical bone of the mandible,
which has moth-eaten appearance on the left side.

Fig 5-6 Bone hardness in the implant site, classified according to Misch’s drill feel (Carl
Misch, DDS, 1947–2017, US). The bone hardness results mainly from the distribution of
cancellous bone and compact bone, as can be seen in the cross sections of the jaws.

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Implants and augmentation with use of antiresorptive medication
A meta-analysis found that among patients with osteoporosis, those taking
bisphosphonates did not have increased implant loss rates compared to
those not taking bisphosphonates.15 Thus, dental implants are in principle
also possible under bisphosphonate medication and possibly also under
denosumab. On the other hand, the cited meta-analysis listed seven studies
in which the occurrence of jaw necrosis in connection with dental implant
placement in patients on antiresorptive medication was reported. Jaw
necrosis occurred in 71% of cases in the mandible, predominantly
posteriorly. Identified triggers of jaw necrosis were Implant placement (15
times), implant removal (5 times), and the pure presence of a dental implant
(41 times). Because of these severe side effects (Fig 5-7), the indication for
dental implants should be made very strictly, weighing the individual risk-
benefit profile. According to current data, bone augmentation should be
avoided altogether. The most favorable approach is to carry out a preventive
sanitation of the dentition, including augmentations and implant
placements, before starting antiresorptive therapy, if the indication permits
this in terms of time.

Fig 5-7 Exposed bone and implant in the course of implant placement in a patient taking
antiresorptive medication.

5.3 Informing the Patient

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A supportive and objective explanation provided by the initial consulting
dentist in a referral case is very helpful. As a surgeon, you can take the time
to inform the patient calmly about the duration, type, typical risks, and
alternatives of the procedure; consequences of nontreatment; and lost
working hours, among other things, and have these points countersigned.
The costs should be clarified in a cost estimate according to the items in the
fee schedule. An appointment for surgery should not be made until this cost
estimate has been signed by the patient, because many legal disputes arise
from the desire to reduce the fee if the costs have not been clearly
communicated in advance. The explanation should also appeal to the
patient’s personal responsibility, because the procedure takes place in the
patient’s body, for which he or she is responsible. In addition, it should be
clear to the patient that he or she must follow the doctor’s instructions.
Postoperative behavior can be explained again in writing at the time of
discharge after the operation.

5.4 Realistic Patient Expectations

Legal disputes often arise from disappointed expectations. Therefore,
realistic patient expectations should be achieved, especially for the esthetics
of the denture. An aid for this can sometimes be a school grading system, in
which the patient is asked to give the initial situation a grade from A to F,
and based on this it is usually only possible to achieve an improvement of
one to two grades. The patient should also realize that in medicine, unlike
technical repairs, 100% predictability or a guarantee of success is not
possible because the outcome depends on a complex biologic system and
the patient’s behavior. In most legal systems the physician owes the patient
the correct performance but not the result of a treatment. This is particularly
true for procedures performed in the nonsterile environment of the oral
cavity.

5.5 Shared Decision Making

Permission to cut open one’s own body is one of the greatest
demonstrations of trust that a human being can express. So it is
understandable if this trust turns into the opposite when a failure occurs,

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and the trust appears to have been misplaced from the patient’s point of
view (Fig 5-8). Many patients intuitively blame the physician for the
failure, and this is all the more true the less the surgical indication was
medically necessary and the more it was to fulfill the patient’s desires. This
is another reason why it is so important to communicate that implant
surgery is not for wish fulfillment but for medical rehabilitation. From the
physician’s point of view, such one-sided blame is difficult to understand
because the physician has little influence on wound healing once the patient
has left the office postoperatively. After that, healing has much to do with
the patient’s postoperative behavior and general health.

Fig 5-8 Step-by-step concept for reducing the bacterial load in the wound prior to
augmentation procedures. According to German Society for Dental, Oral, and Maxillofacial
Medicine (DGZMK) recommendations, this includes preoperative single-shot antibiotics with
a combination preparation of penicillin + beta-lactamase inhibitor (eg, ampicillin sulbactam)
or clindamycin (600 mg orally) in the case of a suspected or confirmed allergy to penicillin.

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 In order to prevent false attribution of blame, the patient’s own
responsibility for the healing and the outcome of implant treatment should
be emphasized. This is done through, among other things, the principle of
shared decision making. This procedure replaces the paternalistic model
(doctor-centered, ie, the doctor decides everything) and the consumer model
(patient-centered, ie, informed patient decides everything). In shared
decision making, both sides are on an equal footing because the doctor is
the expert in medicine, but the patient is the expert in his or her own needs.
The doctor and patient first agree that a decision needs to be made. Then
the patient is shown all the options for action, including nontreatment, and
the viable therapies are worked out as a basis for decisionmaking. Now,
preferences of the physician and the patient are formulated. In the end, a
joint decision is negotiated in the form of a contract. A contract means that
the patient then also bears a share of responsibility if failures occur. Shared
decision making also has positive effects on patient compliance.

5.6 Anti-infective Patient Preparation

Infection prophylaxis is of central importance in bone grafting. The goal is
not a sterile surgical field in the oral cavity, because this is unrealistic, but
the greatest possible reduction of the bacterial load on the surgical wound.
To understand infection prophylaxis, a quantitatve view and long-term
reduction of the bacterial load is useful.
This anti-infective pretreatment begins well in advance of the
augmentation surgery in the form of conservative periodontal
decontamination as part of a four-stage concept (Fig 5-9). Here, carious
lesions are excavated and filled at least provisionally. Periodontal pockets
and predilection sites are also rehabilitated by systematic periodontal
therapy, if necessary. Teeth that are no longer needed or hopeless are
extracted as part of the abutment selection.

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Fig 5-9 Purulent wound-healing disorder with exposed foreign material (titanium mesh).

The second step is professional dental cleaning, which should be

performed even if tartar is not present, simply to remove plaque from the
interdental spaces. This cleaning should therefore take place shortly before
the surgical procedure so that new plaque does not form, ideally 1 to 2 days
before treatment.
The third stage is a disinfecting mouthrinse for 30 seconds immediately
preoperatively with 0.2% chlorhexidine solution (Chlorhexamed,
GlaxoSmithKline) to reduce planktonic bacteria. It can be performed after
local anesthesia, also with the effect of rinsing out the bitter taste of
xylocaine. The disinfecting rinse reduces the number of active planktonic
bacteria in saliva by about 90% for 3 hours (one log level), but a 0.12%
solution achieves a similar value only for 1 hour of effect.16 There is no
reason why chlorhexidine should not also be used to disinfect the perioral
skin.
The final stage before surgery is single-shot antibiotics (see section later
in chapter). From studies on experimental wound healing with
Staphylococcus aureus, it is known that the ID50 (infective dose for 50% of
individuals) without antibiosis is only 10 individual vital bacteria. Under
ampicillin sulbactam, this ID50 increased to 2,000 bacteria, corresponding
to two log levels.17 Thus, together with mouth rinsing, a reduction of the
bacterial load in the wound by three log levels is achieved; respectively, the
inoculum must be three log levels higher under these assumptions for the

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same probability of infection. If antibiotics are administered orally in the
absence of venous access, the tablet should be taken at least half an hour
preoperatively so that the material can be absorbed, processed in the liver,
and released into the larger circulation. The goal is to have all bone grafts
internally infused with the antibiotic even preoperatively. This is achieved
after a circulation time of approximately 30 seconds when administered
intravenously (IV). The rationale for preoperative administration lies in the
rate of expansion of a bacterial population (Fig 5-8). Theoretically, this
follows a natural logarithm with exponential growth in the case of
dichotomous division every 20 minutes, so that with an antibiotic started
only a few hours after the intervention, one would only be chasing the
developing infection.

5.7 Surgical Preparation, Anesthesia, and Sedation

It does not need to be repeated in this book that dental implant procedures
require an adequate surgical environment with sterile coverage of the
patient and an appropriately trained surgical team. According to the SAC
(straightforward, advanced, complex) classification, procedures in which
bone and foreign material transplants are involved would be at least level A
(advanced), as they require an appropriate space and equipment. For
example, having a high-frequency device for bipolar coagulation of
bleeding is recommended (Fig 5-10).
Almost all of the procedures in this book can be performed on an
outpatient basis under local anesthesia. After surface anesthesia with
xylocaine spray, xylocaine 2% with epinephrine supplement 1:100,000 is
sufficient for all dental implant procedures in the author’s experience.
Preferably, nerve blocks are used to save doses. Articaine 4% with
epinephrine supplement 1:100,000 has been associated with an increased
risk of sensory disturbances, especially with nerve blocks on the inferior
alveolar and lingual nerves, based on retrospective data and claims statistics
in relation to market share.18 Using experimental studies on the sciatic
nerve, it was found that twice the concentration of articaine produced 4%
more nerve damage than a 2% concentration,19 which was histologically
attributed to a reduction in myelin sheaths rather than a reduction in the
number of axons and was interpreted as a neurotoxic effect on myelin

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sheaths. In cell culture studies on neurons, no higher toxicity could be
confirmed for articaine 4% compared to xylocaine 2%, so that both
substances can be considered safe in the mentioned concentrations
according to British authors.20 It should be noted that the anesthetic success
of dental local anesthesia is less a question of the concentration and type of
anesthetic, but more a question of prior reduction of inflammatory
hyperalgesia.21

Fig 5-10 High-frequency device for bipolar coagulation (Erbe Elektromedizin).

Intravenous administration of the drugs is preferable, and the placement

of a venous line is convenient, also to obtain venous blood for the
preparation of mixed grafts or leukocyte- and platelet-rich fibrin (L-PRF), if
necessary. If one wishes to prepare L-PRF membranes, centrifugation can
be done during the preparation for surgery.
Drilling on the jaw can be a traumatic experience for some patients.
Even a conservative dentistry procedure with rotary instruments, in the
author’s experience, produces loud noises and vibrations in the patient’s
head that can be traumatic enough on their own, even if perfect analgesia
has been achieved. Traditional restorative dentistry took place more or less
outside the integrity of the ectodermal shell. Through implantology, the
dentist invasively enters the body. Therefore, the classic forms of pain
elimination by exclusive local anesthesia should also be adapted, if
necessary by offering the patient sedation (Fig 5-11). This is especially true

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because it is very likely that an implant procedure is not the last one in a
patient’s life, because there may be other teeth to be replaced; the implant
may need a revision procedure, eg, in the case of peri-implantitis; or
placement may be performed in a two-stage procedure. Sedation is also
helpful because of the avoidance of psychologic trauma to the patient,
which increases through repetition. For example, sedation with midazolam
usually produces postoperative amnesia, which prevents this disadvantage.
The indication for general anesthesia with intubation of the patient
without spontaneous breathing, on the other hand, should be rather
restrictive for implant procedures, even if many patients wish to “not notice
anything at all.” The risks of general anesthesia are increased compared to
sedation with spontaneous breathing, among other things because in
dentistry the airway is in the same surgical field. Consider, for example, the
danger of the tube slipping out during movements of the head. Another
disadvantage of general anesthesia is its abrupt end in contrast to the
prolonged analgesia of dental local anesthesia over several hours.

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Fig 5-11 a. Procedure room for dental surgery. b. Multichannel monitor (electrocardiogram,
bloodpressure, oxygen saturation) for monitoring sedation. c. Peripheral vein cannulation
with lateral injection option and continuous drip infusion.

5.8 Perioperative Medication Including Antibiotics

Analgesia

First, a good medication history is important, because many implant

patients already take prescribed analgesics. In addition, interactions with

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existing medications must be considered.
A clean smooth surgical wound causes little pain, especially in the bone,
because it is numb. Therefore, postoperative implant procedures do not
require special effort in terms of analgesia. On the contrary, if more severe
and prolonged pain is reported, it should be checked whether the wound is
compromised. Depending on tolerability, NSAIDs (eg, ibuprofen) may be
appropriate after augmentation surgery. A Cox-2-specific form is etoricoxib
(not approved for the US market; marketed elsewhere as Arcoxia by
Merck). A Cochrane review confirms the good effect of a single dose of
etoricoxib, which acted only with latency after ingestion, but for 8 hours.22
This fits well with the kinetics of the slowly decaying local anesthesia.

Swelling prophylaxis
There are different views on the prophylaxis of swelling with
corticosteroids. Swelling is part of wound healing, and the patient’s reaction
to swelling is also a question of preoperative education. Moreover, the
tendency to swelling is highly variable on an individual basis. Instead of
anti-edematous medications, swelling should initially be minimized by
minimally invasive, rapid, and tissue-sparing (eg, gentle use of retractors)
surgery. Corticosteroids for swelling prophylaxis have side effects including
immunosuppression, diabetogenic effects, and gastric ulcers. Most study
data on swelling have been collected using the well-standardized procedure
of third molar extraction. According to a meta-analysis, submucosal
injection of corticosteroids during wisdom tooth extraction is effective for
swelling prophylaxis and pain.23 Other routes of corticosteroid application
(intravenous or oral) showed inconsistent results in a systematic review.24 In
summary, the author does not use this option in augmentation procedures,
either topically by injection into the envelope fold or systemically. Cooling
had a small reducing effect on postoperative swelling according to a meta-
analysis on third molar extraction and, used in moderation, may not cause
harm.25

Single-shot antibiotics
In the author’s opinion, perioperative single-shot antibiotic administration
follows the rule that antibiotic treatment in implantology must always be

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performed when implanting or transplanting foreign or autologous
materials. This also applies to simple implant placement at the S level
(straightforward) according to the SAC classification, but even more so to
augmentation procedures. Transplanted or implanted materials have no
defense of their own and should be surrounded by a bactericidal antibiotic
dose in the tissue at the time of placement, so that possibly adhering
bacteria are killed immediately. This is to bridge the period until the
materials are vascularized and integrated into the tissue, about 14 days.
According to the German Society for Dental, Oral, and Maxillofacial
Medicine (DGZMK) guideline,26 a penicillinase-resistant penicillin is
recommended (eg, ampicillin sulbactam 1.5 g IV, Unacid, Pfizer); in case of
allergy, clindamycin 600 mg IV can be used, also as single shot. Unusual or
even reserve antibiotics should generally not be used in augmentation
operations; rather, the augmentation procedure should then be changed or
the indication for augmentation reconsidered.
Antibiotic treatment a few days before the procedure is
counterproductive because it selects resistant germs in the patient and
generally promotes the problem of bacterial resistance.
Prolonged antibiosis over 5 days is also counterproductive for the same
reason. The data on prolonged antibiosis in augmentation procedures is so
poor that no general statements can be made.27 It may be indicated in
patients who are severely immunocompromised, such as patients with
poorly controlled diabetes and those taking antiresorptive or methotrexate
(MTX) medication. In general, antibiotic administration shifts the oral
microbiome and may produce dysbiosis.28
When prescribing antibiotics in the setting of implant procedures, one
comes to the problem of the number needed to treat (NNT). In many large
studies involving thousands of patients, significant reductions in the number
of infections associated with implant placement are found as a result of use
of antibiotics, but the frequency of infections is generally low. Therefore,
you get an NNT of 50 for implant placement,29 which means that to avoid
an infection, you have to treat 49 patients with antibiotics for no reason.
This high number of overtreatments puts antibiotic use into perspective.
The physician is asked to consider the severity of the complication
(postoperative wound infection or implant loss) in relation to the costs and
side effects of antibiotics. Taking into account the patient’s individual safety
needs, both should jointly arrive at a patient-specific participatory decision.

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 A significant problem with the prolonged administration of broad-
spectrum antibiotics is their effects on the bacterial intestinal flora, ranging
from a change in the composition of intestinal bacteria to antibiotic-
associated diarrhea (AAD) and lifethreatening pseudomembranous colitis.
This disease is caused by displacement of physiologic intestinal flora and
overgrowth by clostridia and can lead to death via intestinal wall necrosis,
perforation, and peritonitis. Probiotics are preparations containing viable
intestinal bacteria. Probiotic bacteria of the species Lactobacilli and
Bifidobacterium are added to probiotic foods, eg, as live cultures in
probiotic yogurt. However, it is unclear how these bacteria survive gastric
passage as food and what the dosage is as prophylaxis of AAD. A more
controlled medication is possible through oral probiotic preparations in
capsule form (Omniflora N, GlaxoSmithKline). This preparation contains
Lactobacillus gasseri and Bifidobacterium longum, dosage one to two
capsules three times daily. A recent Cochrane meta-analysis of 33 studies
worldwide clearly showed that probiotics were effective in reducing AAD
during antibiotic therapy. Side effects of probiotic medication were on par
with the placebo control group.30 In practice, the author recommends
patients on antibiotics beyond a single shot to eat probiotic yogurt at least
once daily.

Fig 5-12 a. Because of their overlay positioning, plate dentures are only to be used as
cosmetic dentures after implant procedures and should not be exposed to chewing forces.
b. Provisionals with wing attachments also transfer flexing movements to the surgical site
during mastication due to the overlay positioning.

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Fig 5-13 A temporary splint is favorable because it is tooth-supported. However, there is the
esthetic disadvantage of tooth capping.

5.9 Provisional Prosthetic Restoration

Removable and fixed temporary restorations are available. In implant
dentistry, removable temporaries have the fundamental advantage that the
surgeon retains access to the wound during follow-up treatment. But
removable overdenture prostheses such as clasp prostheses or Valplast
prostheses are rather critical in augmentations because they do not have
occlusal rests and sometimes even clasps protrude into the surgical area
(Fig 5-12). Provisional overdentures exert flexing movements on the
implants and the bone grafts at the alveolar process, which leads to
loosening of the components and contributes to wound infections.

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Fig 5-14 a. Here, two temporary dental implants were placed. b. The temporary implants
(IPI, Nobel Biocare) do not osseointegrate and can be removed again. However, these
useful auxiliaries have since been taken out of the company’s program. c. The implants
were supported by a laboratory-fabricated resin bridge with metal reinforcement.

A simple form of removable restoration is a temporary splint that snaps

over the adjacent teeth and contains the teeth to be replaced, preferably as
pontics (Fig 5-13). If adequate tooth support is no longer available,
temporary implants can be used as abutments (Fig 5-14). Temporary
implants are particularly useful in the edentulous jaw (Fig 5-15), where they
have a survival rate of over 90% in the 4-month restoration period.31 They
do not osseointegrate during this period.
Clasp temporaries can possibly be tooth-supported by occlusal rests. For
these prostheses, the dental technician should be asked explicitly for a
pontic-like design for implant surgery; otherwise the surgeon can grind the
buccal flange into an ovoid pontic shape (Fig 5-16). The buccal flange
usually does not fit the tissue morphology in implant procedures due to the
periosteal incision, the volume increase resulting from augmentation, and
the postoperative wound edema. Ovoid pontics help to shape and support
the interdental papillae. Fixed temporary restorations are actually
disadvantageous in implantology because they do not allow the surgeon to

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access the wound, eg, when removing sutures. At best, they are favorable as
long-term temporaries after wound healing has been completed, eg, as a
single retainer adhesive bridge or as a chairside fabricated bridge on
temporary implants. Fixed provisionals, as often offered in the so-called
“immediate fixed teeth” or “all on four” concepts, have a certain comfort
for the patients, but in the author’s experience they are hardly cleanable due
to the ridge-covering sections, especially over fresh wounds (Fig 5-17). In
this case, a removable design would be more favorable, but this is not
compatible with immediate loading of the implants due to the wobbling
load during removal, given that secondary stabilization by the prosthesis is
part of the concept of immediate loading in the edentulous jaw.

Fig 5-15 a. Use of four Nobel IPI provisional implants for temporary restoration after sinus
elevation and implant placement in the maxilla. b. Temporary implants in situ. c. Pick-up
copings incorporated into the temporary overdenture. Such a prosthesis has limited
chewing stability. d. Removal of the provisional implants with a strong Matthieu needle
holder at the time of definitive prosthetic restoration. The provisional implants are located
further palatal than the definitive implants, which is an effect of the bone augmentation that
has taken place in the meantime.

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Fig 5-16 Provisional restoration with autogenous jaw augmentation. a. Single missing
maxillary left central incisor with horizontal atrophy. b. Conditioning of the bone surface by
scraper and perforation of the cortical bone by Lindemann bur.

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Fig 5-16 c. Locally harvested scraper chips. d. Bone chips harvested locally during graft
harvest in the filter. e. Autogenous bone block from the external oblique ridge and
microscrew osteosynthesis. f. Breaking and smoothing sharp edges of the bone block. g.
Cutting the collagen membrane. h. Clamping the membrane under the palatal flap with the
tongue.

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Fig 5-16 i. Scraper bone, a most biologically valuable graft, is placed at the strategically
important sites. j. A shell or block is always backfilled with autogenous material only. k. The
filter bone is used to fill the contour in the periphery. l. Overcontoured filter bone. m. The

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palatal membrane is folded buccally and made pliable with a few drops of saline solution. n.
A membrane section (see image in g) is inserted in a double layer and treated with saline
solution. o. Flap mobilization is performed with a Gillies single hook and a 15c scalpel.

Fig 5-16 p. The single hook holds the periosteal fibers taut so that selective cutting is
possible with the scalpel. q. The single hook retractor is used to test whether the flap
mobilization is already sufficient. r. Metzenbaum dissecting scissors are used for further flap
mobilization using submucosal movement of the dissecting scissors. s. Trial pulling on the
flap with the single hook. t. Suture closure without tension with 4-0 pseudomonofilament
polyamide sutures (Supramid, Resorba) and interrupted sutures. u. Plate provisional with
buccal flange, as often delivered by the technician without instructions to the contrary.

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Fig 5-16 v. Vestibular flange and full-surface mucosal overlay. w. Pontic remodeling by
grinding. x. Hollow grinding of the overlay to the point of contact with the ovoid pontic. y.
Provisional prosthesis in situ with the ovoid pontic supporting the papillae.

Fig 5-17 a. Removable “all on four” prosthesis designed on a bar, which ensures good
hygienic accessibility of the implants. b. Maxillary restoration according to the “all on four”
method with inclined implants, avoiding sinus elevation.

5.10 References
1. Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants in irradiated versus nonirradiated
patients: A meta-analysis. Head Neck 2016;38:448–481.

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2. Naseri R, Yaghini J, Feizi A. Levels of smoking and dental implants failure: A systematic review
and meta-analysis. J Clin Periodontol 2020; 47:518–528.
3. Antonoglou GN, Stavropoulos A, Samara MD, et al. Clinical performance of dental implants
following sinus floor augmentation: A systematic review and meta-analysis of clinical trials with
at least 3 years of follow-up. Int J Oral Maxillofac Implants 2018;33:e45–e65.
4. Sgolastra F, Petrucci A, Severino M, Gatto R, Monaco A. Periodontitis, implant loss and peri-
implantitis. A meta-analysis. Clin Oral Implants Res 2015;26:e8–e16.
5. Lin CY, Chen Z, Pan WL, Wang HL. Is history of periodontal disease still a negative risk
indicator for peri-implant health under supportive post-implant treatment coverage? A systematic
review and meta-analysis. Int J Oral Maxillofac Implants 2020;35:52–62.
6. Petsinis V, Kamperos G, Alexandridi F, Alexandridis K. The impact of glucocorticosteroids
administered for systemic diseases on the osseointegration and survival of dental implants placed
without bone grafting—A retrospective study in 31 patients. J Craniomaxillofac Surg
2017;45:1197–1200.
7. Etikala A, Tattan M, Askar H, Wang HL. Effects of NSAIDs on periodontal and dental implant
therapy. Compend Contin Educ Dent 2019;40:e1–e9.
8. Chappuis V, Avila-Ortiz G, Araújo MG, Monje A. Medicationrelated dental implant failure:
Systematic review and metaanalysis. Clin Oral Implants Res 2018;29(Suppl 16):55–68.
9. Aghaloo T, Pi-Anfruns J, Moshaverinia A, Sim D, Grogan T, Hadaya D. The effects of systemic
diseases and medications on implant osseointegration: A systematic review. Int J Oral Maxillofac
Implants 2019(Suppl);34:s35–s49.
10. Guido Mangano F, Ghertasi Oskouei S, Paz A, Mangano N, Mangano C. Low serum vitamin D
and early dental implant failure: Is there a connection? A retrospective clinical study on 1740
implants placed in 885 patients. J Dent Res Dent Clin Dent Prospects 2018;12:174–182.
11. Quain AM, Khardori NM. Nutrition in wound care management: A comprehensive overview.
Wounds 2015;27:327–335.
12. Srinivasan M, Meyer S, Mombelli A, Müller F. Dental implants in the elderly population: A
systematic review and meta-analysis. Clin Oral Implants Res 2017;28:920–930.
13. Gómez-Moreno G, Fernández-Cejas E, Aguilar-Salvatierra A, de Carlos F, Delgado-Ruiz RA,
Calvo-Guirado JL. Dental implant surgery in patients under treatment by dabigatran. Clin Oral
Implants Res 2018;29:644–648.
14. de Medeiros FCFL, Kudo GAH, Leme BG, et al. Dental implants in patients with osteoporosis:
A systematic review with meta-analysis. Int J Oral Maxillofac Surg 2018;47:480–491.
15. Stavropoulos A, Bertl K, Pietschmann P, Pandis N, Schiødt M, Klinge B. The effect of
antiresorptive drugs on implant therapy: Systematic review and meta-analysis. Clin Oral
Implants Res 2018;29(Suppl 18):54–92.
16. Cousido MC, Tomás Carmona I, García-Caballero L, Limeres J, Alvarez M, Diz P. In vivo
substantivity of 0.12% and 0.2% chlorhexidine mouthrinses on salivary bacteria. Clin Oral
Investig 2010;14:397–402.
17. Kernodle DS, Kaiser AB. Efficacy of prophylaxis with beta-lactams and beta-lactam-beta-
lactamase inhibitor combinations against wound infection by methicillin-resistant and
borderline-susceptible Staphylococcus aureus in a guinea pig model. Antimicrob Agents
Chemother 1993;37:702–707.
18. Hillerup S, Jensen RH, Ersbøll BK. Trigeminal nerve injury associated with injection of local
anesthetics: Needle lesion or neurotoxicity? J Am Dent Assoc 2011;142:531–539.
19. Hillerup S, Bakke M, Larsen JO, Thomsen CE, Gerds TA. Concentration-dependent
neurotoxicity of articaine: An electrophysiological and stereological study of the rat sciatic

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 nerve. Anesth Analg 2011;112:1330–1338.
20. Hopman AJG, Baart JA, Brand HS. Articaine and neurotoxicity—A review. Br Dent J
2017;223:501–506.
21. Fleiner B, Terheyden H. On the problem of “anesthesia failures”. Dtsch Zahnärztl Z
1991;46:788–790.
22. Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose oral analgesics for acute postoperative
pain in adults an overview of Cochrane reviews. Cochrane Database Syst Rev 2015;9:
CD008659.
23. O’Hare PE, Wilson BJ, Loga MG, Ariyawardana A. Effect of submucosal dexamethasone
injections in the prevention of postoperative pain, trismus, and oedema associated with
mandibular third molar surgery: A systematic review and meta-analysis. Int J Oral Maxillofac
Surg 2019;48:1456–1469.
24. Larsen MK, Kofod T, Christiansen AE, Starch-Jensen T. Different dosages of corticosteroid and
routes of administration in mandibular third molar surgery: A systematic review. J Oral
Maxillofac Res 2018;9:e1.
25. do Nascimento-Júnior EM, Dos Santos GMS, Tavares Mendes ML, et al. Cryotherapy in
reducing pain, trismus, and facial swelling after third-molar surgery: Systematic review and
meta-analysis of randomized clinical trials. J Am Dent Assoc 2019;150:269–277.
26. Scientific statement of the German Society for Dental, Oral and Maxillofacial Medicine. Use of
antibiotics in dental practice.
https://secure.owidi.de/documents/10165/1936750/systemische_antibiotikaprophylaxe_7-
09_literatur_enc.pdf/e2664298-5a15-452a-8895-094e01bba345. Accessed 12 July 2021.
27. Klinge A, Khalil D, Klinge B, et al. Prophylactic antibiotics for staged bone augmentation in
implant dentistry. Acta Odontol Scand 2020;78:64–73.
28. Belibasakis GN, Bostanci N, Marsh PD, Zaura E. Applications of the oral microbiome in
personalized dentistry. Arch Oral Biol 2019;104:7–12.
29. Lund B, Hultin M, Tranaeus S, Naimi-Akbar A, Klinge B. Complex systematic review—
Perioperative antibiotics in conjunction with dental implant placement. Clin Oral Implants Res
2015;26(Suppl 11):1–14.
30. Goldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile-
associated diarrhea in adults and children. Cochrane Database Syst Rev 2017;12:CD006095.
31. Terheyden H, Alsifawo A. Use of temporary implants in the context of larger augmentative
restorations. Implantol 2010;18:417–425.

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 6
Bone Grafting: Standards and
Surgical Technique

Unlike most other tissues, bone can be freely avascularly grafted even in
larger volumes and layer thicknesses. In the case of bone, unlike many soft
tissues, survival of all cells of the graft is not necessarily required, because
bone morphogenetic protein (BMP)-driven remodeling can also restore
avascular grafts to vital functional bone. The natural regenerative potency
of autogenous bone can be therapeutically stimulated and controlled in
terms of form and speed by augmentation materials.

6.1 Conditions for Bone Grafting

Nonsterile environment and defensins

Although the oral cavity is not a sterile surgical field, bone wounds in the
mouth heal with astonishing speed compared to other body regions, and
bone can even be freely grafted via intraoral approaches. This is due in part
to β-defensins.1 Defensins are a group of small proteins with a high
proportion of cationic and hydrophobic amino acids that have a high
affinity for cell membranes not containing cholesterol, as found only in
bacteria. There they form membrane pores that lead to the death of the
microorganism. Defensins are part of the genetically ancient innate
nonadaptive immune system and make up much of the content of the
granules of neutrophil granulocytes, in which they serve to kill bacteria.
They are also expressed in high concentrations by cells of the oral mucosa
and jawbone.2,3 Despite this special defense situation in the oral cavity,

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careful preoperative bacterial count reduction and sterile instrumentation
are prerequisites for the clinical success of an augmentation.
In the case of bone grafts, care must be taken to ensure complete fill of
the defects with coagulum of the defects, which can be supplemented by
admixing venous blood to the bone grafts in case of doubt. The cells of the
medullary cavity may need to be allowed to connect to the defect by
perforating the cortical bone of the recipient bed. In a small human study,
perforation of the recipient bone during augmentations resulted in greater
and faster graft vascularization and better bone formation.4

Storage of bone grafts

Bone proteins are stable up to about 60°C, above which they denature,
especially the BMPs. This, in addition to cell vitality, is the reason why
drilling on bone should only be done under abundant water cooling. Normal
sterile physiologic saline solution is sufficient for cooling.

Fig 6-1 Three types of osteosynthesis for intraoral bone grafts: Lag screw, positioning
screw, and plate fixation.

Experimental data are available on the proper storage conditions for

autogenous bone grafts after harvesting. The vitality of bone cells of bone
grafts decreases significantly by dry storage compared to storage in
physiologic saline or covering with compresses moistened in physiologic

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saline. In contrast, storage in more elaborate media such as cell culture
medium did not provide a significant advantage.5 Platelet-poor plasma also
did not provide an advantage over saline.6 Since cell viability decreased
significantly as early as 2 hours after harvesting, bone grafts should be
harvested immediately prior to placement if possible.7 Ice cooling (without
freezing) increased cell viability compared to room temperature storage.8 In
an experimental study, bone grafts with vital cells resulted in 30% more
bone growth than grafts without vital cells.9

Mechanical rest
Mechanical stability during the healing phase should be ensured by good
fixation of the bone grafts with screws and by avoiding soft tissue pressure.
Internal resorption of the bone graft is desired and necessary in the
sense of “creeping substitution” (see chapter 2). Beyond the healing phase,
desired internal resorption occurs as part of the functional remodeling of the
bone, starting from the recipient side of the bone graft. After about 3 to 4
years, free bone grafts will be almost completely internally resorbed and
replaced by regrown new autologous bone. The bone cutting cones are
responsible for the remodeling process. To ensure that the bone cutting
cones can advance from the recipient bone into the graft without
interference, a form-fitting adaptation of a bone block to the recipient bone
or at least relining with autogenous chips is helpful. An intermediate layer
of bone graft substitute should therefore be avoided under bone blocks, and
when using the shell technique with autogenous compact blocks,
autogenous chips should be used to backfill the shell.

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Fig 6-2 Commercially available microscrew osteosynthesis set in a sterilizable container
(1.5 mm Centre Drive System, KLS Martin).

Fixation of bone block grafts

Mechanical stability is essential for bone healing. There is almost constant
unrest in the oral cavity due to chewing, tongue movements, and
swallowing. Therefore, it is important to reliably secure bone grafts against
movement during augmentations. This is done by means of lag screws, set
screws, or plate fixation (Fig 6-1). Suitable screw sizes (eg, 1.5 mm Micro
System, KLS Martin) are available from osteosynthesis material
manufacturers (Fig 6-2).

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Fig 6-3 Two types of fixation of an intraoral bone block graft. Bone shells should not be
backfilled with bone substitute material, only with autogenous bone chips to allow rapid
remodeling by bone cutting cones.

The screw is applied as a lag screw, by drilling the screw access channel
in the graft larger than the largest screw diameter. Then the screw head pulls
the graft against the bone base when it is screwed in, wedging it. If
tightening is not desired, a positioning screw is indicated. These are needed
for shell techniques, for example (Fig 6-3). For this purpose, the screw
channel is not overdrilled in the graft. When the positioning screw is
screwed in, the distance between the graft and the base is adjusted first. The
distance does not change even with the strongest tightening of the screw. If
there is no space to fix a lag screw, eg, due to existing implants or tooth
roots, the graft can also be fixed with osteosynthesis plates with slightly
increased materials use and cost (Fig 6-4).
As a rule, at least two screws are placed per block to secure it against
rotational loading. Smaller grafts and bone substitute material should be
placed around the block as fillers. Small grafts that cannot support screws

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are somewhat stabilized by the blood coagulum and the tension of the
uninjured periosteum (Fig 6-5).
A barrier membrane performs well for positional fixation of smaller
grafts. However, the block graft provides much more stability after
osteosynthesis than all membrane techniques. When handled correctly, it is
stable as a rock in the surf. This allows more frequent single-stage implant
placement, even if there is insufficient support in the local bone volume for
the implants. In addition, the regeneration potential and resorption stability
of the block graft are higher than those of particulate materials in guided
bone regeneration (GBR), even in critical cases. Osteosynthesis material
removal after 4 months should be performed minimally invasively via stab
incisions, if possible, because deperiostation of the block can jeopardize it
and triggers unnecessary surface resorption (Fig 6-6).

Bone graft healing time

For the practice workflow, it makes sense to set the healing times of the
two-stage bone grafts uniformly to about 4 months prior to implant
placement. This period is based on the healing time required for ridge
augmentation with an autogenous block graft from the external oblique
ridge. If less than 4 months is allowed for autogenous block grafts to heal,
the block may detach from the recipient bone during implant drilling due to
lack of a strong connection. However, with longer healing periods, the
surface absorption progresses too much.
The sinus elevation healing period can also be established as 4 months,
as it frequently has to be performed together with block grafts in the
edentulous maxilla. With autogenous iliac cancellous bone, a sinus
elevation heals in as little as 4 weeks; only bone substitute requires 8
months. The mean value of 4 months is achieved with a mixed bone graft
(25%/75%).

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Fig 6-4 Long-term follow-up of a bone block graft. a. Tooth malformation in the maxillary
right central incisor area with apical radiolucency in a 17-year-old patient. b. Clinical image
of the right central incisor malformation combined with agenesis of both lateral incisors. c.
Panoramic radiograph after gap opening. d. Panoramic radiograph after placement of
dental implants in the maxillary lateral incisor sites immediately after gap opening. e. Defect
after removal of the right central incisor filled by a contoured autogenous bone block graft
from the external oblique ridge using an osteosynthesis plate. The block was multiply
perforated to accelerate healing. f. Four months after grafting, removal of the
osteosynthesis material and placement of the dental implant. Bleeding from the perforation
holes is a sign of the beginning of vital healing of the block.

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Fig 6-4 Long-term follow-up of a bone block graft. g. Radiograph after implant
placement in the block graft. h Peri-implant bone resorption as a sign of remodeling with
formation of a peri-implant soft tissue cuff (biologic width). i. Mirror image of the maxilla after
prosthetic restoration. j. Radiograph 7 years later, nearly identical to that in h, with no further
marginal bone resorption. Remodeling is complete, and the bone is now functionally
defined. k. Intraoral situation at 24 years of age. Slight recession is evident at the implants
in the agenesis sites. Stable tissue conditions at the site of bone transplantation. l. Intraoral
situation at age 33. Stable tissue conditions at the site of bone block grafting.

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Fig 6-5 Bone block grafting for a large maxillary defect. a. Dehiscence defect (1/4
according to the quarter rule; see Fig 1-11) at both central incisor the left lateral incisor
implants with single-stage implant placement. b. Two autogenous bone blocks from the
external oblique ridge. The block in the right central incisor region was regularly fixed with
two screws to secure it against rotational movement. The block in in the left central incisor
site fit tightly to the bone surface so that one screw was sufficient. c. Autogenous bone
chips from the bone filter were used for contour filling. d. Covering with a collagen
membrane to stabilize the position of the bone trap and to protect the block grafts against
resorption.

Sandwich interposition in edentulous segments and jaws also requires 4

months, as does GBR with a mixed graft and ridge splitting.

6.2 Mixed Bone Grafts

Autogenous cancellous bone is rich in cells and BMPs and is
osteoinductive. The material heals quickly, within about 4 weeks, but also
tends to resorb rapidly. Mineral bone substitute material is devoid of cells
and BMPs and therefore takes many months to heal from the defect walls
by osteoconduction, if it ossifies fully at all. On the other hand, xenogeneic
bone mineral, for example, is very stable to resorption resistant, so that a

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selected augmentation level is maintained until the implants are
osseointegrated and from then on can contribute to the maintenance of the
augmentation by functional loading. The best strategy is therefore to use
autogenous chips with the resorption-stable bone substitute material. The
mixing ratio is a compromise between good healing and good resorption
stability. According to animal data on sinus elevation, this compromise is
best achieved with a ratio of 25% autogenous chips to 75% bone
substitute.10 Ridge augmentations are more challenging as a defect type than
sinus elevations; here, osteoinduction is even more important. In a clinical
study on ridge augmentation, the autogenous bone in a 90:10 mixture was
too low in dose; a 60:40 mixture performed better.11

Fig 6-6 Minimally invasive osteosynthesis material removal. a. Implant exposure after
single-stage bone block grafting. The position of the osteosynthesis screw can be identified
by the protrusion and anemia in the vestibule after palpation. b. To avoid compromising the
block by re-entry and deperiostation, the screw is minimally invasively located by stab
incision. c. The square head of the Centre Drive System attachment automatically engages
in the screw head at depth, even without direct vision. This allows the screw to be removed
without raising a flap.

Autogenous chips have the disadvantage that they were usually obtained
in the contaminated oral cavity and are therefore themselves bacterially

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contaminated. If porous bone substitute material is inoculated with bacteria,
there is a risk of biofilm formation and thus infection of the augmentation.
This can be minimized by first mixing the porous bone graft material with
sterile venous blood in a sterile dish. In this way, all cavities of the bone
graft substitute are sealed with sterile liquid and all surfaces with sterile
blood protein, so that bacteria do not find an interface on which to settle.
However, the blood does not yet coagulate after this mixing, so that the
particles of the bone substitute material do not hold together and are
difficult to apply.
Tissue thrombokinase (tissue factor) is required for coagulation to
activate the extrinsic pathway. It makes sense in nature that in an extraction
wound the bleeding stops at the level of the alveolar opening. This is
ensured by saliva, which is a rich source of tissue thrombokinase.12 If some
filter bone is added to the blood/bone substitute mixture, the blood will clot
unless the patient is taking anticoagulants. Filter bone, when harvested
intraorally, always contains some saliva and therefore tissue thrombokinase.
After a few minutes, a firm sheet of bonded bone and bone substitute
particles is formed, which can be grasped with forceps and applied in the
wound without additional stabilization (Fig 6-7).

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Fig 6-7 Mixed bone graft. a. Sinus elevation case with single-stage implant placement. b.
Bone graft material is mixed with sterile venous blood. However, this does not clot. Bone
chips from the bone filter (left) can trigger clotting. c. Clotting takes a few minutes. In this
case, the volume fraction of the autologous chips is well below 10% because little chip
material could be collected on the facial wall of the maxillary sinus and during implant
drilling. d. Coagulation produces easily manageable pieces of bone substitute material that
can be grasped with forceps and have intrinsic stability in the wound. e. The clot is placed in
the sinus floor, and the pieces are sculpted onto the exposed implants. f. Postoperative
panoramic image.

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Fig 6-8 Standard instrument table for intraoral bone grafting.

6.3 Resorption Protection of Bone Block Grafts

A sometimes disturbing disadvantage of avascular bone block grafts is their
difficult-to-predict initial surface resorption in the healing phase and later.
To compensate for surface resorption, augmentations with bone grafts can
be overcontoured by 1 to 2 mm and, to be on the safe side, more autogenous
bone than is thought necessary can be harvested. Preventive measures
against surface resorption of autogenous block grafts include covering the
graft with bone graft substitute13,14 and alternatively15 or additionally with
membranes.16 These clinical measures are based on the idea that osteoclasts
reach out to the bone surface from blood vessels in the overlying soft tissue,
and one blocks this pathway to slow unwanted surface resorption until
internal resorption via bone cutting cones has stabilized the block and
allowed it to heal. Another way to slow surface resorption is to use very
hard, highly mineralized bone types such as block graft from the external
oblique ridge. Bone blocks from the cranial vault are even harder and thus
more resistant to resorption. Osteoclasts initially degrade bone with acid.
This capacity is exhausted when the mineral content of the bone to be
resorbed is high. A similar acidbuffering effect on osteoclasts is achieved by
overlaying a bone graft with bone substitute material, as mentioned above.
Experimentally, the author’s group also performed drug inhibition of
surface resorption by inhibiting osteoclasts with topically applied
bisphosphonates.17 If a bone graft attached to the alveolar process is not

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functionally loaded by implants or teeth after the healing phase, complete
resorption of the attached bone substance usually occurs within a few years.
The placement of the graft within the natural alveolar arch (called the
envelope) also plays a role here. Grafts outside these natural boundaries are
at greater risk of resorption than those inside the envelope.

6.4 Instruments

Basic tools

The basic instrument set is a small but high-quality standard oral surgery
instrument set (Fig 6-8). For grafts in the field of periodontal plastic
surgery, a set of micro-instruments is recommended (Fig 6-9). For implant
procedures, it is important to have a small caliper to measure defect lengths,
ridge widths, gap widths, and distances to teeth.

Fig 6-9 Micro-instruments for grafting in periodontal plastic surgery.

A set of sinus elevation curets is required for maxillary sinus floor

interventions, for example, the set according to A. Kirsch (manufactured by

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Helmut Zepf; Fig 6-10). Gracey curets and other instruments can be added
as required.

Optical magnification aids

A microsurgical instrument set is added to the basic set when working under
optical magnification. The use of optical magnification aids or a surgical
microscope are up to the preference and habits of individual surgeons but is
rather uncommon in bone surgery. When using rotary instruments such as
the Lindemann bur, it is much more important to have a good view of the
surrounding area, for example, to avoid necrosis due to frictional heat at the
lip margin (Fig 6-11), which may escape the surgeon’s attention under the
small field of view of the microscope or magnifying glass. The accuracy of
suture closure is most likely to benefit from magnification, and it is
recommended for training reasons to suture under the microscope every
now and then. With the exception of apicoectomy, for which a better
outcome has been demonstrated for the use of magnification aids for the
creation and tightness control of the apical seal,18 there is insufficient
evidence in the literature for optical magnification in bone surgery. In
periodontal surgery, there is research evidence of benefits for the use of
optical magnification aids and for a microsurgical approach.19

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Fig 6-10 Standard set of rounded and angled special curets for external sinus elevation.

Osteotomy instruments
The basic equipment includes a green contra-angle handpiece and a blue
handpiece. For osteotomies, the basic work is performed with steel ball
burs, Lindemann burs, and diamond balls (Fig 6-12).
The use of a piezoelectric device involves an additional expense to the
rotating instruments that are on the table anyway because of the implant
placement. Certain work, such as the exposure of an inferior alveolar nerve,
is more successful with the piezoelectric technique. Its main advantages are
selective cutting and the narrow cutting width, which is gentle on tissues.
However, a systematic review found that when the sinus membrane was
exposed, no advantage was shown for the piezoelectric method in terms of
perforation rate.20 The piezoelectric device has the disadvantage of a lower

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working speed and higher heat generation. Compared to the Lindemann bur,
the coolant is less able to reach the depth of osteotomies, for example, when
removing blocks, due to the small osteotomy widths. Second, much of the
vibration energy is already absorbed at the osteotomy margin, making cuts
at depth very cumbersome. There are more frequent indications for using
the Frios MicroSaw according to Khoury (Dentsply Sirona), which is also
operated with a surgical motor, for ridge splitting, block removal, and
access to the maxillary sinus (Fig 6-13).

Fig 6-11 Complication: Burn of the lower lip caused by the drill shaft with insufficient field of
view due to excessive optical magnification.

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Fig 6-12 Sterile milling box with standard bone burs. Back row: ball burs of ascending size;
on the far right is a technical bur for processing provisional acrylic restorations. Front row:
Lindemann, diamond flame, and diamond ball burs (Komet, Brasseler).

Fig 6-13 Frios MicroSaw according to Khoury.

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Fig 6-14 Osteotome (chisel) with an 8-mm blade and a surgical mallet.

For ridge splitting, a sharp blade osteotome (blade chisel), 8 mm wide,

and a mallet are recommended (Fig 6-14). Smaller ridge splits can also be
carried out well with the Bein elevator, which is already included in the
standard instrumentation.

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Fig 6-15 Set of osteotomes for internal sinus elevation.

For condensations and internal sinus floor augmentations, a set of

standardized osteotomes of assorted sizes should be available, which are
also used with a mallet (eg, Stoma Dental; Fig 6-15).
Disposable scrapers (SafeScraperTwist, Geistlich) and a sterilizable
bone filter for reuse (Schlumbohm) are suitable for bone harvesting. There
are many different bone mills, differing mainly in size. For alveolar ridge
atrophy and for thin grinding of block grafts, the medium-sized Mondeal
Bone Mill (MBM) is suitable. The bone mill according to R. Quétin (Hess
Medizintechnik GmbH, Munich) is somewhat more powerful in design (see
chapter 3).
A set of trephine drills of various diameters completes the instrument
set.
Special instrument sets, for example from the Bone Management
System (Meisinger), can be added for the standard transfer of bone blocks
and for mechanical ridge splitting.

6.5 Surgical Procedure

Harvesting a block graft from the external oblique ridge

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A block graft from the external oblique ridge is usually harvested from the
mandible via a sulcus incision incision lateral to the three most posterior
teeth with the Lindemann bur (Fig 6-16). The distal relief incision is made
45 degrees to the teeth on the ascending mandibular ramus. It should not be
longer than 1 cm because otherwise the buccal nerve is endangered. The
mobility of the flap is created mostly by the subperiosteal detachment of the
flap onto the ascending mandibular ramus. Since the inferior alveolar nerve
may be sometimes located directly under the buccal compact bone, a
preoperative CBCT is useful but not mandatory.
The bur should always be guided strictly parallel to the outer cortex so
as not to injure any internal structures of the mandible. The bur should only
be countersunk until the first bleeding as an indication of exclusive
corticotomy. The initial enthusiasm for piezoelectric surgery in third molar
removal has subsided, and recent studies show no advantage for
piezoelectric devices, but the disadvantage of a longer surgical time.21
Piezoelectric surgery has the disadvantage of sometimes overheating bone
grafts, as the thin osteotomy gaps allow little coolant access in contrast to
the wide gaps of the conventional bur. However, the wide gaps are not a
disadvantage, if you collect the chips in a bone trap anyway. It is therefore
advisable to run a bone filter to catch the quite large volume of chips. A
prospective comparative study of piezoelectric surgery to Khoury’s
diamond cutting disc showed a three times longer surgical time and a lower
block volume for piezoelectric surgery with the same patient complaints. In
the author’s view, there is little reason to set up a second osteotomy system
on the operating table for block removal, because the rotating instruments
have to be kept on hand anyway for implant placement.

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Fig 6-16 Bone block harvesting from the external oblique ridge. a. Visualization via a
gingival margin incision and short relief incision at 45 degrees on the ascending jaw branch.
b. A monocortical relief cut is made in the bone anterior and posterior to the block graft with
the Lindemann bur under abundant cooling. The bur is always parallel to the outer wall of
the jaw. c. The harvesting site is usually lateral to the third molar site. The vertical bone
sections extend through the cortical bone, but no further. d. The longitudinal cut is marked
by a series of dots. e. The dots are connected monocortically with the Lindemann reamer. It
is not countersunk deeper than the first bleeding point through the cortex. f. The apical cut
is made through the half-submerged ball bur. g. The ball bur creates an apical groove as a
predetermined breaking point, and any chips are collected in the bone trap. h. A Bein root
elevator gently luxates the bone block out. i. The block is a pure cortical graft, with little
cancellous bone adhering internally. j. The block is removed with forceps and stored
temporarily in moist conditions. k. Further chip material is removed with the ball cutter and
collected in the bone trap. This smoothens sharp edges in the donor site defect. l. Wound
closure by two single knot sutures using Supramid 5-0 (Resorba).

A block graft from the external oblique ridge is generally 2 to 3 mm

thick. The apical cut can be made by the Khoury diamond circular saw, but
it is easier to half plunge a 4-mm ball mill and create a groove as a
predetermined breaking point.
The block can be split into thinner bone shells. Grinding the block into
chips is also possible. With most bone mills, the grinding can be done in
such a way that chips are produced and a thinner flat block remains, which
can then be used, for example, in a shell technique22 (Fig 6-17).
In cross section, the graft from the external oblique ridge often has the
appearance of the letter J and is therefore also called a J-graft. The block-
shaped compact graft from the external oblique ridge is obtained in the
horizontal ramus of the mandible lateral to the second and third molars.
Because the external oblique ridge normally transfers most of the
masticatory forces to the horizontal ramus of the jaw, block harvesting
should not be done too far posteriorly on the ascending ramus but rather
lateral to the teeth. For 6 weeks after bone harvesting, the patient should not
bite down too hard. Bicortical harvesting in the ascending ramus creates the
risk of mandibular angle fractures because the tendon of the strongest
masticatory muscle, the temporalis muscle, inserts into this loaded
structure.
Complications of block removal from the external oblique ridge include
sensory disturbance of the inferior alveolar nerve and dental damage. The
author observed a delayed mandibular fracture in an osteoporosis patient
who was treated conservatively. If the J-grafts are harvested correctly,
sensory disturbances are rare if the depth of cut of the instruments is strictly

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limited to the compact bone. Second harvesting of bone from the same site
has also been reported23 because the non-atrophying and functionally
defined bone of the external oblique ridge grows back in humans. There is
no need for defect filling with bone grafts. Sometimes surgical removal of
impacted third molars is indicated in implant patients, and thus the surgical
approach to the retromolar area.

Bone harvesting from the anterior iliac crest

The prerequisites for graft removal from the iliac crest are a sterile
operating room, surgical skin disinfection, sterile draping, and a procedure
that follows the rules of aseptic surgery.
The incision is approximately 4 cm long and is located within the iliac
crest clearly dorsal to the anterior iliac spine (Fig 6-18). The incision is
made medial to the iliac crest because one does not want to place the scar in
the areas directly on the bony crest that would be in contact with a belt
worn on the waist of pants. After dissection through the skin fat slightly
laterally, one exposes the white aponeurosis between the gluteus and
external oblique abdominal muscles and separates them in the middle of the
crista. With this technique, painless or at least minimally painful removal is
possible without injury to the musculature.
Now the periosteum of the inner side of the pelvis and from the medial
part of the iliac crest is detached. Different parts of the bone can be viewed
by moving the overlying soft tissue. As a rule, monocortical chips are taken
from the inner side, along the inner half of the curve of the crest. The inner
curve is removed by a Lindemann cutter or oscillating saw in several
longitudinal pieces that measure approximately 1 × 1 cm in cross section.
From this defect, monocortical strips can now be cut like piano keys toward
the center of the pelvic blade with the oscillating saw. They are detached
from the outer cortical bone by sliding a broad chisel along it. It is
necessary to know that the outer cortex approximates the inner cortex
relatively quickly and can fuse with this a few centimeters below the crest.
One should avoid perforation of the outer cortex (bicortical harvesting) for
implantology purposes.
Finally, infiltration with bupivacaine 0.5%, drainage without suction,
and an elastic bandage to support the soft tissues are recommended.

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Fig 6-17 Bone block grafting using a shell technique. a. Initial situation with horizontal
ridge defect (1/2 according to the quarter rule; see Fig 1-11) in the maxillary left central and

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lateral incisor region. b. Bone block from the external oblique ridge. c. In a bone mill
(Ustomed, Ulrich Storz), the block is ground thin to form a shell. d. This is done in several
stages until the desired thickness of 1 mm is reached. e. The cortical chips collect in the
drum of the bone mill. f. All autogenous bone materials are temporarily stored moist until
use. g. In the defect the shell defines the future outer contour of the alveolar process with
an allowance for resorption of about 1 mm in width and height. It is secured with two
positioning screws (1.5-mm system, KLS Martin).

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Fig 6-17 Bone block grafting using a shell technique. h. The shell is backfilled
exclusively with autogenous chips. i. A membrane made of native collagen (Bio-Gide,
Geistlich) is cut into a tongue shape and adapted with a Luniatschek gauze packer. j. The
tongue of the membrane is placed under the palatal flap. k. The membrane is moistened
with a few drops of saline and is self-adaptive. l. A section of the membrane is applied as a
double layer in the area of the highest resorption. m. The flap mobilization takes place by
means of a single hook retractor and 15c scalpel. n. Wound closure is very tight with a few
interrupted sutures because the gingival margin incision and the midline incision of the
alveolar ridge can be well adapted due to the rigid marginal gingiva.

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Fig 6-18 a. Marking of the left iliac spine (rounded line) and the inner side of the iliac crest
(dashed line). b. Incision with the 15-gauge scalpel. The incision is only about 3 cm long,
although bone grafts can be significantly longer. c. Hemostasis in the subcutaneous fat by
bipolar coagulation. d. Visualization of the aponeurosis between the gluteus and abdominal
muscles. e. Incision of the aponeurosis on the iliac crest. f. Removal of the periosteum from
the inner side of the iliac crest. g. Osteotomy with the oscillating saw to remove the inner
curve of the iliac crest.

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Fig 6-18 h. Longitudinal osteotomy on the iliac crest with the oscillating saw. i. Removal of
the inner curve of the iliac crest with a chisel. j. The inner curve of the crest as a
monocortical bone graft with a high proportion of cancellous bone. k. Vertical osteotomies
(piano keys) can be used to harvest monocortical strips from the inner curve of the iliac
bone. l. Additional bone is harvested from the cancellous bone of the inner side of the pelvis
using a strong curet. m. A drainage tube is inserted without suction. If necessary,
hemostasis from the bone can be achieved with bone wax, but usually there is little
bleeding. n. An injection of bupivacaine alleviates most of the wound pain for the first 24
hours.

Complications of iliac bone harvesting include impaired sensation of the

lateral femoral cutaneous nerve, which runs medial to the anterior iliac
spine and is at risk here. In bicortical harvest, the superior gluteal nerve is at
risk, which innervates the tensor fasciae latae muscle and can cause gait
disturbance if it fails. Particularly in patients with osteoporosis and with
heavy use of chisels, a fracture of the pelvic rim may occur, which can
usually be treated conservatively. To avoid this, the ends of the saw cuts
should be rounded by a ball cutter so as not to set a predetermined fracture
point by notch action. Bruising can occur and should be avoided by good
hemostasis of the bone marrow cavity using bone wax if necessary.
Infection almost never occurs when the above requirements of antisepsis
are met.

Transplantation of a bone block of a retromolar bone block graft

First, the recipient defect is exposed subperiosteally by means of a full-
length flap and measured with a caliper or ruler. Then the bone is freed
from soft tissue remnants with a ball bur and multiply perforated with a
small rose bur. The bone trap runs alongside during this work. The surface
of the recipient bone can be removed with the scraper to obtain chips and to
remove the cambium layer. Now the external oblique ridge block is
elevated instead according to the measured length transferred with the
calipers (see chapter 3), closing the recipient wound with some temporary
sutures in the meantime to give access to as few bacteria as possible. The
block is tried in to the defect. It is then trimmed by breaking sharp edges
with the diamond ball bur. In most cases, a groove must be milled apically
in the recipient bone so that the block is as flush as possible with the ridge.
The block is vertically positioned so that it stands 3 mm below the
prospective gingival height of the planned restoration. Horizontally, it
should lie slightly outside the envelope. Osteosynthesis is then performed.

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To increase precision, resorption protection can be provided by applying
fine-grained bone substitute material (Bio-Oss, Geistlich). It is important to
compensate for contour gaps on the alveolar ridge in the mesiodistal
direction and on the alveolar ridge with a mixed bone graft so that no
grooves or bulges are created later. It is also important to break sharp edges
and palpate them with the finger, otherwise flap necrosis may occur. An
absorbable collagen membrane acts as protection against dehiscence by
cushioning the block against the flap.

6.6 One- or Two-Stage Implant Placement with Bone

Grafting
In principle, the two-stage procedure, first augmentation and then implant
placement after successful bony healing of the augmentation, is the safer
alternative compared to simultaneous implant placement.
The two-stage procedure is safer because in this case the implant is
placed in an already vascularized bone bed and is therefore more likely to
heal without problems. In addition, the alignment of the implant is usually
more successful in the already regenerated bone bed than in a bone bed in
the atrophy stage. In the single-stage procedure, the implant surface is
adjacent to the temporarily devitalized augmentation material, which must
first heal before bone can attach to the implant surface. Simply put, dead
bone material does not function well on a dead implant surface. The
advantage of the one-stage procedure is the shorter overall treatment time
and the lower surgical and cost burden on the patient. With the one-stage
procedure, there must still be sufficient bone to stabilize the implant, which
is usually only the case with the 1/4 defect. With sinus elevation surgery,
the required residual bone height at the maxillary sinus floor depends on the
implant system used. Implants with particularly sharp threads or a press-fit
design in the cervical portion may well have primary stability even with 1
to 2 mm of residual bone height.

6.7 References
1. Lee PH, Chen MY, Lai YL, Lee SY, Chen HL. Human beta-defensin-2 and -3 mitigate the
negative effects of bacterial contamination on bone healing in rat calvarial defect. Tissue Eng

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 Part A 2018;24:653–661.
2. Warnke PH, Springer IN, Russo PA, et al. Innate immunity in human bone. Bone 2006;38:400–
408.
3. Warnke PH, Voss E, Russo PA, et al. Antimicrobial peptide coating of dental implants:
Biocompatibility assessment of recombinant human beta defensin-2 for human cells. Int J Oral
Maxillofac Implants 2013;28:982–988.
4. Danesh-Sani SA, Tarnow D, Yip JK, Mojaver R. The influence of cortical bone perforation on
guided bone regeneration in humans. Int J Oral Maxillofac Surg 2017;46:261–266.
5. Maus U, Andereya S, Gravius S, et al. How to store autologous bone graft perioperatively: An in
vitro study. Arch Orthop Trauma Surg 2008;128:1007–1011.
6. Rocha FS, Batista JD, Zanetta-Barbosa D, Dechichi P. Effect of different storage media on the
regenerative potential of autogenous bone grafts: A histomorphometrical analysis in rabbits. J
Oral Implantol 2013;39:635–642.
7. Laursen M, Christensen FB, Bünger C, Lind M. Optimal handling of fresh cancellous bone graft:
Different peroperative storing techniques evaluated by in vitro osteoblast-like cell metabolism.
Acta Orthop Scand 2003;74:490–496.
8. Hassanein AH, Greene AK, Arany PR, Padwa BL. Intraoperative cooling of iliac bone graft: An
experimental evaluation of cell viability. J Oral Maxillofac Surg 2012;70:1633–1635.
9. Kruyt MC, Delawi D, Habibovic P, Oner FC, van Blitterswijk CA, Dhert WJ. Relevance of bone
graft viability in a goat transverse process model. J Orthop Res 2009;27:1055–1059.
10. Jensen T, Schou S, Gundersen HJ, Forman JL, Terheyden H, Holmstrup P. Bone-to-implant
contact after maxillary sinus floor augmentation with Bio-Oss and autogenous bone in different
ratios in mini pigs. Clin Oral Implants Res 2013; 24:635–644.
11. Mordenfeld A, Aludden H, Starch-Jensen T. Lateral ridge augmentation with two different ratios
of deproteinized bovine bone and autogenous bone: A 2-year follow-up of a randomized and
controlled trial. Clin Implant Dent Relat Res 2017;19:884–894.
12. Brand HS, Ligtenberg AJ, Veerman EC. Saliva and wound healing. Monogr Oral Sci
2014;24:52–60.
13. Maiorana C, Beretta M, Salina S, Santoro F. Reduction of autogenous bone graft resorption by
means of bio-oss coverage: A prospective study. Int J Periodontics Restorative Dent 2005;25:19–
25.
14. Wiltfang J, Jätschmann N, Hedderich J, Neukam FW, Schlegel KA, Gierloff M. Effect of
deproteinized bovine bone matrix coverage on the resorption of iliac cortico-spongeous bone
grafts—A prospective study of two cohorts. Clin Oral Implants Res 2014;25:e127–e132.
15. Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing two
techniques of bone augmentation: Onlay graft alone or associated with a membrane. Clin Oral
Implants Res 2001;12:632–639.
16. Cordaro L, Torsello F, Morcavallo S, di Torresanto VM. Effect of bovine bone and collagen
membranes on healing of mandibular bone blocks: A prospective randomized controlled study.
Clin Oral Implants Res 2011;22:1145–1150.
17. Möller B, Wiltfang J, Acil Y, Gierloff M, Lippross S, Terheyden H. Prevention of the surface
resorption of bone grafts by topical application of bisphosphonate on different carrier materials.
Clin Oral Investig 2014;18:2203–2211.
18. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-
analysis of the literature—Part 2: Comparison of endodontic microsurgical techniques with and
without the use of higher magnification. J Endod 2012;38:1–10.

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19. Francetti L, Del Fabbro M, Calace S, Testori T, Weinstein RL. Microsurgical treatment of
gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent 2005;25: 181–
188.
20. Atieh MA, Alsabeeha NH, Tawse-Smith A, Faggion CM Jr, Duncan WJ. Piezoelectric surgery vs
rotary instruments for lateral maxillary sinus floor elevation: A systematic review and meta-
analysis of intraand postoperative complications. Int J Oral Maxillofac Implants 2015;30:1262–
1271.
21. Menziletoglu D, Basturk F, Isik BK, Esen A. A prospective split-mouth clinical study:
Comparison of piezosurgery and conventional rotary instruments in impacted third molar
surgery. Oral Maxillofac Surg 2020;24:51–55.
22. Stimmelmayr M, Beuer F, Schlee M, Edelhoff D, Güth JF. Vertical ridge augmentation using the
modified shell technique —A case series. Br J Oral Maxillofac Surg 2014;52:945–950.
23. Fontão FN, Diez GF, Bassi AP, Claudino M. Second harvest of mandibular ramus blocks in bone
augmentation procedures: A case letter. J Oral Implantol 2014;40(Spec No):397–400.

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 7
Soft Tissue Management and
Augmentation

In the contaminated environment of the oral cavity, an avascular bone block

graft requires a closed soft tissue covering that is as bacteria-proof as
possible for trouble-free healing. The soft tissue covering keeps bacteria out
in a phase in which the grafted material does not yet have its own defense
and vascularization. In some cases, blood vessels grow from the soft tissue
into the graft, as a result of which the osteoclasts and osteoblasts required
for incorporation appear.

7.1 Dimensions of the Soft Tissue around the Dental

Implant
As a rule of thumb, the soft tissue height in the edentulous region is 1.5
mm. If the gingiva can rest on one side against a crown on the vestibular
surface, it rises to 3 mm, which corresponds to the average value of the
biologic width. If it can support itself between two teeth on both sides, it
rises 6 mm above the bone, which is easy to remember because the amount
doubles in each case (Figs 7-1 and 7-2).
There is little human data on true soft tissue dimensions, which is also
due to the clinical measurement inaccuracy of periodontal probes. The soft
tissue thickness of edentulous areas in the implant site can be inferred from
clinical studies to be about 2 mm, depending on the biotype.1 There are
animal experimental data on the biologic width at dental implants, which
have been measured very accurately histologically. According to this, the
biologic width is about 2 mm of junctional epithelium and 1.3 to 1.8 mm
connective tissue plus the sulcus depth.2 The Tarnow rule on teeth stated

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that a contact point 5 mm above the bone crest had a greater than 98%
probability of a papilla, >6 mm had a 56% probability, and >7 mm had a
27% probability.3 These measurements were repeated by Tarnow for the
space between an implant and a tooth, and these were slightly lower, with
100% at <5 mm and 50% probability at >5 mm papilla height above the
bone.4 A recent meta-analysis showed a 95% probability that the papilla will
rise 5.94 mm above the bone.5 Between two adjacent dental implants, only
3.4 mm of soft tissue height can be expected,6 which is why this situation
should be avoided in the anterior region by inserting pontics or bridge
attachments if possible.

Fig 7-1 The mean values of the biologic width in millimeters on the tooth on the left and on
the implant on the right. The soft tissue attachment apparatus consists of a connective
tissue zone, inner marginal epithelium, and free gingiva. For the implant it is indicated that
the bone can be thicker and higher than at the tooth. The coronal starting point for the
apical marginal epithelium is usually the abutment gap, as this generates an inflammatory
infiltrate via escaping bacterial toxins, which leads to detachment of the marginal epithelium
coronal to the gap.

7.2 Access Incision Guidelines

As access incisions, the exact midcrestal incision in edentulous areas and
the sulcular incision on teeth takes into account the blood supply conditions
in the alveolar process7 (Fig 7-3). The midline of the alveolar ridge can be

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recognized by the linea alba, meaning “pale line,” whose appearance is
caused by the minimal blood supply in the tissue underneath. This is due to
scar healing after the two occurrences of both tooth eruption and tooth loss,
at least in the anterior jaw, where the primary and permanent teeth were
present prior to edentulism (Fig 7-4).
When there was still a tooth in the edentulous segment, the vestibular
gingiva was vascularized externally by vessels from the labial artery, and
the palatal gingiva was vascularized internally by the palatine artery, with
similar nerve development. Tooth loss does not change this; anastomoses
rarely form between these supply areas after tooth extraction. Shifting the
incisions palatally or vestibularly may cause wound margin necrosis of the
protruding, poorly perfused flap margin. This portion of the flap likely is
saved in such displaced incisions in the edentulous ridge by connecting it
longitudinally as in a bridge flap. Blood flow to the wound margin is
essential for soft tissue healing, and this should be the most important
criterion for incision placement. Vertical relief incisions should be used
sparingly and, if possible, not at all in the esthetic area. It is better to place
relief incisions in the labial frenum and retromolar area.
If teeth are adjacent to an edentulous jaw section, the midline incisions
are continued intrasulcularly as a gingival margin incision. The gingival
margin incision is bacteria-proof after only 24 hours due to the high rate of
cell division in the junctional epithelium, as these cells attach to the tooth
with hemidesmosomes. In addition, the marginal gingiva is by nature the
zone of confrontation with plaque bacteria and is immunologically best
prepared (Fig 7-5).
The scar in the sulcus has already been created by the erupting tooth, so
the surgeon does not create any new scars, as in the case of the alveolar
midcrestal incision. Both the midcrestal incision and the sulcular incision
leave no visible scars and do not cut any important vessels. Thus, the flap in
between remains scar-free and unaffected in its nervous and vascular
architecture. This is important in case further interventions are needed at
this site later in life, which would not be uncommon with implants.
Augmentation surgery is not always the last intervention at this site in the
patient’s life. Perhaps peri-implantitis treatment or other revision treatment
will need to be performed a few years later. If the bone augmentation
procedure is so critical that it can only be healed with atypical soft tissue
flaps such as vestibular incisions, then in case of doubt the augmentation

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procedure should be focused on rather than the incision, or the former
should be adapted to the soft tissue anatomy. As a surgeon, the following
applies once again: Primum non nocere!

Fig 7-2 Approximate soft tissue thickness as a rule of thumb in the edentulous, vestibular,
and interdental regions, which doubles each time. By bringing the bone to the correct
height, these figures can be used to control the soft tissue height and achieve optimum
esthetics.

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Fig 7-3 The gingival margin incision (sulcular incision), together with the alveolar ridge
incision, causes the least damage to the natural blood flow pathways and the innervation of
the gingiva. In a sense, the midcrestal incision is the sulcular incision of the edentulous
ridge, because the palatal and buccal gingival flaps have previously shrunk to the center in
the course of alveolar healing, thus taking their vascularization (red) and innervation
(yellow) with them.

Fig 7-4 In the edentulous jaw, there is hardly any anastomosis beyond the center of the
alveolar ridge. In the center of the alveolar ridge, therefore, the linea alba is found as a zone
of low blood supply and favorable for incision.

Fig 7-5 The sulcular incision is located in a natural scar already created by the erupting
tooth, and no additional scars are created by the sulcus incision. In addition, the sulcus
incision can heal within 24 hours in a bacteria-proof manner because the inner junctionall
epithelium has a high cell division rate and can quickly form hemidesmosomes to the tooth

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or restoration. Finally, the sulcular incision is in the region of natural defense against plaque
bacteria, so the immune system is already present. This all explains the enormously reliable
and rapid healing of a sulcular incision.

7.3 Flap Types

In the implant placement and bone grafting phase, it makes sense to
preserve the alveolar ridge periosteum of the intact mucoperiosteal flap by
gentle subperiosteal preparation (Fig 7-6). Partial-thickness flaps are
generally not indicated in bone augmentation surgery. There are several
reasons for this. There is hardly any bleeding in the subperiosteal layer, so
the wound remains dry and clear. The intact periosteum protects the nerves
and vessels behind it, such as the mental nerve. Due to the fully permanent
detachment of the mucoperiosteal flap, the juga alveolaria (alveolar yokes)
are clearly visible, which is a good orientation aid, eg, for assessing the axis
of adjacent teeth next to the implant site. In addition to serving as a
membrane, the periosteum is also a good structure for positional
stabilization of particulate bone grafts.
The alternative, further preparation not beneath but on top of the
periosteum to form a split-thickness flap, takes place directly in the blood-
bearing layer of the flap and destroys part of its vascular architecture. The
extent to which this also compromises the nerve supply and thus the
sensitivity of the marginal gingiva is largely unknown. Split-thickness
epiperiosteal flaps have little place in bone augmentation surgery. The
advantage of split-thickness flaps is their mobility due to the elasticity of
the vestibular alveolar mucosa. Therefore, split-thickness flaps are a good
alternative for coverage of extraction sockets in case of a history of
bisphosphonate use or for fistula coverage in the maxillary sinus. Another
advantage is that a perfused periosteum remains on the maxillary bone,
which is why this flap provides good soft tissue support for nourishing a
soft tissue graft. The split-thickness flap is therefore the standard flap in
periodontal plastic surgery. The mobility of the gingiva on the periosteal
support is also the reason why this flap is popular for implant uncovering.

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Fig 7-6 Full-thickness flaps (mucoperiosteal flaps, left) are more suitable for general oral
surgery, bone augmentation, and implant placement in phase 1. This preparation heals
without scarring and can be repeated several times without changes for the patient. Partial-
thickness flaps (right) are used less frequently, especially for implant uncovering (phase 2)
and periodontal plastic surgery, where a vascularized bed on the periosteum is needed for
soft tissue grafts. Otherwise, epiperiosteal preparation destroys the natural soft tissue
architecture and its vessels.

Both flaps, full thickness and partial thickness, can be displaced

laterally, apically, and coronally. Apically positioned flaps are used, for
example, in surgical crown lengthening or in peri-implantitis therapy for
pocket elimination. Periosteal sutures are required to position a flap
apically. Coronally positioned flaps are used for recession coverage, for
example. To anchor a flap coronally, double crossed sutures are required,
which are placed on the interdental contact point for tight adaptation. In the
case of loose contact points, non-bonded composite bridges are placed on
the contact point to prevent the gingival pull-up sutures from slipping.

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7.4 Vestibuloplasty and Other Soft Tissue Plastic Surgery
If the partial-thickness flap is prepared further apically on the periosteum,
the muscle attachments of the buccinator muscle reach halfway up the tooth
roots. Vestibuloplasty begins when the dissection is deeper than this muscle
and the muscle fiber attachments are separated from the bone.
Vestibuloplasty is indicated in the edentulous jaw to improve the denture
support. If performed in partial areas of the jaw, the technique is performed
to obtain a periosteal surface that can be covered with a mucosal graft with
the aim of widening the attached gingiva. In the mandible, when the
attachment of the mylohyoid muscle is separated lingually, it is referred to
as lowering of the floor of the mouth (Fig 7-7).
Further soft tissue plastic surgery, such as ligament correction by Z-
plasty or V-Y plasty, is rarely indicated in augmentation surgery because the
underlying ligaments usually disappear by themselves in the course of flap
coverage of the augmented bone.

Fig 7-7 Definition of lowering of the floor of the mouth or vestibuloplasty by severing the
muscle attachments of the mylohyoid or buccinator muscles.

7.5 Flap Tension and Mobilization

A problem of all overlay bone grafts in contrast to interpositional grafts is
the flap tension generated in the soft tissue to cover the additional volume.

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Flap tension causes compression of the capillaries on a microscopic scale.
This can be thought of as similar to a wire mesh. If this is stretched in the
longitudinal direction, the mesh closes more and more until the tubes of the
capillaries contained therein are closed off. This is how necrosis of the flap
tip and the wound dehiscence develop.
Anything that impairs local tissue blood flow, such as nicotine use,
uncontrolled diabetes mellitus, history of tumor irradiation, or points and
sharp edges below the flap, can promote dehiscence. The flap should be
well cushioned from below, eg, by smoothing the bone or placing collagen
membranes. The effect of a sharp edge, eg, a protruding particle of a bone
graft substitute, is to concentrate force on a point of the tissue, resulting in a
pinpoint depression of blood flow. When this pressure is applied for some
time, ischemic necrosis of the flap is thus produced.

Surgical flap procedures

The flap tension should be relieved by particularly gentle tissue
mobilization. To do this, the flap is grasped with a fine Gillies single hook
retractor and pulled over the augmentation on a trial basis. This shows how
much length is missing. The flap should never be grasped with tweezers
because they unnecessarily compress the edge of the tissue to hold it! One
can least afford such an unnecessary trauma at the edge of the flap, where
the primary wound healing is to take place later.
The flap is held tightly with the single hook in one hand. The taut
periosteum is seen as the limiting structure. With a fresh 15c scalpel in the
other hand, the taut periosteal fibers are now cut individually under visual
control. This brings about 5 mm of flap extension, which can be seen
immediately under traction with the single hook. This is done very
carefully, as the nerves (eg, mental nerve) and blood vessels running behind
the periosteum must not be damaged under any circumstances. The scalpel
should be able to avoid these because they lie more loosely than the taut
periosteal fibers. Blood vessels that are inadvertently injured in the deep
opening of the periosteum are responsible for the cheek hematomas of some
patients after augmentation procedures. They are largely avoidable with a
proper surgical technique; at the very least, such hemorrhages should be
carefully stopped intraoperatively by means of bipolar coagulation. Another
mistake in periosteal incisions is perforations into the vestibule. It is best to

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ensure that both sides of the flap are well visible and to work only in the
uppermost periosteal layer.
The single hook is now inserted again for testing. If the flap is still too
short or is under too much tension, closed Metzenbaum dissecting scissors
(with round ends) should be inserted into the periosteal incision and used to
spread the tissue in a submucosal direction. If this is still not enough, one
can insert a blunt elevator into the periosteal incision and elevate the flap.
One should never make a deep incision in this situation because the
restraining structure in the maxillary vestibule is often the infraorbital
nerve, which at most should be stretched slightly but not cut. In the end, the
flap should be able to be pulled loosely with the single hook over the
augmentation with some excess; this indicates the mobilization is correct.

7.6 Suture Technique and Material

Sutures that are too tight or too taut have a similar effect on blood flow as
harmful flap tension. In surgical courses and books, enormous emphasis is
sometimes placed on suturing techniques and elaborate interlacing of
sutures is presented in drawings. In nature, however, blood must still be
able to flow between the stitches and loops of the sutures; otherwise, the
tissue becomes necrotic. The transverse lines that are sometimes seen after
the sutures are removed, and that are often drawn in popular depictions of
scars, are the zones of necrosis where the tissue directly under the suture
has been squeezed and has become necrotic. So every suture creates a
trauma; one should be aware of that.
The suture technique should be selected in such a way that, as far as
possible, there is an optimum ratio between the tightness of the suture
against the oral cavity and the strangulation of the microcirculation at the
wound margin. This can be achieved, for example, by fine sutures (5-0) at
the wound margin, supplemented by somewhat stronger holding sutures (4-
0) in the flap periosteum away from the wound margin, which absorb the
tension. However, less is often more. Although it appears simple, the
interrupted suture strikes a very good balance between trauma and flap
adaptive force. It is surpassed only by the continuous (spiral) suture, which
uses half the number of stitches. “It can only heal between the sutures,” was
a popular saying of the author’s teacher Prof. Dr. Dr. Franz Härle. This

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meant that it was better to have a few well-placed, strong sutures than
countless small sutures under the microscope.
In the end, suturing depends on a clean macroscopic adaptation of
perfused wound edges. Ultimately, it is probably illusory to believe that
sutures can be used to close the wound in a bacteria-proof manner; at least
in the stitch holes, the bacteria can penetrate along the suture into the
depths. A surgical suture must, along the threads, always leave gaps in the
woung margin for circulation, and at these points the tissue layers lie more
loosely against each other. Tight sutures are most likely to work in the
attached gingiva, because here the tissue elasticity of the alveolar mucosa
does not allow the muscles of the cheek to pull the wound open.
In practice, bone augmentation wounds are on average sutured with
atraumatic 4-0 pseudomonofilament polyamide with a sharp needle (eg,
Supramid, Resorba; Fig 7-8). For smaller bone grafts, the thickness 5-0 or
6-0 is also sufficient, but these threads are then no longer twisted
pseudomonofilament but monofilament, which results in poorer knot
strength. Pseudomonofilament means that a thread is twisted like silk, but
coated with plastic. Purely twisted polyfilaments, such as absorbable
polylactide filaments, accumulate an enormous number of bacteria after
some time8 and have a wicking effect into the interior of the tissue.9,10 Thus,
they do not heal as irritation-free as monofilament or pseudomonofilament
types.
It is also important to have a defined final strength of the knotted loop,
which should not loosen again over time. This is particularly important for
sutures in the attached gingiva and at the gingival margin. The rubbery
elasticity of some suture materials is rather counterproductive in these
areas.

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Fig 7-8 Standard suture material (Supramid) as pseudomonofilament and thus with good
lubricity and little wicking action. Pseudomonofilament suture material is twisted on the
inside for tight knotting properties. The triangle on the package indicates a sharp cutting
needle, which is important for suturing in the attached gingiva.

For handling the 4-0 and 5-0 sutures, a Crile-Wood needle holder is
optimal if it is coated with tungsten carbide at the tip so that it grips the
needle securely (Fig 7-9). The same coating should be applied to the end
pieces of the anatomical forceps, which are placed in the surgeon’s other
hand. This allows the needle to be passed back and forth between the needle
holder and the forceps with the same tactility during suturing.

7.7 Implant Uncovering After Bone Augmentation

The marginal soft tissue attachment and sealing apparatus on the dental
implant is formed by the neuroectodermal cells of the tooth attachment in
the center of the alveolar ridge. Only these cells are capable of forming the
dentogingival fibrous cuff and hemidesmosomes. Therefore, lasting implant
health is best achieved by making an incision exactly in the center of the
residual attached gingiva, even during implant uncovering. Starting from
this incision, the residual attached gingiva should be distributed in equal
parts to the buccal and lingual sides. In the simplest case, this is done by
uprighting the formerly flat lying tissues in a vertical position with a
healing abutment (Fig 7-10).

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Fig 7-9 Both the Crile-Wood needle holder and the ends of the tweezers have the same
hard metal coating (tungsten carbide). Having the same working ends allow consistent
tactility when the needle moves back and forth during suturing.

However, if, for example, the increased volume to be covered in a bone

augmentation case has caused an oral displacement of the mucogingival
borderline, then this technique is not sufficient (Fig 7-11). In this case, the
flap should be prepared epiperiosteally beyond the mucogingival borderline
with the flat scalpel so that the palatally displaced gingiva can slide
vestibularly as an apically displaced flap. This technique can be extended
by a bridge flap preparation if the implant has inadvertantly perforated the
vestibular tissues (Fig 7-12).

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Fig 7-10 Implant exposure. a. A short midcrestal incision, slightly larger than the implant, is
made without papilla injury. No attached gingiva is cut away. b. By angling the scalpel, a
short section can be prepared epiperiosteally in a vestibular direction. c. Using a sharp
periosteal elevator, the flap portion is detached over the implant head. d. After removing the
cover screw, the implant interior is cleaned with disinfectant. e. The gingiva former is
inserted. Since the gingiva has the tendency to always adapt to the tooth shape, it can be
modeled with it. Therefore, an anatomically shaped crown is not an absolute necessity, as
some advocates of immediate restorations demand. f. The gingiva, which was previously
flat at a height of 1.5 mm, can be vertically raised to about 3 mm at the gingiva former. This
means that there is no need for the body to extend the biologic width in depth at the
expense of the bone. g. An overcorrected vestibular contour created by augmentation and
an implant position within the envelope is the best guarantee against recession and
vestibular show-through of the dark metal.

Fig 7-11 Example of a palatally displaced mucogingival margin. The gray of the titanium
implant shows through the gingiva.

In the maxilla, the creation of a wide zone of attached gingiva buccal to

the implants is easier than in the mandible. In the maxilla, this mucosa can
be moved buccally from the palate via a pedicled epiperiosteal flap (Fig 7-
13). The incision for exposure is always made in the previous midcrestal
incision made during implant placement. However, if it is evident that there
is insufficient attached gingiva for the implants, the incision can also be
made further palatally in order to move attached gingiva to the buccal side.
From the incision, the scalpel is then used to further prepare epiperiosteally
until the flap can be moved buccally and positioned at the gingiva former at
a height of 3 mm. This can also be supplemented with incisions to
reconstruct the papillae (Fig 7-14).

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7.8 Soft Tissue Augmentation for Widening Keratinized
Attached Gingiva on Dental Implants
In the mandible, vestibuloplasties and gingival grafts are rarely necessary
because the attached gingiva on implants can recover under function even
from a small residual trace of attached gingiva after insertion of the
prosthetics. If there is almost no gingiva left at all, then the residual trace of
attached gingiva can be moved to the lingual side, and buccal
vestibuloplasty can be performed with a free mucosal graft from the palate.
The access flap for widening attached gingiva is the epiperiosteal
partial-thickness flap, which is then extended apically, usually in
combination with vestibuloplasty with detachment of the buccinator
muscles and deepening of the oral vestibule. An exposed periosteal surface
is created (Fig 7-15). Since the early days of preprosthetic surgery it has
been known that such a periosteal surface recurs by creeping of the
buccinator fibers, in the mandible by almost 100% and in the maxilla by
about 70%.11 It is therefore appropriate to cover the exposed periosteum by
epithelium, for which the free mucosal graft from the hard palate is
classically considered. In contrast to the past, when this material was taken
from the palate in wafer-thin layers using the mucotome according to
Mörmann, thicker grafts taken with a scalpel are preferred today. These are
easier to suture, especially at the healing abutment (Fig 7-16).
The further advantage is that tissue differentiation to keratinized
attached gingiva is thought to originate from the subepithelial connective
tissue, which is why it should be included in the graft. In the esthetic area of
the anterior maxilla, free mucosal grafts should not be used because they do
not match the surrounding area in texture and color (Fig 7-17).
The donor site on the palate epithelializes relatively quickly, after about
14 days, from the incised excretory ducts of the palatal salivary glands. The
donor site should be covered with a palatal stent for protection (Fig 7-18)
during this time. Nevertheless, the follow-up period after removal can be
painful, and alternatives to free mucosal grafts are sought. Here, foreign
materials, such as porcine connective tissue matrix,12 work. However, in a
meta-analysis, direct comparison showed an effect on the gingival width
that was on average 1.55 mm better when a vestibuloplasty was covered (ie,
using an apically positioned flap [APF]) with autogenous material than with
a foreign material.13

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Fig 7-12 Bridge flap to address inadvertant buccal impalnt exposure. a. Unfavorable
spontaneous vestibular exposure of an implant. b. Preparation of a bridge flap
approximately 4 mm palatal to the implant head. c. The flap is lifted over the implant and
prevented from sliding back by the gingiva former. d. Adaptation with absorbable sutures
(polyglycolic acid [PGA] 5-0, Resorba).

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Fig 7-13 Exposure in case of gingival deficiency. a. Mucogingival margin displaced
palatally after plastic coverage of an augmentation. b. The section follows the mucogingival
coverage of a grafted area, leaving 3 mm of attached gingiva on the vestibular flap. c. The
flap is dissected epiperiosteally by the obliquely positioned scalpel blade. The gingiva
former prevents it from sliding back.

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Fig 7-14 Papilla reconstruction. a. Initial situation with insufficiently attached gingiva after
soft tissue coverage of an augmentation. b. Palacci flap technique. c. Papilla reconstruction.
d. Epiperiosteally prepared flap with a zone of attached gingiva. e. Anterior suture fixation of

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the flap. f. Preparation of small rotation flaps using a No. 11 scalpel. g. Pivoting of the first
flap for papilla reconstruction distal the maxillary right canine. h. Pivoting of the remaining
flaps in series.

Fig 7-14 i. Completion after soft tissue healing 3 weeks later.

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Fig 7-15 Reconstruction of the vestibular gingiva using a gingival graft from the
palate. a. Bone defect in the lateral mandible, anterior osteotomy for block elevation at the
external oblique ridge. b. Longitudinal monocortical osteotomy for block elevation. c.
Monocortical bone block, almost 4 cm long, from the external oblique ridge. d. Bridging
fixation as a shell graft vestibular to the bone defect with resorbable pins (Resorb X, KLS
Martin); the recipient bone was perforated.

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Fig 7-15 Reconstruction of the vestibular gingiva using a gingival graft from the
palate. e. Mixed bone graft containing bone substitute material, filter bone chips, and
venous blood. f. Insertion of a Bio-Gide collagen membrane (Geistlich) under the lingual
flap. g. Backfilling of the shell with bone chips and and covering with a mixed graft. h.
Covering of the particulate graft with the moistened collagen membrane. i. Wound closure
by interrupted sutures. j. Panoramic image of vertical bone defect distal to the mandibular
left canine. k. Panoramic image after bone block grafting and resorbable, nonradiopaque
osteosynthesis. l. Implant planning after prosthetic mock-up. m. Implant placement 4
months after bone grafting. The area of the particulate mixed graft behind the shell is
completely ossified and regenerated. n. Panoramic image showing implant planning with a
surgical guide. o. Panoramic image showing implant placement; the last implant was
omitted. p. Three months after implant insertion, the area is exposed through an
epiperiosteal flap and vestibuloplasty. q. Covering of the vestibuloplasty by a gingival graft
from the hard palate. Fixation by three rows of sutures: at the coronal abutment margins, at
the periosteum, and between the periosteum and vestibular flap to define the new

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vestibulum depth. r. Final photo with regeneration of the missing bone and soft tissue:
Restitutio ad integrum.

Fig 7-16 Schematic of the fixation of a gingival graft from the palate by three rows of
sutures. a. The diagram shows the lasso suture, in which the periosteal suture is wrapped
around a tooth or the gingiva former of an implant. Due to the curvature of the alveolar
process, this suture presses the graft firmly onto the base so that it is not underperfused
and capillaries can grow in better from below. Accurate fixation at the abutment margin
should allow lateral vascular connection into the graft, so that nutrition is not only obtained
through the base. b. Harvest defect on the palate after removal of a gingival graft using a
scalpel technique. c. Fixation of the graft by three rows of sutures, including the lasso
suture. d. Clearly recognizable former graft 10 years later.

A sufficient, firm zone of keratinized gingiva surrounding the implant is

a clinical prerequisite for the esthetics, function, and hygiene of an implant
restoration. However, it cannot be deduced from the literature that more
than a 2-mm width of keratinized tissue is mandatory.14 The width of
keratinized tissue had no significant effect on pocket depth and sulcus
bleeding on implants15,16 and did not improve the results of peri-implantitis
therapy17 (Figs 7-19 and 7-20).

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Fig 7-17 Gingival grafts with deviating color, texture, and contour should be avoided in an
esthetic area.

Fig 7-18 Vacuum-formed palatal stent for covering the donor site after harvesting a gingival
graft.

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Fig 7-19 Long-term survival of an implant without attached gingiva. a. Panoramic
tomogram with initial situation in 2000. b. Panoramic tomogram after implant placement with
simultaneous bone block grafting. c. Panoramic tomogram of situation after prosthetic
restoration in 2001. d. Radiograph taken 15 years later with identical bone conditions as in
2001. e. Clinical image 15 years later without recession in complete absence of attached
gingiva.

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Fig 7-20 Reinforcement of a thin biotype. a. Radiograph showing a hopeless maxillary
left lateral incisor after tooth trauma. b. Initial situation of the single-tooth gap in the
maxillary left lateral incisor site with bone atrophy (1/4 according to the quarter rule; see Fig
1-11). Thin periodontal biotype with multiple spontaneous recessions. c. Condition 4 months
after implant placement and bone block grafting. The osteosynthesis screw is already
palpable and visible through the mucosa apical to the maxillary left central incisor. d. Screw
removal was performed minimally invasively by stab incision to avoid re-denudation of the
bone graft. e. Preparation of a closed recipient pocket using a scalpel blade, epiperiosteally
if possible. f. Fitting of the connective tissue graft from the palate. g. Donor site defect on
the palate in the region of the left premolars following harvest of the connective tissue graft .
h. The connective tissue graft should be expanded as much as possible in the recipient
pocket in order to be nourished as well as possible. The larger this is, the more the chance
of ingrowing capillaries increases. i. The connective tissue graft lies labial to the healing
abutment, with its keratinized edge peeking out of the wound. j and k. Thickening of the
gingival contour by the connective tissue graft is clearly visible. l. After soft tissue

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consolidation, approximately 3 weeks after connective tissue grafting, the prosthetic
restoration can begin. m. The gingival margin continues to remodel under the horizontal
prosthetic restoration. For this purpose, it is important that no scars have been created on
the labial aspect. n. Successful avoidance of soft tissue recession due to the reinforcement
of the biotype.

7.9 Soft Tissue Augmentation to Increase the Mucosal

Thickness at Dental Implants
Mucosal thickening of the gingiva is performed to reinforce a thin gingival
biotype (Fig 7-21) and thus prevent recession, bone loss, and visibility of
the titanium through the gingiva (Fig 7-22).
The purpose of thickening the attached gingiva in the emergence profile
of the implant is to create a thicker soft tissue flap at the penetration point
of the implant. The natural height of the soft tissue in edentulous areas is
about 1.5 mm, whereas the biologic width measures about 3 mm. After
simple implant exposure by tissue punching, the latter occurs at the expense
of marginal bone resorption. Marginal bone resorption during remodeling of
dental implants should be reduced by thickening the soft tissue height to 3
mm by soft tissue grafting even before implant uncovering. A recently
completed review found that for this indication, most of the data available
are on autogenous connective tissue grafting. However, the authors
fundamentally questioned the method of gingival thickening because to date
there are no long-term data longer than 1 year and, in the authors’ opinion,
such a short-term gain could be offset by the natural remodeling of the
biologic width of approximately 3 mm.18 Individual papers have used
allogeneic matrix for the purpose of soft tissue thickening and have
demonstrated a protective effect on marginal bone stability.19 A direct
comparison study showed better results for the autogenous connective
tissue graft compared to a porcine material.20 Critically, however, it should
be noted that the soft tissue height of 3 mm at the implant can also be
achieved without grafting via implant exposure with an upright positioned
flap or by the flap placement technique or by supracrestal implant
positioning.

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7.10 Soft Tissue Augmentation in Conjunction with
Immediate Implant Placement
Connective tissue grafts from the hard palate could not prevent resorption
of the buccal wall in immediate implant placement in a randomized clinical
trial in the esthetic region, but they resulted in slightly higher gingival
coverage than without soft tissue augmentation.21 In a meta-analysis, no
evidence for mandatory connective tissue grafting in immediate implant
placement could be derived.22

7.11 Soft Tissue Augmentation Instead of Guided Bone

Regeneration
Connective tissue grafts from the palate have volume and stability. Several
studies have shown that in small buccal contour defects on dental implants,
connective tissue grafting can replace guided bone regeneration in terms of
esthetics and soft tissue parameters and is the less traumatic method for
patients.23,24 However, the observation periods have only been a maximum
of 1 year.

7.12 Soft Tissue Augmentation for Recession Coverage on

Dental Implants
There is not yet much evidence from the literature regarding recession
coverage on dental implants using a coronally displaced flap. Initial studies
with 5-year results used autogenous connective tissue grafts25,26 and
achieved long-term stable mean recession coverage of 86% and complete
implant coverage in 62% to 79% of patients. The use of foreign materials as
support for the coronally displaced flap has been reported for this indication
on a case-by-case basis only.27 In recession coverage on teeth, no foreign
material achieves effects equal to a connective tissue graft from the palate.
Among the foreign materials, the acellular dermal matrix achieved the best
effects.28

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Fig 7-21 a. Formation of biologic width at the expense of bone with insufficient soft tissue
height at the implant. This leads to bone loss and consecutive recession via remodeling. b.
Preventive thickening of the mucosa by a soft tissue graft over the implant head to avoid
recession due to remodeling. c. Supracrestal placement of an implant to avoid recession
(eg, Straumann tissue-level implant). d. The flap eversion technique presented in Fig 7-10
also creates sufficient soft tissue height to avoid bone remodeling.

As an alternative to the coronally displaced flap, a connective tissue

graft with epithelial strips from the palate can be used (Fig 7-23).

7.13 Vascularized Connective Tissue Flap Coverage

Because the free connective tissue graft is temporarily nourished only by
diffusion, it usually requires vascularized periosteal support and a closed
flap for coverage. If these conditions are not met, a vascularized connective
tissue flap of axial pattern can be obtained from the palate. This is arterially
(and venously) pedicled at the terminal branches of the descending palatine
artery at the incisive foramen. The flap has self-sufficient blood supply and
is thus a first-order flap (Fig 7-24; see Fig 15-2d). Dissection is difficult,
and there is a risk of re-bleeding.

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Fig 7-22 Gray discoloration of titanium implants in a case of insufficient augmentation of the
vestibular bone wall.

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Fig 7-23 Connective tissue graft with epithelial strips. a. Panoramic with maxillary
anterior vertical defect after midfacial fracture. b. Distraction osteogenesis to treat the bone
defect. c. Segmental osteotomy and attachment of the distractor (TRACK 1.5, KLS Martin).
d. Panoramic after implant placement. e. Initial clinical situation with recession tendency at
the neighboring lateral incisors.

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Fig 7-23 Connective tissue graft with epithelial strips. f. Checking the fit of a connective
tissue graft with epithelial strips. g. Insertion of the graft into a buccal epiperiosteal pocket
(closed recipient defect) using the Luniatschek gauze packer. h. The epithelial strip peeks
out coronally from the pocket. i. Almost necrotic aspect of the epithelial strip a few days
postoperatively. j. Slow color improvement of epithelial strips due to revascularization 1
week postoperatively. k. Significant harversting defect on the palate. l. Vital grafts beginning
to cover the recessions on the adjacent teeth to a small extent (creeping attachment). m.
Further coverage of recessions by healed grafts. Discoloration of the teeth from
chlorhexidine use.

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Fig 7-23 Connective tissue graft with epithelial strips. n. Nearly healed harvest site on
the palate 3 weeks postoperatively. o. Final situation after prosthetic restoration with full
recession coverage.

7.14 Tunneling Techniques

For recession coverage with coronally advanced flaps, tunnel preparation of
the interdental papillae is the least invasive procedure because no scars are
created and the blood supply via the interdental pathways is maintained (Fig
7-25).
Wound dehiscence is the main complication of onlay bone grafts and
occurs particularly after midline incision of the alveolar ridge, which is,
however, required for reasons of flap perfusion. Therefore, one can try to
reach a defect via a vertical incision in the vestibule, so that the ridge-
covering mucosa is preserved. This procedure works well in the maxillary
and mandibular posterior regions and used to be standard in preprosthetic
surgery for many years for ridge augmentation with hydroxyapatite in a
vicryl tube.11 In the maxillary anterior region, the approach is difficult and,
in the author’s experience, rather inadvisable. A variant of the tunneling
technique is the implantation of soft tissue expanders that create a tunnel

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over a few weeks into which bone augmentation materials can subsequently
be introduced.29

7.15 Contraindications
Soft tissue augmentation should not be used to compensate for implant
positioning errors in the transverse (Fig 7-26) and mesiodistal directions
(Figs 7-27 and 7-28).

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Fig 7-24 Arterialized connective tissue graft. a. Initial situation: Bone defect with loss of
the vestibular wall after loss of an immediate implant. b. Re-implantation into the socket. c.
Augmentation on the implant surface with autogenous bone chips (filter bone). d. Marking of
a vascularized connective tissue flap of axial pattern, which is prepared subperiosteally up
to the septum and is supplied anteriorly by the incisive artery from the nasal canal. e.
Pivoting of the vascularized connective tissue up to the anterior defect. Bleeding points at
the tip of the flap, demonstrating blood supply to the flap (see Fig 15-2d). f. Augmentation
by autogenous block graft from the external oblique ridge covered by a vascularized
connective tissue flap.

Fig 7-24 Arterialized connective tissue graft. g. Vestibular sutured closure without flap
mobilization, only by apposition of the vestibular flap. h. The actual coronal coverage of the
bone block graft is provided by the vascularized connective tissue. This additionally causes
thickening on the buccal side. i. Considerable swelling of the flap tissue 1 week

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postoperatively as a sign of flap vitality. j. Formation of granulation tissue in the defect as a
sign of the beginning of the proliferative phase of wound healing. k. Two weeks
postoperatively, swelling of the flap and beginning of epithelialization. l. Almost complete
epithelialization of the defect area.

Fig 7-24 Arterialized connective tissue graft. m. Healed defect. n. Healed palatal graft
harvest incision 4 months postoperatively. o. The osteosynthesis screw (see Fig 7-24f) can
be palpated and exposed minimally invasively by stab incision. p. Minimally invasive screw
removal is facilitated by the Centre Drive System (KLS Martin), in whose head the
screwdriver engages blindly. q. Due to the great thickness of the soft tissue achieved
through the palatal flap, the soft tissue access channel to the implant in this rare case can
be shaped by tissue punch. r. The punch indicates the approximately 3-mm thickness of the
flap.

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Fig 7-24 Arterialized connective tissue graft. s. Inserted gingiva former. Due to the
adaptability of the marginal gingiva, an anatomically shaped crown is not absolutely
necessary to form the emergence profile. t. Occlusal view of the gingiva former showing
planned overcompensation of the vestibular contour. Position of the implant within the
envelope. u. Completed case with esthetic gingival contour. The results are better than on
the maxillary left lateral incisor.

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Fig 7-25 Gingival thickening using a tunneling technique. a. Initial situation with
exposed crown margins due to increasing recession as a result of scarring in the vestibular
incisions after implant placement in bilateral maxillary lateral incisor sites that were

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edentulous due to agenesis. b. Removal of the connective tissue grafts from the premolar
region on the hard palate. c. Try-in of connective tissue grafts without an epithelial margin.
d. Tunneling dissection with several short sulcular incisions. The papillae are undermined.
This works well, as shown here, with an excavator as a mini-raspatory with a magnifying
glass. e. Gripping the graft with a pull-through suture (absorbable, PGA 5-0, Resorba). f.
Insertion of the graft into the tunnel preparation using the pull of the pull-through suture and
the thrust of the Luniatschek gauze packer. g. Coronal suturing with double crossed sutures
(Supramid 6-0). h. End result with resolved tendency to recession against the scar pull but
with only a slight esthetic effect. At least the crown margins of the lateral incisors are
covered.

Fig 7-26 Soft tissue improvement by correcting the implant position. a. Initial situation:
unrestorable implant due to positioning error with insufficient soft gingiva quality and
mucositis. b. Realignment osteotomy of the implant together with the surrounding bone
block, pivoting about 5 mm palatally, and osteosynthesis with an x-shaped plate. c. New
implant position within the envelope. d. Spontaneous recovery of soft tissue with the
appearance of keratinized gingiva without any soft tissue surgical intervention.

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Fig 7-27 Incorrect positioning of implants in the maxillary right lateral incisor and canine
sites with violation of the horizontal biologic width. As a result, recession with papilla loss
has developed.

Fig 7-28 Schematic drawing of the horizontal biologic width. If implants are placed closer
together than the minimum distance shown here, the bone ridge between the implants is
resorbed due to the horizontal space requirement of the soft tissue attachment apparatus.
This causes the interdental papilla to recede, as shown in Fig 7-27.

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7.16 References
1. Spinato S, Stacchi C, Lombardi T, Bernardello F, Messina M, Zaffe D. Biological width
establishment around dental implants is influenced by abutment height irrespective of vertical
mucosal thickness: A cluster randomized controlled trial. Clin Oral Implants Res 2019;30:649–
659.
2. Sculean A, Gruber R, Bosshardt DD. Soft tissue wound healing around teeth and dental implants.
J Clin Periodontol 2014;41(Suppl 15):S6–S22.
3. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest
of bone on the presence or absence of the interproximal dental papilla. J Periodontol
1992:63:995–996.
4. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and
radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A
retrospective study in the maxillary anterior region. J Periodontol 2001;72:1364–1371.
5. Roccuzzo M, Roccuzzo A, Ramanuskaite A. Papilla height in relation to the distance between
bone crest and interproximal contact point at single-tooth implants: A systematic review. Clin
Oral Implants Res 2018;29(Suppl 15):50–61.
6. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest of bone to the height of the
interproximal papilla between adjacent implants. J Periodontol 2003:74:1785–1788.
7. Kleinheinz J, Büchter A, Kruse-Lösler B, Weingart D, Joos U. Incision design in implant
dentistry based on vascularization of the mucosa. Clin Oral Implants Res 2005;16(5):518–523.
8. Banche G, Roana J, Mandras N, et al. Microbial adherence on various intraoral suture materials
in patients undergoing dental surgery. J Oral Maxillofac Surg 2007;65:1503–1507.
9. Geiger D, Debus ES, Ziegler UE, et al. Capillary activity of surgical sutures and suture-
dependent bacterial transport: A qualitative study. Surg Infect (Larchmt) 2005;6:377–383.
10. Grigg TR, Liewehr FR, Patton WR, Buxton TB, McPherson JC. Effect of the wicking behavior
of multifilament sutures. J Endod 2004;30:649–652.
11. Härle F. Atlas of Preprosthetic Surgery. Munich: Hanser, 1989.
12. Maiorana C, Pivetti L, Signorino F, Grossi GB, Herford AS, Beretta M. The efficacy of a porcine
collagen matrix in keratinized tissue augmentation: A 5-year follow-up study. Int J Implant Dent
2018;4:1.
13. Bertl K, Melchard M, Pandis N, Müller-Kern M, Stavropoulos A. Soft tissue substitutes in non-
root coverage procedures: A systematic review and meta-analysis. Clin Oral Investig
2017;21:505–518.
14. Wennström JL, Derks J. Is there a need for keratinized mucosa around implants to maintain
health and tissue stability? Clin Oral Implants Res 2012;23(Suppl 6):136–146.
15. Longoni S, Tinto M, Pacifico C, Sartori M, Andreano A. Effect of peri-implant keratinized tissue
width on tissue health and stability: Systematic review and meta-analysis. Int J Oral Maxillofac
Implants 2019;34:1307–1317.
16. Gobbato L, Avila-Ortiz G, Sohrabi K, Wang CW, Karimbux N. The effect of keratinized mucosa
width on peri-implant health: A systematic review. Int J Oral Maxillofac Implants 2013;28:1536–
1545.
17. Ravidà A, Saleh I, Siqueira R, et al. Influence of keratinized mucosa on the surgical therapeutical
outcomes of periimplantitis. J Clin Periodontol 2020;47:529–539.
18. Rotundo R, Pagliaro U, Bendinelli E, Esposito M, Buti J. Long-term outcomes of soft tissue
augmentation around dental implants on soft and hard tissue stability: A systematic review. Clin
Oral Implants Res 2015;26(Suppl 11):123–138.

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19. Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone stability
around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res
2015;26:123–129.
20. Cairo F, Barbato L, Tonelli P, Batalocco G, Pagavino G, Nieri M. Xenogeneic collagen matrix
versus connective tissue graft for buccal soft tissue augmentation at implant site. A randomized,
controlled clinical trial. J Clin Periodontol 2017;44:769–776.
21. van Nimwegen WG, Raghoebar GM, Zuiderveld EG, Jung RE, Meijer HJA, Mühlemann S.
Immediate placement and provisionalization of implants in the aesthetic zone with or without a
connective tissue graft: A 1-year randomized controlled trial and volumetric study. Clin Oral
Implants Res 2018;29:671–678.
22. Lee CT, Tao CY, Stoupel J. The effect of subepithelial connective tissue graft placement on
esthetic outcomes after immediate implant placement: Systematic review. J Periodontol
2016;87:156–167.
23. De Bruyckere T, Cosyn J, Younes F, et al. A randomized controlled study comparing guided bone
regeneration with connective tissue graft to re-establish buccal convexity: One-year aesthetic and
patient-reported outcomes. Clin Oral Implants Res 2020;31:507–516.
24. D’Elia C, Baldini N, Cagidiaco EF, Nofri G, Goracci C, de Sanctis M. Peri-implant soft tissue
stability after single implant restorations using either guided bone regeneration or a connective
tissue graft: A randomized clinical trial. Int J Periodontics Restorative Dent 2017;37:413–421.
25. Roccuzzo M, Dalmasso P, Pittoni D, Roccuzzo A. Treatment of buccal soft tissue dehiscence
around single implant: 5-year results from a prospective study. Clin Oral Investig 2019;23:1977–
1983.
26. Zucchelli G, Felice P, Mazzotti C, et al. 5-year outcomes after coverage of soft tissue dehiscence
around single implants: A prospective cohort study. Eur J Oral Implantol 2018;11:215–224.
27. Mazzotti C, Stefanini M, Felice P, Bentivogli V, Mounssif I, Zucchelli G. Soft-tissue dehiscence
coverage at peri-implant sites. Periodontol 2000 2018;77:256–272.
28. Chambrone L, Ortega MAS, Sukekava F, et al. Root coverage procedures for treating single and
multiple recession-type defects: An updated Cochrane systematic review. J Periodontol
2019;90:1399–1422.
29. Kaner D, Zhao H, Arnold W, Terheyden H, Friedmann A. Pre-augmentation soft tissue expansion
improves scaffold-based vertical bone regeneration—A randomized study in dogs. Clin Oral
Implants Res 2017;28:640–647.

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 8
Standard Surgical Techniques for
Augmentation

The degree of difficulty of augmentation surgery depends on the defect

shape. The most favorable situation is an inlay graft, followed by an
interpositional graft. More challenging is an appositional graft (horizontal
augmentation), and the most difficult situation is an onlay graft (vertical
augmentation). This ranking relates to the choice of bone graft, the
difficulty of soft tissue coverage, and the professional demands placed on
the team. Nevertheless, the long-term results of all four procedures are very
good, and implants in regenerated bone do not have a worse prognosis than
implants in local bone.1

8.1 Inlay Grafts

External sinus floor augmentation with graft

External sinus floor augmentation is performed via an approach through the

facial sinus wall, which allows an open view of the sinus membrane and is
therefore also called an open sinus elevation (Figs 8-1 and 8-2). This is not
possible with the internal (crestal) approach via the alveolar process, which
is therefore referred to as a closed sinus elevation. Sinus floor augmentation
is, in type, an inlay graft similar to filling a cyst, with all the advantages for
healing of mechanical rest and almost circumferential bony containment.
Sinus floor augmentation is also called sinus elevation, sinus lift, or
subantral augmentation.
In the posterior maxilla, there is often reduced bone height due to
maxillary sinus pneumatization after tooth loss. Bone augmentation of the

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maxillary sinus floor creates the bone conditions to use rotationally
symmetric dental implants of a length analogous to human tooth roots,
which can be positioned exactly according to the prosthetic requirements in
the center of the masticatory functional load (Fig 8-3). Sinus floor
augmentation has an excellent long-term prognosis, with 97.7% implant
survival after 3 years in prospective studies at a high level of evidence2 as
well as 95% after 10 years and 85% after 20 years in a retrospective study.3
Autogenous bone alone or mixed with bone graft substitute showed better
histologic bone densities than bone graft substitute alone according to a
recent meta-analysis.2 The addition of platelet-rich fibrin (PRF)4 or platelet
rich plasma (PRP)5 did not provide any benefit for bone regeneration in
sinus augmentation. Sinus floor augmentation has also been described with
leukocyte- and platelet-rich fibrin (L-PRF) as an augmentation material.6

Fig 8-1 Sinus floor augmentation via external access on the left and via internal crestal
access on the right. Control via a maxillary sinus endoscope is optional.

The healing time of a sinus floor augmentation is usually given in the

literature as 6 months. However, studies with a high proportion (50%) of
autogenous bone scraper chips were able to demonstrate sufficient implant
stability after only 8 weeks.7 Autogenous bone accelerates healing.
According to studies by the author’s group (see chapter 3), an admixture of
25% autogenous bone chips to 75% bone graft substitute is the best
compromise, resulting in a healing time of 4 months.

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 The facial wall of the maxillary sinus is exposed via a lateral approach.
The positions of the roots of any teeth still present are marked, and an oval
window is planned with a base point near the deepest part of the alveolar
recess of the maxillary sinus. The window should not be extended
unnecessarily far cranially because slightly below the infraorbital foramen
in the facial bone wall of the maxillary sinus, the antral alveolar artery8
makes a strong connection to the superior posterior alveolar artery. The
bone is flattened first with the ball bur and then, as it approaches the
mucosa, with a diamond ball bur. Here, bone can be left in the center of the
window so that it can later be swung as a bone lid into the maxillary sinus.
This bone plate then ideally lies above the apices of the implants and
protects the sinus membrane from perforation. With careful handling, the
diamond bur does not injure the mucosa, so that after some time the bone
flap becomes mobile with a pedicle on the sinus membrane (also called the
Schneiderian membrane after Konrad Viktor Schneider, anatomist,
Wittenberg, 1614–1680). Now, using blunt instruments, the mucosa is first
detached internally from the bone margins with pressing rather than
scraping movements. When the mucosa is circularly mobile, the sharp
edges of the bone are deburred all around with the diamond ball bur. The
sinus mucosa is then detached from the alveolar recess internally without
perforation using curved blunt instruments (eg, Joseph elevator) or special
sinus elevation curets. In most cases, due to the additional coronal and
lateral atrophy (Fig 8-4), it is necessary to augment the ridge additionally,
which can be done by guided bone regeneration (GBR), block grafts, and
ridge splitting in the most anterior parts (Figs 8-5 and 8-6).

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Fig 8-2 External access. Here, a bone lid was prepared, still attached to the sinus
membrane, which acts like a hinge.

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Fig 8-3 External sinus floor augmentation. a. Initial situation with unilateral free-end
situation without significant crestal bone atrophy. b. Access is via a midcrestal incision,
gingival margin incision, and distal relief latereral to the tuberosity. The facial maxillary sinus

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wall is first ground thin with a steel ball bur. The sinus membrane preparation is performed
using a diamond ball bur. c. Using special rounded curets with different angular positions,
the sinus membrane is first detached from the bone in a circular fashion and elevated
secondarily. d. A mixture of autologous bone and bone substitute (25%:75%), and venous
blood is filled in. e. The implants can be placed simultaneously as long as they are still
primarily held stable by the residual bone. The limit of minimal residual bone for this
purpose depends on the implant system. f. Implant exposure 4 months later. g. Prosthetic
restoration. h. Postoperative panoramic tomogram.

Fig 8-4 In case of atrophy of the maxillary sinus floor, the line connecting the alveolar ridges
does not change. In the case of atrophy from the crestal side, the altered line connecting
the alveolar ridges must be observed and corrected by lateral augmentation in addition to
the sinus elevation so that no crossbite occurs. In the case of pronounced crestal atrophy,
sinus elevation is contraindicated, and vertical ridge augmentation is preferable instead.

Piezoelectric opening of the facial maxillary sinus wall has the initial
advantage that the ultrasonic vibration avoids the the sinus membrane.
However, prospective comparative studies have not found lower perforation
rates than with the diamond ball method.9
Preparing the sinus membrane opens the subantral space, which is now
filled with, eg, a 75%/25% mixture of bone substitute/autogenous bone (see
chapter 4). The filling height should correspond approximately to the height
of the sinus floor and allow the anchorage of 10- to 12-mm-long implants in
the residual bone. Wall closure is achieved by folding back the uninjured
mucoperiosteal flap. The periosteum of the sinus membrane also exerts an
osteogenic effect.10 Covering of the window with a barrier membrane offers
no advantage according to studies11 and a meta-analysis.12

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External sinus floor augmentation without graft
The subantral space has such a high healing potential that, according to
Stefan Lundgren,13 bony filling of the subantral space can be achieved
entirely without bone graft (graftless) and by spontaneous filling with
autologous blood alone. A meta-analysis showed better implant survival
rates without graft, suggesting that a bone graft material may pose
additional risks such as infections.14 A prerequisite is the stabilization of the
elevated membrane in a cranial position over the implants. This can be
achieved, for example, by simultaneously inserting dental implants to serve
a “tenting” function. However, there are also techniques to achieve this
stabilization using rigid membranes or a metal or plastic mesh. Implant
survival was 95.9% with an average bone height gain of 4 mm.15 An
advantage of the graftless technique is that no foreign material is applied,
which consequently cannot cause infections by forming a bacterial biofilm.
A meta-analysis comparing the graftless technique with the application of a
bone graft showed no difference in implant survival but a significant
difference in mean bone gain of 0.7 mm less without a graft.16

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Fig 8-5 Combination sinus elevation with bone splitting. a. In free-end situations in the
maxilla, there is usually pronounced horizontal atrophy on the premolars (omega shape of
the maxilla). Here, the sinus membrane is already elevated. b. In the ascending part of the
maxillary sinus floor of the premolar region, bone splitting can be performed with a
Lindemann bur. c. This is completed with the blade chisel, which may penetrate into the
maxillary sinus floor. d. This allows an implant with low primary stability to be placed in the
first premolar region. The splitting gap and the maxillary sinus floor are filled with a bone
substitute material mixture. e. Postoperative panoramic image. f. Panoramic image after
prosthetic restoration. The consolidation of the graft with formation of a cranial cortical layer
can be seen.

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Fig 8-6 Internal sinus elevation with hydraulic technique. a. Water pressure is used to
lift the sinus membrane via crestal access, and the subantral space released is filled with
bone substitute mixture. b. Diagram showing the internal sinus elevation technique.

In accordance with the original method described above, the facial

maxillary sinus wall is first exposed (Fig 8-7). Then, using a piezoelectric
device or fine saws or drills, a faceted bone lid is formed using oblique cuts.
The oblique cut surfaces allow this lid to be repositioned later so that it
clamps and does not fall into the maxillary sinus. After the bone lid is lifted
off and placed temporarily in saline solution, the sinus membrane is
elevated. Then the dental implants are inserted. In most cases, the subantral
space fills with wound blood on its own. Now the bone flap is repositioned.
If it does not clamp itself securely, it is secured with histoacryl glue.
Alternatively, holes can be drilled for suturing with an absorbable material.
This is followed by primary wound closure.

Internal sinus floor augmentation (crestal technique) with the

hydraulic technique
Crestal sinus floor augmentation according to Summers,17 also referred to as
the osteotome sinus floor elevation (OSFE), is a minimally invasive
technique because it can be performed through the implant osteotomy,
which is required anyway, and with a minimal mucosal incision (see Fig 8-
6b). A meta-analysis yielded 96.9% implant survival with bone height
greater than 5 mm and 92.6% with bone height less than 5 mm.18 The 10-
year results of a prospective study were 90.7% implant survival with bone
graft substitutes and 95% with the graftless approach. It was reported as
90.7% for 6-mm implants and 95% for 10-mm implants, although the

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differences were not significant.19 The crestal sinus elevation is very well
tolerated by patients. As a minimally invasive method, it did not burden
patients more than implant placement without augmentation in a clinical
study.20
The procedure is somewhat time consuming because each implant site
must be operated on individually, so the external technique is time saving in
the case of multiple implants. Generally, the existing bone is drilled to
about 0.5 mm below the subantral cortex. The experienced surgeon feels the
subantral cortex as drilling resistance. A CBCT is recommended to
accurately plan this distance in advance. Then the sinus floor is infracted by
malleting with an osteotome and deformed cranially, inserting the
instruments through the implant osteotomy. The resulting fragments can
then be pushed a few millimeters into the maxillary sinus. An attempt can
also be made to enlarge the subantral space with blunt elevators by lifting
the sinus membrane and then filling with autologous blood or bone grafts.
Finally, the dental implant is placed, sealing the access cavity to the
maxillary sinus airtight to avoid an oroantral fistula. In most cases, the basic
technique results in membrane perforation, but this remains undetected due
to lack of visibility. However, this can be diagnosed by probing or irrigation
if saline leaks to the nose. Better control of the sinus membrane is allowed
by simultaneous endoscopy of the maxillary sinus via a punctate transoral
perforation of the facial maxillary sinus wall.

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Fig 8-7 Graftless sinus elevation. a. With the aid of a small cutting disc, a faceted bone lid
is cut out of the facial sinus wall, lifted off, and stored temporarily under moist conditions. b.
The sinus membrane is lifted with special angled blunt curets. The dental implant acts like a
tent post and prevents the sinus membrane from falling back into the alveolar recess. The
subantral space spontaneously fills with autologous blood. c. The bone lid is repositioned.
The faceting and the oblique cut surfaces prevent the flap from falling inward. d. Histoacrylic
adhesive is used to secure the lid. e. Postoperative panoramic image following flap
exposure with bilateral sinus elevation without grafting.

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Fig 8-8 Hydraulic sinus elevation using the Jeder System. a. Panoramic tomogram. b.
Jeder technique. The drill tip is under water pressure via a pressure cuff on the contra-angle
handpiece, so that the sinus membrane is pushed away at the moment of cortical
perforation and is protected. Computer control of the water pressure also allows controlled
augmentation volume to be introduced. (Image in b courtesy of Jeder GmbH, Vienna,
Austria.)

The critical phases of an internal sinus floor augmentation are firstly the
entry into the maxillary sinus and secondly the elevation of the sinus
membrane, because membrane rupture can occur during both procedures,
with studies showing its occurrence in 28% of cases.21 The first risk is
increased if the maxillary sinus floor is rippled, oblique, or even septated.
Several techniques have been developed to reduce the risk of membrane
tears. The most obvious are calibrated burs in half-millimeter increments,
which are controlled by CBCT to precisely drill the thin cortical bone of the
maxillary sinus and perforate it without touching the membrane. Another
approach is stop burs, which decouple and stop turning when
counterpressure is lost. Other types of burs transport the bone shavings
apically, where they act like a cushion to displace the sinus membrane at the
moment of entry. Finally, there is the suggestion of screwing in a fine-
threaded implant, which then lifts the maxillary sinus floor very slowly and
in a more controlled manner compared with a plunger. The most advanced
solution to the entry problem is the contra-angle handpiece of the Jeder
System, which holds a small steel drill under constant water pressure
maintained at the edges of the osteotomy by seals.22 At the moment of entry
of the small steel drill, pressurized water is pumped into the subantral
space, pushing the intact membrane in front of it (Fig 8-8).
The second risk is rupture of the membrane during elevation and
creation of the subantral space. To reduce the risk of rupture of the

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membrane during elevation, various techniques have also been developed.
One modification of the osteotome method is balloon-assisted sinus floor
augmentation. A balloon distributes the pressure of a filling liquid over a
large area and can protect the sinus membrane. However, the balloon is a
disposable product and relatively expensive. From Israel came the
suggestion of a dental implant with a pump channel that exits at the apex.
This channel can be filled with bone augmentation material is paste form,
which slowly pushes up the sinus membrane while simultaneously building
up the bone.
As a clinical synthesis of all these approaches, the author uses the
hydraulic method modified from Chen and Cha.23 In the original method, a
diamond ball bur is first used to drill a 3-mm hole at the future implant site
up to 1 mm short of the cortical bone. Then the cortical bone is perforated
punctiform with a 2-mm ball drill, whereby a water/air mixture enters the
drill tunnel with pressure from the handpiece of Chen and Cha,23 which
detaches the sinus membrane. The author of this book proceeds in such a
way that after the punctiform perforation, a blunt irrigation needle is
inserted into the osteotomy and sealed circumferentially with a moistened
swab. A syringe is used to manually inject saline solution, which lifts the
sinus membrane. Relatively strong pressure is required for this.
Approximately 2 mL of saline solution is injected, recognizable by the
graduation of the syringe. A noticeable loss of pressure would indicate a
perforation, and in this case one can switch to the lateral technique.
Augmentation material can be filled into the raised space of a perforation-
free internal membrane elevation through the implant osteotomy. With good
technique, impressive membrane-covered domes of bone substitute material
(Fig 8-8a) can be built up in this way, with the implant in the center.
Patients are usually very satisfied because the approach is minimally
invasive and there is hardly any discomfort. However, the tapping noises
when advancing the osteotome may annoy the patient.
Due to the reduced field of view compared to the lateral method, the
crestal technique is recommended only for experienced surgeons, who can
switch to the lateral approach if necessary.

8.2 Interpositional Grafts

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Interpositional defects can be created by vertical or horizontal (sandwich)
splitting of the alveolar process. In the case of knife edge alveolar ridges,
the split segment can also be swung up like a garage door (so-called swing
osteotomy). A common feature of interpositional grafts is the creation of a
bone bed bordered on two sides by vascularized bone tissue, which doubles
the distance of angiogenesis (Fig 8-9). Because bone segments remain
pedicled by soft tissue over the periosteum, they are also referred to as
osteoperiosteal flaps. Interpositional grafts are also called alveolar ridge
expansion because the existing bone is expanded from within. They also
work beyond the envelope because they relocate it.

Vertical interpositional bone grafts (sandwich technique)

According to a recent study by the author, the implant survival rate after
vertical augmentation by the sandwich method is 96.7% with up to 8.3-mm
height gain and hardly any long-term resorption (0.27 mm after 12 years).
Wound dehiscence occurred in 12%, but without infection of the bone graft
because its depth protects it24 (Fig 8-10). A meta-analysis of 10 studies
reported 94% implant survival at 5 years.25 An advantage of sandwich bone
grafting is that the soft tissue, and in particular the residual attached
gingiva, does not need to be detached from the alveolar ridge (Fig 8-11).
The technique can be combined very well with the physiologic midcrestal
incision. As a result, the specialized tissues of the marginal periodontium
(neuroectodermal cells) are preserved at the subsequent implant emergence
site and can form a new soft tissue attachment apparatus around implants
here. In addition, the periosteum is not detached on the oral side of the
segment. It is assumed that this results in less resorption of the augmented
bone height than with overlay grafts.
In the lateral mandible, the buccal compact bone is osteotomized above
the nerve plane using the Lindemann bur (Fig 8-12). This is followed by
full-depth vertical osteotomies mesially and distally of the segment,
extending through to the lingual aspect. Here, one can carefully insert a
finger to palpate the floor of the mouth so as not to perforate the lingual
mucosa with the drill. Lingually, the horizontal osteotomy is performed
with thin blade chisels, because it is too dangerous to use the Lindemann
bur in the vicinity of the lingual nerve. The segment usually becomes
suddenly mobile after one to two chisel blows, when the lingual compact

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bone fractures. It must be completely mobile but still pedicled on the
lingual soft tissues, which supply it with blood. The lingual periosteum is
usually pliable enough to follow the upward movement of the segment
without resistance and also allows the segment to be navigated into the
desired position to allow dental implants to be placed within the prosthetic
axis. Stable fixation of the segment at the desired height is achieved from
the vestibular aspect with 1.5-mm Micro titanium plates (KLS Martin).
Thereby a box-shaped cavity opens up under the segment, which can be
filled with the drill chips and bone substitute material. Then, after 4 months,
a loadable implant site is present, and the plates can be removed. The
technique can also be used analogously in the anterior maxilla, but there the
palatal mucosa is rigid, so distraction osteogenesis is used for height
deficits of more than 2 to 3 mm.

Fig 8-9 Bone defects according to the quarter classification. The size of the circle shows the
increasing demand on neoangiogenesis; defects larger than 1/4 overtax angiogenesis, so
that they ossify only partially or the bone substitute does not heal (see Fig 2-21). The
sandwich osteotomy doubles the angiogenesis distance, because both of the connecting
bone surfaces are supplied with blood.

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Fig 8-10 a. Average bone height gain by jaw region and partially edentulous and edentulous
cases. About 2 mm of the original height gain is lost due to remodeling prior to implant
placement. b. From the time of implant placement, bone loss after sandwich bone grafting
averages only 0.27 mm. c. Implant survival rate and implant success rate according to
Kaplan Meier.

Swing osteotomy
In the 3/4 stage (according to the quarter rule; see Fig 1-11), a depressed
pointed ridge is still present lingually, which would interfere with pure
upward movement. In this situation, a shell technique with block grafts
could be used (Fig 8-13). However, as an onlay technique, this is at risk of
dehiscence. It is better to use the swing osteotomy. Here, the transport
segment is mobilized as described above. However, it is not shifted
vertically upwards, but swung up like a garage door. The inclined surface of
the atrophied jaw positions itself horizontally and becomes a plateau for the
subsequent implant placement. Therefore, the segment must also be of
sufficient width, eg, 8 mm wide: 4 mm for the implant and 2 mm each to
form the lingual and buccal implant sockets (Fig 8-14).

Fig 8-11 The position of the residual attached gingiva is shown in the center of the alveolar
ridge by a short red line. During simultaneous GBR as well as during block placement, this
zone moves lingually (shifted mucogingival border). Only in distraction osteogenesis and
the sandwich procedure derived from it does the attached gingiva remain in the center of
the alveolar ridge, where it stays in the emergence profile of the future implants.

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Fig 8-12 Sandwich interposition. a. Initial position with vertical atrophy in bilateral free-
end situation in the mandible. Minimal bone height above the nerve (about 4 mm). b. The
soft tissue-supported bone segment is stabilized in the cranial position with microplates
(KLS Martin). A box-shaped bone cavity opens up. c. Mixture of venous blood, 75% bone
substitute (Bio-Oss, Geistlich), and 25% autologous bone chips (from the filter). d. Filled
interpositional defect. e. Postoperative panoramic tomography. f. After 4 months, the plates
are removed, and the new bone height is used for dental implants. g. Fixed prosthetic
restoration. h. Left mandible 10 years later. i. Right mandible 10 years later. j. Panoramic
image 10 years later, with no sign of vertical bone resorption in the area of the previous
augmentations.

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Fig 8-13 The 3/4 atrophy can be treated with a shell or interposition technique (top and
middle). In contrast to the sandwich osteotomy (bottom), the segment is swung up like a
garage door, which is why the method is called a swing osteotomy.

Horizontal interpositional bone grafts (ridge splitting)

Ridge splitting can be performed simultaneously with implant placement. In
a comparative study, splitting had better implant survival (100%) than block
placement (92.9%).26 In another study using the split-crest technique
implant survival was 97% after 10 years.27
The prerequisite for ridge splitting is two splittable compact lamellae in
the CBCT cross-section separated by a layer of cancellous bone. Normally,
an excessively narrow stage 2/4 ridge no longer has enough bone to
primarily stabilize the implant. With ridge splitting, however, the bone is
widened so that it is possible to place the implants in a reasonably stable
manner. This makes the overall treatment cheaper and faster than a two-
stage procedure. But there is also a price to pay. The disadvantage of ridge
splitting is that the splitting direction determines the implant axis, and in the
anterior maxilla, with its inclination of about 20 degrees, it does not
correspond to the ideal prosthetic axis (Fig 8-15). Therefore, angulated
implants must be accepted, and, if necessary, screw-retained prosthetics
must be dispensed with, because the screw axes protrude labially in the
anterior maxilla after ridge splitting.

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Fig 8-14 Interpositional bone graft with swing osteotomy. a. Initial situation with the
mandibular right posterior prosthesis out of occlusion due to atrophy and clasp trauma at
the canine. b. Panoramic radiograph showing initial situation. Bone height above the nerve

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is approximately 8 mm. c. Segment osteotomy and swinging up of the segment, pedicled at
the lingual soft tissues. d. Interpositional gap filled with bone mixture. e. Incision in the
center of the alveolar ridge (with residual attached gingiva) allows for excellent suturing. f.
The left side following augmentation. g. Postoperative panoramic image. h. Implant
placement on the left side.

Fig 8-14 Interpositional bone graft with swing osteotomy. i. Panoramic image after
insertion of normal-length implants (11 mm). j. The midcrestal incision is used as access for
all surgical steps. k. The residual trace of the attached gingiva is automatically distributed
around the implant like a cuff through the midcrestal incision. The implant emerges at the
point where the tooth had already erupted. l. Perfect cuff of attached gingiva, created
spontaneously without any soft tissue augmentation. Proper incision guidance saves
patients the effort and expense of soft tissue grafting surgery. m. Anterior maxillary
prosthesis. n. Mandibular left (left) and right (right) prostheses.

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Fig 8-14 Interpositional bone graft with swing osteotomy. o. Prosthetic restoration in the
left mandible. p. Prosthetic restoration in the right mandible. q. Occlusal view of the restored
mandible. r and s. Panoramic and periapical radiographs 11 years after prosthetic
restoration without signs of bone resorption in the augmented areas (PD Dr Mehl, Kiel
University.).

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Fig 8-15 Ridge splitting. a. A palatal screw access hole does not correspond to the tooth
axis. b. Bone augmentation is required for a palatal screw access hole. c. Ridge splitting
follows the bone direction. d. A palatal screw access hole cannot be achieved with ridge
splitting.

Closed versus open ridge splitting

Particularly when raising a vestibular periosteal flap, the buccal bone
lamella is no longer well nourished after ridge splitting, because the
splitting gap severs the vascular supply to the buccal bone. Splitting tends
to cause height resorption of the vestibular lamella with the implant
shoulder exposed because the vestibular lamella is no longer nourished
during open ridge splitting (Fig 8-16). This is a disadvantage especially for
single-stage implant placement. Studies suggest that resorption is lower
when bone graft substitute is placed in the gap created by maxillary ridge
splitting.
If the soft tissue flap is left attached intact vestibularly, it cannot be
mobilized, and therefore the gap cannot be sutured closed (Fig 8-17). The
implants and any bone augmentation material therefore heal open to the oral
cavity during splitting. Although this seems unusual at first, it does not
make much difference in practice. Raising a periosteal flap at the buccal
lamella would allow ridge splitting under visualization. However, this loss
of soft tissue support quickly leads to the loss of small fragments if
fracturing of the buccal lamella occurs. It is better to leave the soft tissue on
the vestibular bone, for example, with a split-thickness flap. Technically
somewhat more difficult, but most biologically sound, is to leave the
complete soft tissue flap intact on the lamella. In this case, the soft tissue is

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only detached via a midcrestal incision just sufficient to allow the full width
of the most coronal aspect of the ridge to be assessed. Due to the preserved
periosteal nutrition, the resorption tendency is lower, and the blood
circulation in the bones is better preserved.28 However, implant drilling is
then performed in the apical region without a view of the bone, which
explains why splitting requires surgical experience and technical safety.
A complication of ridge splitting is fracture of the buccal lamella due to
splintering, particularly due to the brittle bone in the mandibular posterior
region. Here, despite soft tissue coverage, sometimes only reattachment of
the fractured lamella and two-stage implant placement after healing are
effective. This method was also indicated as three-stage mandibular ridge
splitting: first, controlled osteotomy with bone mobilization under
visualization, then expansion and filling of the gap after healing of the
periosteal attachment, and finally implant placement.

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Fig 8-16 Open ridge split. a. Initial situation with horizontal atrophy. b. Midcrestal incision
and vestibular periosteal flap raised. c. In the midline of the ridge, the osteotomy is marked
by points with the Lindemann bur. d. The points are connected to form a line. Vertical
corticotomies (relief osteotomies) are performed in front of and behind the split lamella. e.
The cancellous bone layer is broken up with the blade chisel. f. The osteotomy is performed
in the middle of the ridge. After stretching within the elastic limits of the buccal compact
bone, the implants are placed in the cancellous bone layer. They do not have true primary
stability because the buccal lamella would spring away under load.

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Fig 8-16 Open ridge split. g. Collagen membrane under the palatal flap. h. The mixture of
bone substitute material (75%), autologous bone chips (25%), and venous blood is
coagulated. i. The graft material is pressed into the gap and in this case is also applied
vestibularly over a wide area on the lamella (resorption protection). j. The vestibular
periosteal detachment and flap mobilization is performed with a single hook and scalpel. k.
The collagen membrane is applied in a double layer. l. Wound closure is simplified by
cutting into the hard attached gingiva in the center of the alveolar ridge. Interrupted sutures
achieve tight wound closure.

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Fig 8-17 Closed ridge split. a. Panoramic tomogram showing the initial situation with
anterior residual dentition in the mandible. b. The CBCT shows sufficient bone height but, at
5 mm, an insufficient width of the implant site. Lingual and buccal compact bone and a

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cancellous bone layer in between are the anatomical prerequisites for bone splitting. c. The
crest of the excessively narrow alveolar ridge is visualized via a midline incision of the
alveolar ridge. Here, the osteotomy has already been performed with the Lindemann bur. d.
After expansion of the compact lamellae, the implants are more or less clamped in the gap.
They have no real primary stability due to the mobility of the split lamellae. The suture is
only adaptive. The center of the alveolar ridge remains uncovered because the flap has not
been mobilized.

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Fig 8-17 Closed ridge split. e. Osteotomy in the contralateral side. f. Implant insertion in
the contralateral side. g. Postoperative panoramic image. h. Implant exposure is again
performed via the midcrestal incision. The gingiva automatically wraps around the gingiva
former like a cuff without the need for soft tissue management. i. Panoramic tomograph

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after exposure of the implants. j. Prosthetic restoration on the right. k. Prosthetic restoration
on the left. l. Panoramic tomogram after prosthetic restoration.

Vertical splitting of the alveolar process is usually easier in the maxilla

than in the mandible due to the more cancellous bone structure. Splitting
begins with a longitudinal osteotomy of the alveolar process using a narrow
Lindemann bur. Here, the piezoelectric device or the soft tissue diamond
circular saw according to Khoury can also provide good service. Vertical
relief cuts are usually required, which are made from the interior of the
longitudinal cut to beneath the soft tissue covering without perforating it.
Further splitting of the ridge is done by blade chisels. Bone or bone
substitute material can be placed in the resulting gap, which, according to a
randomized study, reduces bone height resorption by about 0.5 mm.29 In the
mandible, this surgical technique is more difficult due to the brittle bone
structure. Prior visualization by 3D diagnostics is useful, because some
mandibular alveolar processes become very narrow at the base despite good
crestal width. This occurs in conjunction with very brittle bone with a
tendency to splinter, especially in the case of edentulous gaps after tooth
aplasia. Ridge splitting is not recommended in these situations.

Interpositional bone grafts in the edentulous maxilla (Le Fort

osteotomy)
Interpositional bone grafting of the edentulous maxilla is a long-standing
method used in preprosthetic surgery. The 10-year implant survival rate was
recently calculated to be 90.2% in a meta-analysis of 26 studies in 483
patients.30 In the author’s own patient population, the 10-year survival rate
of 579 implants in 106 patients was 95.9%. The mean bone height gain was
8.7 mm, of which 1.8 mm resorbed prior to implant placement. After
prosthetic loading of the implants, long-term resorption was only 0.13 mm.
The method was originally developed for orthognathic surgeryof
dysgnathia and therefore has the advantage of compensating for the often
atrophyrelated retrognathia of the maxilla (pseudoprognathism of
edentulous patients). Due to the inclination of the superior alveolar process,
the atrophy creates a posterior-superior movement of the alveolar ridge,
which can be revised back to its initial anteriorinferior position by the Le
Fort osteotomy (Fig 8-18). Via a ridge incision, a full thickness flap is
dissected down to the infraorbital foramen on both sides to spare these

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nerves under visualization. It makes sense to perform the Le Fort I
osteotomy with prior preparation of the basal sinus mucosa by sinus
elevation as well as the basal nasal mucosa by nasal lift, because this keeps
the beds for the bone grafts closed cranially (Fig 8-19). The exposed canine
abutments on both sides are then separated with the Lindemann bur. From
the prepared bony nasal floor, the lateral nasal wall and the palatine bone
are fractured with chisels. Using a curved chisel, the maxilla is detached
from the pterygoid process in the pterygomaxillary fissure and mobilized
after down-fracture. It remains pedicled at the palatal vessels and at the
pharyngeal mucosa. Now the maxilla can be moved inferiorly and
anteriorly and stably secured in this position by mini osteosynthesis plates
(2.0 mm, Mini System, KLS Martin). Care must be taken in this phase so
that the atrophied jaw does not break into individual pieces, especially in
osteoporosis patients. A mixed bone graft (25%/75%) is now inserted into
the Le Fort I plane, and the maxilla is then reduced. In the new position,
between 5 and 15 mm deeper depending on the augmentation requirement
and slightly further anterior according to the opposing ridge, the maxilla is
now repositioned with four osteosynthesis plates (2.0 mm, Mini System).
The interposition is usually combined with an anterior and lateral
apposition of iliac bone blocks, which are fixed circularly with small micro
lag screws (1.5 mm, Micro System).

Interpositional bone grafts in the edentulous mandible (sandwich

technique)
Sandwich osteotomy of the edentulous mandible was also developed in the
era of preprosthetic surgery, long before the introduction of dental implants.
The disadvantage of that time was that physiologic jaw atrophy continued
to progress even after augmentation, and after some time the initial level
was reached again. This changed only in more recent times, when it was
learned to combine the known osteotomy techniques with dental implants,
which stimulate and maintain the bone through the masticatory forces
introduced. This is called the osteoprotective effect of dental implants. In a
10-year study in the edentulous jaw, resorption after sandwich interposition
and dental implants was only 0.2 mm.32

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Fig 8-18 Le Fort I osteotomy (partially edentulous case). a. Initial situation with atrophy,
especially anteriorly, and salvageable maxillary molars. b. Initial clinical situation after
extraction of the maxillary left first premolar. c. Le Fort I osteotomy created a closed
recipient site for particulate bone grafts (75%/25% substitute/autogenous mixture) at the
sinus and nasal floor. In addition, the maxilla was extended anteriorly and inferiorly to avoid
long protruding dental crowns. d. To widen the narrow anterior maxilla, a frame is created
from a few thin strips of pelvic bone. e. The interstices of the frame are filled with the
particulate bone graft (75%/25%) and covered with a collagen membrane (Bio-Gide,
Geistlich). f. The primary wound closure does not require as extensive soft tissue
mobilization as vertical onlays and therefore produces less swelling, and the attached
gingiva remains exactly in the center of the ridge in the subsequent implant emergence
profile. g. Existing denture remodeled as a provisional prosthesis. h. Two temporary dental
implants (IPI, Nobel Biocare) support the denture so that no pressure is exerted on the bone
graft. i. Postoperative panoramic radiograph. j. Preoperative lateral cephalometric
radiograph with anterior narrow ridge that is too high in relation to the lip. k. Postoperative

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lateral cephalometric radiograph with widened and elongated (by approximately 8 mm)
anterior maxilla. l. Osteosynthesis material removal after 4 months shows little resorption of
the bone grafts except for rounding of the bone edges.

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Fig 8-18 Le Fort I osteotomy (partially edentulous case). m. Panoramic tomographic
image after implant placement. n. During implant exposure, the gingiva spontaneously
wraps around the dental implants like a cuff without vestibuloplasty or soft tissue grafts. o.
Panoramic radiograph after implant exposure. p. Lateral cephalometric radiograph after
exposure shows the implants in the optimal prosthetic position in contrast to the provisional
implants, which had to be placed with oblique angulation in the ridge prior to augmentation.
q. Prosthetic restoration with normally configured dental crowns protruding from natural
gingiva.

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Fig 8-18 Le Fort I osteotomy (partially edentulous case). r. Comparison of the
preoperative situation, in which the transverse and vertical deficit had to be compensated by
denture acrylic. The implant restoration with augmentation thus enabled the patient to return
to a tooth restoration similar to that of his youth; in a sense, the clock was set back. s.
Panoramic tomographic image after prosthetic restoration.

Fig 8-19 Comparison of the old and new Le Fort I interpositional bone graft techniques. In
the old technique, no sinus and nasal floor elevations were performed. As a result, the bone
grafts were exposed to the maxillary and nasal cavities, which only worked with high-quality
iliac crest blocks with associated harvesting morbidity. With the new technique, these blocks
can be replaced by bone substitute material, because the recipient site is closed to the
maxillary and nasal cavities. (Modified from Härle.31)

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 The sandwich osteotomy can be performed in the interforaminal region
or above the inferior alveolar nerve in the molar region in Cawood class IV
cases (Fig 8-20). Extension into the molar region is not possible in Cawood
class V without dissecting and lateralizing the nerve, which is not
recommended due to sensory disturbances. Therefore, in Cawood class V,
the interpositional grafts in the interforaminal region can be combined with
bilateral onlay iliac bone blocks in the posterior region. The sandwich
osteotomy is particularly safe from a surgical point of view in the
mandibular midline because the interforaminal bone segment is adequately
supplied with blood via lingually entering vessels independent of the
inferior alveolar artery.

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Fig 8-20 Sandwich interpositional bone graft in the edentulous mandible. a. Baseline:
panoramic radiograph with Cawood class V atrophy. b. Lateral cephalometric radiograph
with symphyseal height of 13 mm. c. Intraoperative image after sandwich osteotomy. The
lingual soft tissues and the attached gingiva of the alveolar ridge remain on the transport
segment and ensure its blood supply. d. The sandwich interpositional defect is filled with a
mixed particulate bone graft (75%/25%). e. Clinical view after healing. As a minimum, two
dental implants should be placed to provide masticatory function for the augmentation and
thus prevent resorption and renewed jaw atrophy.

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Fig 8-20 Sandwich interpositional bone graft in the edentulous mandible. f. The lateral
cephalometric image shows the bone height gain of about 8 mm. g. Postoperative
panoramic image. Iliac crest blocks were placed laterally posterior to the interforaminal
sandwich segment.

The method is technically demanding and the more advanced the

atrophy, the more indicated it is. For symphyseal height, 8 mm is the limit,
because the risk of fracture of the jaw increases with heights below this
threshold. Fracture in the severely atrophied anterior mandible can be
prevented by positioning the osteotomy somewhat obliquely. This leaves a
little more of the anterior cortical arch vestibularly for stability, while the
osteotomy is slightly more inferior on the lingual aspect so that the lingual
vessels are securely contained within the segment. In osteoporosis, the risk
of fracture is increased, so this technique should be used more cautiously.

8.3 Appositional Bone Grafts (Horizontal Augmentation)

GBR (membrane technique)
GBR uses a resorbable or nonresorbable barrier membrane as a core
element. This shields the bone regeneration volume from the surrounding

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soft tissue to prevent the ingrowth of scar-forming fibroblasts and to ensure
as much true new bone formation as possible. The fact that real bone is
formed during GBR has been demonstrated, for example, in a
histomorphometric study of lateral augmentation in humans, where
xenogeneic bone substitute material under a collagen membrane served as a
control group to a bone morphogenetic protein (BMP)-2 group. Here, a
bone density of 30% was observed in the control group, with an average of
50% surface coverage of the bone graft substitute particles with new bone.33

Fig 8-21 Single-stage GBR works best in contained defects within the envelope and when a
regenerative space remains between the implant surface and the envelope (top). Lack of
bone at the adjacent roots, eg, due to marginal periodontitis, leads to loss of these defect
walls (middle). The implant should have 2 mm of space on all sides; however, it can usually
be placed directly against the palatal wall (bottom).

A second element of GBR is the support structure against collapse of

the membrane protected volume.Stable particulate bone substitutes,
titanium reinforcements in the membrane, meshes, or tenting umbrella
screws can serve as support.

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 A third element of GBR is overcorrection. Especially when implants are
placed simultaneously, it is found that GBR regenerates only about 80% of
the defect length on the implant.34 This is due to the sintering together of the
bone augmentation materials, resorption of the bone, and other factors. As a
result, the most sensitive coronal portion of the implant is exposed before
prosthetics are placed, with all the consequences such as the risk of peri-
implantitis and gingival recession. The antidote is overcorrection by about 2
mm in all directions. Vertical overcorrection is achieved by screwing in a 2-
mm gingiva former instead of the cover screw in bone-level implants.
Horizontal overcorrection is achieved by layering with bone substitute
material. In the long term, 2 mm of buccal bone thickness at the implant is
desirable to avoid gray discoloration of the gingiva, so about 4 mm of
material thickness should be built up during augmentation. More than 3.7
mm of bone accretion cannot be expected in any spatial direction with
particulate materials for reasons of angiogenesis (see chapter 2).35
A fourth element of the GBR is the so-called envelope. The term
alveolar bone envelope is an established linguistic usage originally from the
orthodontic and periodontal literature36 and describes the buccal contour
line of the alveolar bone in the dental arch. One-stage GBR works reliably
only within the envelope.37 Particularly good results are achieved with GBR
in short defects (eg, single-tooth gaps) with preserved bony walls that are
within the envelope. The walls are formed by teeth with healthy adjacent
periodontium. Such defects are called enclosed defects or contained defects
(Fig 8-21). GBR then allows the buccal bone contour of the adjacent teeth
to be continued over the edentulous defect area, thus achieving a good
contour of the soft tissue. The so-called contour augmentation compensates
for the buccal resorption of the bone lamella and is best performed with
early implant placement, 8 to 12 weeks after tooth extraction of an anterior
tooth.
The augmentation volume has a good chance of ossification and long-
term stability if it lies within the envelope. Therefore, in case of doubt, a
narrower implant is preferable if it allows thicker augmentation. For this
reason, the implant should also be located on the palatal wall of the alveolar
process.
Healing prior to implant exposure takes approximately 4 months in this
configuration. It has been shown in meta-analyses38 and direct randomized

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comparative studies39 that a barrier membrane is better than periosteum
alone and results in a thicker bone regenerate.
In prospective long-term data over 10 years, contour stability with only
0.17-mm soft tissue recession on the buccal side and 1-mm bone thickness
on the buccal implant shoulder was demonstrated for GBR,33 although these
data were obtained under optimal study conditions. Because of the
improved healing tendency and the reduced tendency to infection,
interpositional bone grafts (horizontal ridge splitting and swing osteotomy
and vertical sandwich techniques) should generally be considered as
alternative approaches.

GBR with collagen membrane and simultaneous implant placement

For GBR, a midcrestal incision without vertical relief incisions is
recommended, which is continued to the neighboring teeth with a sulcus
incision (Fig 8-22). For laterally located defects, eg, in the canine region,
flap relief can also be made centrally in the labial frenum. A precise
subperiosteally prepared flap spares the periosteum and makes the bone
broadly visible. The bony base is then conditioned. This is well
accomplished by gentle grinding with a ball bur, catching the bone chips in
the bone trap. Care should be taken on the adjacent teeth so as not to expose
or injure their roots. Milling the bone is intended to remove the cambium
layer, which is in any case nourished only from the periosteum. In addition,
the last soft tissue remnants originating from the insertion sites of the
buccinator muscle and the minimal musculature should be removed. These
would otherwise hinder bone formation due to their different cell
differentiation. The scraper can also be used to prepare the bone, but its
strong abrasion tends to expose the neighboring roots and must be used
with practice and caution. If the bone in the defect is not yet bleeding
vigorously from the medullary cavity, it should be opened up by drilling
small perforations. All chips are collected in the bone trap. The implant is
then placed according to the drilling template, initially only marking the
entry point, which in the case of the 1/4 defect is usually on an incline. If
one were to continue drilling unsuspectingly, the drill would be deflected by
the slope to the buccal side and migrate. This leads to the dreaded buccal
misplacement of the implant. Instead, after marking the entry point, the first
step is to create a plateau the width of the future implant with the ball bur.

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When the surgical guide is reinserted, the drill can drill straight on the
plateau without being diverted. All bone chips are collected. The implant
now shows a buccal dehiscence defect. Because the maxillary alveolar
process in humans is inclined anteriorly by about 20 degrees, an implant
placed in the prosthetic axis inevitably also shows an apical fenestration
defect. This must be the case if the implant is to emerge palatally with the
screw channel. However, the oblique position of the human anterior
superior alveolar process can also be compensated prosthetically with
angled abutments or cemented crowns without a screw channel.

Fig 8-22 The free space within the envelope can be favored by a more palatal positioning of
the implant and by a smaller implant diameter.

A square collagen membrane is trimmed to size, preferably by first

removing a strip for the doublelayer technique to be used later, giving the
membrane a rectangular shape. The width is reduced by a quarter of a circle
at the points of the neighboring teeth, creating a tongue. This is clamped
under the palatal flap, preferably while the membrane is still dry. The
collagen membrane should be adjacent to the neighboring teeth, but not

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protrude from their sulcus. The membrane is folded up at the hinge of the
tongue. Three layers (autogenous bone chips on the implant, mixture of
chips and bone substitute material, and pure bone substitute material for
contour filling) are applied. Depending on the situation, it is not always
necessary to apply all three layers. However, it is important to understand
the functions of the three layers (Fig 8-23):

Fig 8-23 GBR with layering technique and over correction.

Autogenous chips: osseointegration

Mixture: regeneration layer, minimum 2 mm
Pure bone substitute: contour filling, overcorrection

The goal is to build up a thickness of about 4 mm on the implant, of which

about 2 mm will remain permanently after sintering. By working against a
2-mm healing abutment, vertical overcorrection is also achieved. The
membrane is then folded over the augmentation. Collagen membranes do
not usually need to be tacked; they hold by adhesion like blotting paper
when wet. For this purpose, a few drops of saline solution are dribbled on
the membrane after folding it down. To cushion the flap even more against
the sharp edges of the buildup material and to increase the service life of the
barrier, the previously obtained strip is now placed vestibularly at the point
of greatest flap tension (at the upper bend of the flap) in double or triple

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layer. This strip can also be used to cover the neighboring tooth roots and
will help to compensate for any gingival recession.
Soft tissue coverage is achieved without tension by careful periosteal
incisions and additional flap mobilization. A stronger interrupted suture (4-0
Supramid, Resorba) in the papillae is useful, followed by finer single
stitches (Fig 8-24).

GBR with open membrane or PRF membrane

Analogous to ridge preservation, in which the membrane is usually exposed
to the oral cavity, there is also the approach of leaving a GBR site open (Fig
8-25) or covering it only with PRF. This prevents the need for soft tissue
mobilization, which is responsible for most of the postoperative discomfort.
The risk of partial rejection of the graft can be compensated by
overcorrection. This technique is still under development; it will take
several years to evaluate the data on this procedure.

GBR with titanium-reinforced non-resorbable ePTFE membranes

Non-resorbable expanded polytetrafluoroethylene (ePTFE; ie, Teflon) can
be used with comparable results to resorbable membranes, according to a
randomized controlled clinical study that compared them with collagen
membranes.40 However, ePTFE membranes must be surgically removed.
The tacks should also be taken out, which is sometimes difficult and
requires wide open flap procedures. This traumatic step is omitted with
collagen membranes. The results may even be better than with collagen
membranes because of the longer barrier function, as long as the whole
structure does not become dehiscent prematurely. They are traditionally
considered more technique-sensitive than collagen membranes because,
unlike collagen, the ePTFE, as a foreign body, does not bond to the body
tissue without gaps and can build up a solid-liquid interface with the body.
Interfaces are always susceptible to biofilm formation. A recent meta-
analysis found no difference between collagen and ePTFE membranes, with
approximately 18% exposure rate.41 However, in such studies incision rules
are disregarded, and a vestibular incision produces many disadvantages in
terms of scarring, esthetics, and blood flow. Umbrella screws and implants
placed at the same time can also be used as spacers for underneath a

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membrane. In these cases of membrane stabilization, successful healing is
described with autologous blood filling even without other filling materials.

Bone block grafting

Bone block veneering grafts showed excellent long-term results in a
prospective study, with 98.1% implant success after 10 years and 0.38-mm
surface resorption.42 They achieved better bone volumes than particulate
materials.43 The initial remodeling phase takes about 3 years.44 With the
block technique, only 0.46 mm of vertical bone loss can be expected at the
buccal bone shoulder within 5 years if used correctly, according to a
prospective study. The bone block is a very precise form of augmentation,
especially in the esthetic field.45 Among all ridge augmentation forms, the
autogenous bone block is the best-documented procedure, and implant
survival is no different than in native bone, exceeding 95% at 5 years
according to a literature review.1 Small jaw sections can be built up
threedimensionally using the shell technique with thin autogenous cortical
shells if they are backfilled with autogenous cancellous bone or chips46 to
allow access to the bone cutting cones (see chapter 2).
For standard alveolar ridge widening with autogenous bone blocks, a
block-shaped bone graft is attached without gaps with lag screws or
screwed at a distance with positioning screws (shell technique). The latter
shells should be relined with autogenous chips, preferably bone scraper
chips. They should not lie hollow or be relined with bone substitute
material.
Because this block consists of slowly resorbing compact bone, ideally
from the external oblique ridge, the method is more precise and stable than
GBR, which is susceptible to resorption and achieves only about 80%
defect fill. With block grafting, no overcontouring is required as with GBR,
but the augmentation is performed precisely. The required vestibular bone
height is derived from the prospective soft tissue height visible from the
implant guide. The block is placed as a new buccal bone shoulder 3 mm
below the planned gingival margin. From the height of the block, 5 to 6 mm
of interdental soft tissue height to the contact point can be expected
according to the Tarnow rule. Block grafting has a greater regenerative
potential than GBR, so that filling of larger defects and augmentations
outside the envelope are also possible (Fig 8-26).

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 It is always important to prepare the recipient site well by grinding off
the cambium layer of the cortical bone and creating perforation holes
(collecting bone chips in the process). A groove is then ground into the
base, into which the block is fitted like an inlay. Secondarily, the block is
also ground to shape so that the block is as flush as possible with the
vestibular bone surface. The positive fit allows the cutting cones from the
base to enter the block and rapidly remodel it. If there is a widening of more
than 3 mm or a greater vertical defect component, the block is applied as
the thinnest possible shell with positioning screws and backfilled with
autologous chips. The thinner the shell, the less work the cutting cones have
to do. Autogenous chips also lead to rapid woven bone formation, which
does not hinder the cutting cones, unlike bone substitute material.
A block graft is usually stabilized with two lag or positioning screws. A
single screw still leaves a degree of freedom of rotation. When the block is
securely fixed, it already determines the height and position of the
vestibular bone shoulder laterally to the subsequent implants. An implant
drilling template already helps at this stage. In cases, if the patient is
reliable and does not have any major risk factors, it is also possible to place
an implant with the block graft in one stage. Then the alveolar ridge contour
oral and vestibular to the block is filled with bone particles and scraper
chips and adapted to the desired shape.
It is important to smooth sharp edges on the outer surface of the graft
with the diamond ball bur. There must be no pressure points on the
underside of the flap. Good cushioning of the underside of the flap is
achieved by ballasting the block with bone substitute material. This material
can be used to fill the remaining contour gaps in the mesiodistal direction so
that no protrusions are created on the alveolar process, which would cause
significant chafing during horizontal tooth brushing movements. Instead,
the augmentation should align well with the contour the alveolar process.

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Fig 8-24 One-stage GBR. a. The initial clinical situation shows a single-tooth gap in the
maxillary right first premolar site with horizontal atrophy (1/4 defect). The ligament into the
vestibule is conspicuous due to creeping of the fibers of the buccinator muscle into the
atrophic region. b. Exposure via gingival margin incision. c. Perforation of the cortical bone
and removal of the cambium layer. d. Single-stage implant placement with buccal
dehiscence defect (1/4). The implant was restored with a short gingiva former to allow the
graft to be pulled up further later for overcorrection. e. The filter was used in all osteotomies.
f. Bone substitute material (BoneCeramic, Straumann) was added with aspirated wound
blood and the bone chips from the filter.

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Fig 8-24 One-stage GBR. g. The Bio-Gide collagen membrane is placed with the
embossing “up” toward the soft tissue. h. Quarter-circle segments are cut out on both sides
to form a tongue. i. The tongue is placed under the palatal flap with the Luniatschek gauze
packer, where it clamps without additional membrane tacking. j. Pure filter bone with vital
cells and BMPs is placed on the implant surface; bone substitute material should not be
placed directly on the inanimate implant surface (“No dead on dead!”). k. The actual defect
is filled with vital autologous material. l. The bone substitute material mixture in the matrix of
coagulated blood is placed buccally as contour filling, overcompensation, and resorption
protection.

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Fig 8-24 One-stage GBR. m. An overcorrection of at least 2 mm in the vertical and
horizontal directions should be aimed for. n. The palatal membrane is folded buccally. o.
The membrane is made pliable by adding a few drops of saline solution. p. The membrane
now adheres to the augmentation material by adhesion due to the surface tension of the
water. Additional fixation via tacks is not necessary. q. Soft tissue mobilization is necessary
to cover the increased ridge volume. Periosteal incisions with the scalpel have already been
performed here. The Metzenbaum dissecting scissors further release the periosteal flap. r.
The flap length obtained is checked by traction with the single Gillies hook.

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Fig 8-24 One-stage GBR. s. Wound closure is safely achieved with a few interrupted
sutures (Supramid 5-0), because the attached gingiva can be sutured very well due to the
midcrestal incision on the alveolar ridge. t. Postoperative radiograph with spacing rules
observed (see Fig 8-21). u. Postoperative panoramic image with stable long-term result. v.
The clinical image after prosthetic restoration shows that the ligament (see Fig 8-24a)
disappeared on its own, without soft tissue correction, due to the bony augmentation

As a rule, the augmentation is covered by a collagen membrane and, if

necessary, also by fine bone substitute material as resorption protection to
increase precision at the esthetically important buccal bone shoulder.
The waiting time after insertion of a cortical block graft until reopening
for removal of osteosynthesis material is approximately 4 months in the
maxilla and mandible. If the implant can be placed with primary stability in
the residual alveolar bone, a one-stage augmentation with simultaneous
bone block and implant placement can be performed.
In contrast to the removal of an ePTFE membrane and its tacks, which
requires wide exposure for removal, the screws of a block graft can often be
removed minimally invasively. This can prevent the need to raise a
periosteal flap and the associated surface resorption and nutritional
disturbance of the graft. For minimally invasive osteosynthesis material
removal, the screw heads are palpated and located with a stab incision.

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Using a small excavator as a mini-raspatory, the soft tissue is detached from
the screw head. Even without visualization, the center-drive attachment of
the screwdriver finds the head of the screw by palpable engagement. The
screw can then be turned back and appears at the surface after a short time.

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Fig 8-25 GBR with open healing. a. Baseline clinical situation 6 weeks after tooth
extraction. b. Panoramic radiograph of the initial situation. c. Minimally invasive opening via
a midcrestal incision without major flap mobilization to avoid postoperative discomfort and
swelling. Pilot drilling according to the drill template on the palatal side of the partially
healed extraction sockets. d. Bone filter to collect drill chips. e. Bone-level implants are
placed slightly below the level of the palatal bone, resulting in buccal dehiscence defects. f.
A mixed particulate bone graft (75%/25%) is placed in excess. g. The collagen membrane is
custom shaped. h. The membrane is tucked under the flap margins without mobilizing them.
i. The suture is adaptive without aiming for primary wound closure (without flap traction). j.
Postoperative panoramic view. k. Healed sites 4 months later. l. Implant exposure through
midcrestal incision and apical displacement flap. There is adequate attached gingiva without
the need for soft tissue grafts. m. Panoramic radiograph after implant exposure. The bone
level is above the implant shoulders of the bone-level implants. n. Intraoral view
immediately after prosthetic restoration; the gingival level is more coronal than on the
neighboring teeth and thus has a reserve for the expected remodeling. An interdental

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growth of the gingiva to close the black triangles is to be expected (according to the Tarnow
rule; see chapter 7).

8.4 Onlay Bone Grafts (Vertical Augmentation)

Vertical augmentation by block placement requires better bone material
than horizontal augmentation. Monocortical cancellous bone blocks from
the iliac crest or blocks from the cranium are best documented (Fig 8-27).
Block augmentation should always be carried out in two stages. Because
these grafts heal through cutting cones, there is not the height limitation of
3.7 mm for blocks due to angiogenesis. Implant survival after placement in
a iliac bone graft in the mandibular anterior region was 97.5% in a 5-year
study from the Netherlands, with an average of only 1-mm bone height loss
and 0.6-mm bone resorption at the implants.47 This study also proves the
boneprotective effect of implants, because without implants, onlay bone
resorption is almost 100%.
Larger defects in edentulous jaws are the domain of monocortical iliac
grafts due to the amount of graft material required. For shape matching, the
upper inner curve of the iliac crest, for example, can be used as a substitute
for the esthetically demanding anterior maxilla (Fig 8-28). Fixation of the
bone graft on the alveolar ridge is performed after adaptation and
perforation of the recipient surface using positioning screws and lag screws
and, if necessary, plates. Finally, the crestal shape should be rounded again
and freed from sharp edges. Allogeneic grafts from human donors (either
deceased or living donors; usually femoral heads) have also been
successfully used for onlay bone grafts. An interesting approach is to
manufacture such bone blocks preoperatively in milling machines based on
3D imaging data. Although there is no shortage of efforts, the studies that
have attempted vertical augmentation with xenogeneic or alloplastic blocks
have mostly failed.
Experience has shown that soft tissue coverage of these grafts is
difficult. If tunneling techniques are not used (see chapter 7), the vestibular
flap must be mobilized three times. It must be guided up the graft on the
vestibular side, pulled orally over the graft, and from there it usually must
be pulled down a little further to the palatal/lingual side. This results in a
further shift of the mucogingival borderline. Therefore, secondary
vestibuloplasty and measures to create attached gingiva are usually

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required, which is a real disadvantage of this method compared to sandwich
techniques. Another disadvantage is the resorption and dehiscence tendency
of overlay bone grafts.
Generally 4 months after placement of a iliac bone graft, osteosynthesis
material removal and implant placement can take place. If implants are
placed too late or not at all, resorption of the graft usually occurs.

Digitization
The CAD/CAM-printed patient-specific titanium grids discussed in the next
chapter represent a digitization of the onlay bone graft. The new procedure
does not change the old disadvantages of the onlay. These include the 3.7-
mm limit of neoangiogenesis, soft tissue tension due to triple shift
displacement of the mucogingival border, the location of the material
directly under the suture, and the resulting tendency to biofilm formation
and increased need for antibiotics.

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Fig 8-26 Bone block grafting for 1/4 defect. a. Baseline clinical situation with horizontal
atrophy. b. Access via midcrestal incision, continued to the sides as a gingival sulcus
incision. c. The provisional prosthesis, used as a drilling and esthetic template, shows that
there is no vertical deficit. d. Pilot drilling. A single-stage procedure is possible if the
implants can be safely primarily stabilized in the residual bone. e. “Bone-level” implants
must not always be placed at bone level; in cases such as this one, they would be too deep.
The vertical insertion depth is 3 mm below the prospective gingival height and is therefore
determined by esthetics. f. The implants show vestibular dehiscence defects (1/4 defects).

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Fig 8-26 Bone block grafting for 1/4 defect. g. The membrane is equipped with two
tongues so that the incisive foramen can be spared. h. The autogenous bone block from the
external oblique ridge is 3 mm below the prospective gingival height and stabilized with two
osteosynthesis screws. i. Bone chips are collected in the filter. j. The autogenous bone
chips are pressed into the contour gaps of the bone block and vestibularly deposited in
excess. k. The collagen membrane (Bio-Gide) adheres to the bone chips by polymerization
of the fibrin and does not need to be tacked. The stability of this bone construct results from
the bone block and not from the membrane. l. Flap mobilization safely covers the additional
ridge volume. This results in a palatal shift of the mucogingival margin line.

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Fig 8-26 Bone block grafting for 1/4 defect. m. Removal of the osteosynthesis screws is
minimally invasive to avoid risk of resorption or wound dehiscence over the bone block. n.
The displaced mucogingival borderline is relocated by midline incision and an apical
displacement flap. Sufficiently attached gingiva is formed spontaneously without soft tissue
grafting. o. Prosthetic restoration with normally proportioned dental crowns. The gingival
height has been achieved as specified by the bone block grafting. With regard to the
interdental black triangles, a further filling to 5.5 mm is to be expected in accordance with
the Tarnow rule.

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Fig 8-27 Example of an overlay bone graft with an autogenous monocortical iliac block graft
to correct a vertical defect in the right posterior mandible.

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Fig 8-28 Onlay iliac bone graft in a historical case from the 1990s. The case is meant
to illustrate the relatively traumatic surgical technique of that time and would be
performed differently today. a. Baseline situation with pronounced atrophy of the
edentulous superior alveolar process (Cawood class V). b. Raising of a large periosteal
flap, exposing the maxilla and nasal passages. c. The bone harvesting template (top left)
indicates the extent of the horseshoe-shaped pelvic bone graft (bottom left). Additional chip
material is required (right). d. Positioning of the monocortical graft with osteosynthesis. e.
Extensive soft tissue mobilization into the inner labial mucosa provides primary coverage of
the graft. The mucogingival border has moved far inward. f. Postoperative panoramic view.

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Fig 8-28 Onlay iliac bone graft in a historical case from the 1990s. The case is meant
to illustrate the relatively traumatic surgical technique of that time and would be
performed differently today. g. In contrast to the sandwich and interpositional techniques
presented in this book, the implants have penetrated the outer mobile alveolar mucosa due
to the procedure. The cuff of attached gingiva is missing. h. The lateral radiographic images
show that a correct occlusal relationship and a prosthetically friendly implant position can be
achieved even with onlay grafts. i. Panoramic radiograph after prosthetic restoration with
ball attachements. j. Prosthetic restoration with overdenture.

8.5 References
1. Jensen SS, Terheyden H. Bone augmentation procedures in localized defects in the alveolar
ridge: Clinical results with different bone grafts and bone-substitute materials. Int J Oral
Maxillofac Implants 2009;24(Suppl):218–236.
2. Antonoglou GN, Stavropoulos A, Samara MD, et al. Clinical performance of dental implants
following sinus floor augmentation: A systematic review and meta-analysis of clinical trials with
at least 3 years of follow-up. Int J Oral Maxillofac Implants 2018;33:e45–e65.
3. Park WB, Kang KL, Han JY. Factors influencing long-term survival rates of implants placed
simultaneously with lateral maxillary sinus floor augmentation: A 6- to 20-year retrospective
study. Clin Oral Implants Res 2019;30:977–988.
4. Liu R, Yan M, Chen S, Huang W, Wu D, Chen J. Effectiveness of platelet-rich fibrin as an
adjunctive material to bone graft in maxillary sinus augmentation: A meta-analysis of
randomized controlled trails. Biomed Res Int 2019:7267062.

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5. Abdalla RIB, Alqutaibi AY, Kaddah A. Does the adjunctive use of platelet-rich plasma to bone
graft during sinus augmentation reduce implant failure and complication? Systematic review and
meta-analysis. Quintessence Int 2018;49:139–146.
6. Simonpieri A, Choukroun J, Del Corso M, Sammartino G, Dohan Ehrenfest DM. Simultaneous
sinus-lift and implantation using microthreaded implants and leukocyteand platelet-rich fibrin as
sole grafting material: A six-year experience. Implant Dent 2011;20:2–12.
7. Kuchler U, Chappuis V, Bornstein MM, et al. Development of implant stability quotient values
of implants placed with simultaneous sinus floor elevation - Results of a prospective study with
109 implants. Clin Oral Implants Res 2017;28:109–115.
8. Varela-Centelles P, Seoane J, Loira-Gago M, González-Mosquera A, Seoane-Romero JM.
Diameter of alveolar antral artery in the lateral sinus wall: Study of related factors. Br J Oral
Maxillofac Surg 2017;55:413–415.
9. Atieh MA, Alsabeeha NH, Tawse-Smith A, Faggion CM Jr, Duncan WJ. Piezoelectric surgery vs
rotary instruments for lateral maxillary sinus floor elevation: A systematic review and meta-
analysis of intra- and postoperative complications. Int J Oral Maxillofac Implants 2015;30:1262–
1271.
10. Srouji S, Ben-David D, Lotan R, Riminucci M, Livne E, Bianco P. The innate osteogenic
potential of the maxillary sinus (Schneiderian) membrane: An ectopic tissue transplant model
simulating sinus lifting. Int J Oral Maxillofac Surg 2010;39:793–801.
11. Barone A, Ricci M, Grassi RF, Nannmark U, Quaranta A, Covani U. A 6-month histological
analysis on maxillary sinus augmentation with and without use of collagen membranes over the
osteotomy window: Randomized clinical trial. Clin Oral Implants Res 2013;24:1–6.
12. Suárez-López Del Amo F, Ortega-Oller I, Catena A, et al. Effect of barrier membranes on the
outcomes of maxillary sinus floor augmentation: A meta-analysis of histomorphometric
outcomes. Int J Oral Maxillofac Implants 2015;30:607–618.
13. Lundgren S, Cricchio G, Hallman M, Jungner M, Rasmusson L, Sennerby L. Sinus floor
elevation procedures to enable implant placement and integration: Techniques, biological aspects
and clinical outcomes. Periodontol 2000 2017;73:103–120.
14. Shi JY, Gu YX, Zhuang LF, Lai HC. Survival of implants using the osteotome technique with or
without grafting in the posterior maxilla: A systematic review. Int J Oral Maxillofac Implants
2016;31:1077–1088.
15. Lundgren S, Johansson AS, Cricchio G, Lundgren S. Clinical outcome and factors determining
new bone formation in lateral sinus membrane elevation with simultaneous implant placement
without grafting material: A crosssectional, 3-17 year follow-up study. Clin Implant Dent Relat
Res 2019;21:827–834.
16. Yang J, Xia T, Wang H, Cheng Z, Shi B. Outcomes of maxillary sinus floor augmentation
without grafts in atrophic maxilla: A systematic review and meta-analysis based on randomised
controlled trials. J Oral Rehabil 2019;46:282–290.
17. Summers RB. A new concept in maxillary implant surgery: The osteotome technique.
Compendium 1994;15:152–158.
18. Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant survival rates after
osteotome-mediated maxillary sinus augmentation: A systematic review. Clin Implant Dent Relat
Res 2012;14(Suppl 1):e159–e168.
19. Qian SJ, Mo JJ, Si M, Qiao SC, Shi JY, Lai HC. Long-term outcomes of osteotome sinus floor
elevation with or without bone grafting: The 10-year results of a randomized controlled trial. J
Clin Periodontol 2020;47:1016-1025.
20. Franceshetti G, Rizzi A, Minenna L, Pramstraller M, Trombelli L, Farina R. Patient-reported
outcomes of implant placement performed concomitantly with transcresstal sinus floor elevation

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 or entirely in native bone. Clin Oral Implants Res 2017;28:156–162.
21. Testori T, Weinstein RL, Tashieri S, Del Fabbro M. Risk factor analyses following maxillary
sinus augmentation: A retrospective multicentre study. Int J Oral Maxillofac Implants
2012;27:1170–1176.
22. Bruckmoser E, Gruber R, Steinmassl O, et al. Crestal sinus floor augmentation using hydraulic
pressure and vibrations: A retrospective single cohort study. Int J Oral Maxillofac Implants
2018;33:1149–1154.
23. Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the
minimally invasive hydraulic sinus condensing technique. J Periodontol 2005;76: 482–491.
24. Geng YM, Zhou M, Parvini P, et al. Sandwich osteotomy in atrophic mandibles: A retrospective
study with a 2- to 144-month follow-up. Clin Oral Implants Res 2019;30:1027–1037.
25. Roccuzzo A, Marchese S, Worsaae N, Jensen SS. The sandwich osteotomy technique to treat
vertical alveolar bone defects prior to implant placement: A systematic review. Clin Oral Investig
2020;24:1073–1089.
26. Altiparmak N, Akdeniz SS, Bayram B, Gulsever S, Uckan S. Alveolar ridge splitting versus
autogenous onlay bone grafting: Complications and implant survival rates. Implant Dent
2017;26:284–287.
27. Garcez-Filho J, Tolentino L, Sukekava F, Seabra M, Cesar-Neto JB, Araújo MG. Long-term
outcomes from implants installed by using split-crest technique in posterior maxillae: 10 years of
follow-up. Clin Oral Implants Res 2015;26: 326–331.
28. Mounir M, Beheiri G, El-Beialy W. Assessment of marginal bone loss using full thickness versus
partial thickness flaps for alveolar ridge splitting and immediate implant placement in the
anterior maxilla. Int J Oral Maxillofac Surg 2014;43:1373–1380.
29. Tang YL, Yuan J, Song YL, Ma W, Chao X, Li DH. Ridge expansion alone or in combination
with guided bone regeneration to facilitate implant placement in narrow alveolar ridges: A
retrospective study. Clin Oral Implants Res 2015;26:204–211.
30. Poli PP, de Nunes Lima V, Souza FÁ, Garcia Junior IR, Maiorana C. Clinical outcome of dental
implant therapy in association with Le Fort I osteotomy preprosthetic surgery: A systematic
review. Int J Oral Maxillofac Implants 2019;34:47–60.
31. Härle F. Atlas of Preprosthetic Surgery. Munich: Hanser, 1989.
32. Stellingsma K, Raghoebar GM, Visser A, Vissink A, Meijer HJ. The extremely resorbed
mandible, 10-year results of a randomized controlled trial on 3 treatment strategies. Clin Oral
Implants Res 2014;25:926–932.
33. Jung RE, Glauser R, Schärer P, Hämmerle CH, Sailer HF, Weber FE. Effect of rhBMP-2 on
guided bone regeneration in humans. Clin Oral Implants Res 2003;14:556–568.
34. Jensen SS, Terheyden H. Bone augmentation procedures in localized defects in the alveolar
ridge: Clinical results with different bone grafts and bone-substitute materials. Int J Oral
Maxillofac Implants 2009;24(Suppl):218–236.
35. Troeltzsch M, Troeltzsch M, Kauffmann P, et al. Clinical efficacy of grafting materials in
alveolar ridge augmentation: A systematic review. J Craniomaxillofac Surg 2016;44: 1618–1629.
36. Wennström JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to
orthodontic tooth movement in monkeys. J Clin Periodontol 1987;14:121–129.
37. Jiang X, Zhang Y, Di P, Lin Y. Hard tissue volume stability of guided bone regeneration during
the healing stage in the anterior maxilla: A clinical and radiographic study. Clin Implant Dent
Relat Res 2018;20:68–75.
38. Sanz-Sánchez I, Ortiz-Vigón A, Sanz-Martín I, Figuero E, Sanz M. Effectiveness of lateral bone
augmentation on the alveolar crest dimension: A systematic review and meta-analysis. J Dent

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 Res 2015;94(9 Suppl):128S–142S.
39. Fu JH, Rios H, Al-Hezaimi K, Oh TJ, Benavides E, Wang HL. A randomized clinical trial
evaluating the efficacy of the sandwich bone augmentation technique in increasing buccal bone
thickness during implant placement. II. Tomographic, histologic, immunohistochemical, and
RNA analyses. Clin Oral Implants Res 2015;26:1150–1157.
40. Basler T, Naenni N, Schneider D, Hämmerle CHF, Jung RE, Thoma DS. Randomized controlled
clinical study assessing two membranes for guided bone regeneration of periimplant bone
defects: 3-year results. Clin Oral Implants Res 2018;29:499–507.
41. Lim G, Lin GH, Monje A, Chan HL, Wang HL. Wound healing complications following guided
bone regeneration for ridge augmentation: A systematic review and meta-analysis. Int J Oral
Maxillofac Implants 2018;33:41–50.
42. Chappuis V, Cavusoglu Y, Buser D, von Arx T. Lateral ridge augmentation using autogenous
block grafts and guided bone regeneration: A 10-year prospective case series study. Clin Implant
Dent Relat Res 2017;19:85–96.
43. Benic GI, Eisner BM, Jung RE, Basler T, Schneider D, Hämmerle CHF. Hard tissue changes
after guided bone regeneration of peri-implant defects comparing block versus particulate bone
substitutes: 6-month results of a randomized controlled clinical trial. Clin Oral Implants Res
2019;30: 1016–1026.
44. Michalczik V, Terheyden H. Long-term stability of bone blocks. Zeitschr Zahnärzt Implantol
2007;23:266–279.
45. Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Esthetic outcome and tissue stability of maxillary
anterior single-tooth implants following reconstruction with mandibular block grafts: A 5-year
prospective study. Int J Oral Maxillofac Implants 2013;28:270–280.
46. Khoury F, Hanser T. Mandibular bone block harvesting from the retromolar region: A 10-year
prospective clinical study. Int J Oral Maxillofac Implants 2015;30:688–697.
47. Boven GC, Meijer HJ, Vissink A, Raghoebar GM. Reconstruction of the extremely atrophied
mandible with iliac crest onlay grafts followed by two endosteal implants: A retrospective study
with long-term follow-up. Int J Oral Maxillofac Surg 2014;43:626–632.

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 9
Alternatives and Adjuncts to
Standard Augmentation Techniques

The innovative power of dentists, surgeons, and manufacturing companies

worldwide is great. Numerous procedures and modifications are published
almost daily in the literature, so that the modifications and additions to the
standard techniques presented here represent only an incomplete selection.
What most of the procedures in this chapter have in common is that they
work in the hands of good surgeons in special situations and have been
documented in small case series but have not been comparatively tested
multicenter in larger studies.

9.1 Titanium Mesh Technology

Bone grafts require contour and stability for healing, especially when
working beyond the alveolar envelope. Both requirements can be met by a
titanium mesh. There are 10-year data on mesh technology with 94.1%
implant survival.1 Meshes have a long history in reconstructive surgery, for
example, in the treatment of orbital fractures or for cranial vault
reconstruction.
However, it is difficult to shape the rigid mesh structure in three
dimensions, and material removal is difficult because the mesh becomes
entangled in the soft tissue scar. For three-dimensional shaping, companies
in the pre-digital era devised special mesh structures (eg, Micro Mesh, KLS
Martin) that can yield in two directions and the clinician can shape
spherically in three dimensions with the aid of pincers in a similar way to a
building a car body (Fig 9-1). With a little experience, any desired rounding
of the alveolar process can be created chairside. For the less experienced,

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this step is now facilitated by additively building up the meshes layer by
layer in a patient-specific shape by means of selective laser melting (SLM)
after electronic preliminary planning on computed tomography (CT) or
CBCT data (Yxoss CBR, ReOss). Clinically, the fitting accuracy is often
impressive. The mesh is clinically underfilled with bone chips obtained as
sterilely as possible (via bone mill or scraper) and, if necessary, mixed with
bone substitute material in a 50/50 ratio. The mesh can be fixed to the bone
with screws. It usually has to be surgically removed before implant
placement because the mesh structures block implant placement and
because there is a risk of mesh exposure later in the life of the patient. The
processing technology of meshes is well developed on the engineering side.

Fig 9-1 Mesh technology a. The Micro Mesh has special bars that facilitate spherical
shaping. The pincers allow spherical curves in two planes. b. Shaped mesh in situ for
vertical defect in the maxillary right central incisor to canine area after trauma. It is filled with
autogenous iliac crest cancellous bone. c. Panoramic image shows the placement of the
mesh. d. Regenerate after mesh removal 4 months later. The implants have primary
stability, but the bone regenerate is not yet mature.

The problem, as with all overlay bone grafts, is the 3- to 4-mm limit of
neoangiogenesis and biofilm formation. The soft tissue of an overlay bone

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graft must be mobilized three times (see chapter 8), which creates flap
tension, and the material lies under the suture. Premature exposure of the
meshes due to biofilm formation is common depending on the defect size
and buildup height and has been reported in studies with individually
prefabricated meshes as being between 37%2 and 66%.3,4 The working
group of Ghanaati has therefore proposed a way to allow the meshes to heal
openly in critical cases from the outset, covering them only with collagen
membranes and leukocyte- and platelet-rich fibrin (L-PRF) membranes.5
Successful open, uncovered healing of bone graft substitutes has been
reported in other fields such as ridge preservation. In CAD/CAM meshes
that initially healed without problems for a few weeks, later exposure after
6 to 8 weeks is often observed. The portion of material not incorporated by
angiogenesis is secondarily rejected via biofilm. Mesh implantations above
3- to 4-mm buildup height could therefore also be described as a partial loss
strategy (Figs 9-2 to 9-3).

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Fig 9-2 Customized mesh technique. a. The panoramic tomogram shows a bilateral free-
end situation in the maxilla with a fissured alveolar ridge 9 months after tooth extractions as
the initial situation. b. The mesh is virtually preplanned based on data from a CBCT,
showing a buildup of the ridge height to the level of the canine. c. Occlusal view of the
preplanning of the printed customized mesh (Yxoss CBR). d. Panoramic with the meshes in
situ, each filled with a mixture of 50% xenogeneic bone substitute and 50% autogenous
bone from the scraper; 1.5-mm Micro Screws (KLS Martin) were used for fixation. Sinus
floor augmentations were performed at the same time. e. For osteosynthesis material
removal on the occasion of implant placement 4 months after mesh insertion, the mesh
must be completely excised from the scar, which requires a wide soft tissue opening. f. The
regenerate after 4 months still has a granular structure and is not yet completely remodeled
bone. Nevertheless, it provides sufficient support for the dental implants.

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Fig 9-2 Customized mesh technique. g. The dental implants in situ, which healed
unloaded for 3 months. In the mandible, short implants of 6-mm length were used. h.
Panoramic tomographic image of the completed prosthetic restoration.

Fig 9-3 Premature mesh exposure. a. Panoramic with non-salvageable maxillary right
lateral incisor to left first molar and a significant vertical bone defect at the pontic. b. 3D
model of the defect area based on CBCT data. c. Virtual planning of the customized mesh
(Yxoss CBR). d. Defect situation after unfolding via midcrestal incision.

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Fig 9-3 Premature mesh exposure. e. Fitting of the prefabricated patient-specific mesh.
This requires a wide flap of the soft tissue. f. Mixture of 50% scraper bone and 50% bone
graft substitute and venous blood. g. The mixture is filled into the mesh in excess. h. The

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mixture is compacted in the mesh. i. The mixture is further compacted by pressing it onto
the bone. The mesh is fixed with a microscrew (KLS Martin 1.5 mm system, Tuttlingen,
Germany). j. A Bio-Gide (Geistlich) collagen membrane is cut to size in the dry state. k. The
membrane is placed neatly under the palatal and buccal soft tissue flaps. Afterward, the
collagen membrane is rehydrated by saline solution.

Fig 9-3 Premature mesh exposure. l. The rehydrated membrane adheres to the support
by capillary forces and therefore does not require additional fixation. m. Meanwhile, the
remaining maxillary incisors were extracted, and the sockets were restored by ridge
preservation. A temporary dental implant (IPI, Nobel Biocare) was placed in the interdental
septum between the lateral incisors and canines to support the provisional prosthesis and
prevent pressure on the soft tissue superior to the mesh. n. The panoramic view shows a
correct fit of the mesh in the planned position. o. The soft tissue has healed without
interference, and the midcrestal incision has healed without irritation. A soft tissue

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dehiscence occurs in the vestibule after 8 weeks, in an area that was not in contact with the
provisional prosthesis. There is an additional dehiscence in the maxillary left second
premolar region. p. The mesh continued to heal open for another 8 weeks under local
disinfecting measures. Here, clinically hard bone is seen after mesh removal with placement
of the bone graft substitute particles. q. The panoramic radiograph shows that there is a
bone gain of about 3 to 4 mm compared to the initial position, but not a complete filling of
the defect. After partial loss, the portion of the bone graft close to the bone has healed; the
rest has been rejected (see the discussion of neoangiogenesis in chapter 2).

9.2 Partial Tooth Extractions

Loading of the Sharpey fibers stimulates the alveolar bone and can prevent
its resorption or even build up new bone. There have been different
approaches suggested for leaving root remnants in place during the initial
tooth extraction. The socket-shield technique is a form of ridge preservation
to prevent resorption of the facial bundle bone after tooth extraction (Fig 9-
4). At the level of retrospective case series, good results were shown,
especially for the preservation of buccal bone.6 However, fistulae or
rejection reactions starting from the root remnant occurred in 18% of the
cases.7
Bone can be developed vertically by forced eruption of a root remnant;
for this purpose, the tooth to be extracted is reduced to the gingival level
and extruded with orthodontic brackets and wires; this process is repeated
several times if necessary.8 The Tissue Master Concept goes one step further
than the socket-shield technique by replanting a slice of an extracted tooth
and extruding it crestally with the attached bone.9 This method is
biologically well designed. Similar to distraction osteogenesis, new bone
forms in a crestal direction, resulting in a vertical augmentation (see also
section 10.8 in chapter 10).

9.3 Implant Site Preparation by Condensation, Bone

Expansion Screws, Conical Implants, and Bone
Spreaders
The maxilla, in contrast to the mandible, has a thin compact bone layer, a
peripheral blood supply type via multiple periosteal vessels, and a fine-
mesh cancellous internal bone structure. Therefore, special surgical

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procedures have evolved for the maxilla to stretch, micro-fracturing and
reshaping the cancellous bone. If the bone is then compressed by cylindric
condensers of ascending size, the primary stability of an implant in the
usually loose cancellous bone of the maxilla (eg, Misch type D4 bone) can
be improved. The technique can be made more comfortable by replacing the
tapped condensation instruments with expansion implants (ie, bone
expansion screws), which are screwed into the jaw with high torque. The
condensation techniques have in common that nutrition is maintained over
the fractured bone portions via an intact soft tissue attachment. Because of
the minimal surgical access and the lack of soft tissue incisions, the
condensation techniques are usually well tolerated by patients. However,
there is evidence that bone, especially in the mandible, reacts to the strong
pressure during condensation with increased peri-implant bone resorption
of up to 2 mm10 and that implants with high insertion torque (>50 Ncm)
develop soft tissue recession.11

Fig 9-4 Principle of partial tooth extraction. In the socket-shield technique, part of the tooth
root is left with an intact periodontal ligament so that the vestibular bone is not lost (see

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chapter 10).

A normal dental elevator is well suited as a spreader (Fig 9-5). There are
commonalities among bone expansion screws, spreaders, and bone splitting.
What all splitting procedures have in common, as is the case with expansion
implants, is that unlike true augmentation (apposition), one cannot influence
the implant axis, which always follows the bone axis. Furthermore, there is
a risk of resorption of the buccal lamella due to insufficient nutrition of the
bone.

Fig 9-5 Bone spreading. a. The horizontally atrophied alveolar ridge is revealed via a
midcrestal incision. The buccal soft tissue flap is not detached so that periosteal blood

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supply to the fragments is preserved. The ridge is split using a flame-shaped diamond bur in
a way that is gentle to the tissues. The bur cut extends to just below the buccal flap,
resulting in a vertical relief incision in the bone. b. Entering with a dental elevator a few
millimeters deeper than the planned implant length. The elevator is advanced within the
cancellous bone layer along the bone axis, and then it is pivoted outward and expands the
ridge. c. Behind the elastic expanded bone lamella, implant site preparation is performed at
slow speed, allowing the buccal bone to yield and the drill bone chips to be carefully picked
up. d. The infracted and expanded buccal lamella is covered and nourished by intact soft
tissue. e. After the implant has been inserted, all gaps are filled with the bone chips
obtained.

9.4 Vertical Distraction Osteogenesis of the Alveolar

Process
The indication for distraction osteogenesis (DO) in implantology is for
vertical augmentation in the partially edentulous and completely edentulous
maxilla and mandible. According to a meta-analysis, the method is well
documented with a mean implant survival of 98% with an average of 7.9-
mm vertical bone gain and only 0.9 mm of long-term resorption.12 A
contraindication applies to single-tooth gaps because in such narrow
transport segments, nutrition of the bone segment via the narrow soft tissue
pedicle is unlikely, and osteotomies become very difficult. In contrast to
bone augmentation, the indication for DO is limited to bone formation at
least 6 months after tooth extraction. The bone segment to be transported
must be stable and completely remodeled. Distraction osteogenesis is a
gentle procedure that still works even if severe soft tissue scarring has
occurred due to previous failed augmentation attempts or trauma (Fig 9-6).
It also does not require antibiotics.
In vertical augmentation in the esthetic region, one is faced with the
problem that the soft tissue in the area of the defect must be considerably
enlarged to cover the augmented bone volume. If this problem is solved by
flap advancement with periosteal releasing incisions, then in the anterior
maxilla the mucogingival margin shifts to the palatal side. This type of
coverage is often no longer feasible if there is considerable scarring, eg,
after trauma. DO offers a solution. Through DO, by slowly moving up a
transport segment of bone, the covering soft tissue is stretched slowly
enough to allow it to regrow and form a sufficient amount of soft tissue
around the augmentation (Fig 9-7).

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 DO is a surgically demanding procedure that requires appropriate
training. In addition, it requires significantly greater patient cooperation
than guided bone regneration. Nevertheless, many patients opt for the DO
when faced with the choice between it and a major augmentation with an
iliac crest bone harvest.

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Fig 9-6 Distraction osteogenesis maxilla. a. Temporary removable restoration after
trauma with resulting defect in the maxillary right central incisor to left first premolar sites. b.
Vertical defect after previous implant placement and bone augmentation attempt. c. The
panoramic image shows that the soft tissue partially conceals the bone defect.

Fig 9-6 Distraction osteogenesis maxilla. d. The osteotomies are completed, and the
distractor is attached so that the vector is buccal to the opposing dentition and the post is
supported on the provisional (KLS Martin TRACK 1.5). e. The distractor in the initial position
shows the extent of the vertical defect. f. The distractor is activated at a rate of 0.3 mm per
day until the transport segment abuts the opposing dentition. g. The distractor was
removed, and soft tissue healing was allowed for 4 weeks. Because the DO only allows
vertical development, horizontal augmentation must be performed in a second step in most
cases. In this case, bone splitting was performed. For this purpose, the alveolar ridge is
longitudinally slit with a diamond flame bur. h. The bone splitting is completed with a blade

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chisel. i. The implants were placed in the bone splitting gap, and the gap was filled with
autogenous bone chips (from the bone filters).

Fig 9-6 Distraction osteogenesis maxilla. j. After bone splitting, only adaptive suturing
can be performed because the soft tissue flap is intended to nourish the bone segment and
is therefore not detached. k. Because a midcrestal incision was made and there was no
displacement of the mucogingival border during any surgical steps, sufficiently attached
gingiva was present circumferentially around the dental implants when the implants were
exposed. l. Correct vertical positioning of the dental implants at the bone level of the
neighboring teeth. m. Without additional soft tissue surgical measures, only with bone
surgical methods and a conservative incision in the center of the alveolar ridge, a good soft
tissue situation is spontaneously present before the start of the prosthetic phase. n. Final
image after insertion of the prosthetic restoration. o. Panoramic image (detail) after

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prosthetic restoration, again showing that the implants are at the bone level of the adjacent
teeth.

Fig 9-7 Distraction osteogenesis in the mandible. a. Peri-implant defects 10 years after
restoration of a mandibular fracture after the patient was kicked by a horse with subsequent
iliac bone grafting and implant restoration. b. Photographed an older printed panoramic
radiograph showing a vertical bone defect at the implant in the mandibular right lateral
incisor site, which could not be salvaged. c. The soft tissue conditions are challenging after
mandibular fracture with scarring into the vestibulum and floor of mouth. Thus it is a poor
bone graft recipient site. d. Panoramic image showing 15-mm-deep vertical bone defect. e.
Completed osteotomy of the transport segment and aligned distractor (KLS Martin TRACK
2.0). The vector points to the buccal surface of the opposing dentition. A distractor footplate
is screwed to the chin to counteract the strong pull of the tongue muscles on the segment. f.
Panoramic image with distractor in initial position.

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Fig 9-7 Distraction osteogenesis in the mandible. g. Partially activated distractor
generating 0.5-mm height gain per revolution. h. Distractor carriage almost in final position
after 18-mm height gain. An overcorrection of about 20% should be targeted. i. Lateral
cephalometric image showing the partially activated distractor and alignment of the vector
with the buccal surface of the opposing dentition. Thanks to the footplate, the vector has
remained stable despite the pull of the lingual muscles. j. At the end of distraction, there is a
slight lingual shift of the vector. k. View of the transport segment and the callus on the
occasion of distractor removal. l. Sufficient bone was created to carry two dental implants.

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Fig 9-7 Distraction osteogenesis in the mandible. m. Immediately upon distractor
removal, two dental implants were placed to prevent the transport segment from slipping
back into the still soft callus. n. Exposure of the dental implants with a palatal mucosa graft
to create circumferential attached gingiva. Compare to the lack of gingiva shown in Fig 9-7c.
o. Healed gingival graft and initial situation before prosthetic restoration. p. Radiograph
showing the position of the distracted bone at the level of the implant shoulders without
resorption or recurrence 3 months after prosthetic restoration. q. Prosthetic restoration. (Dr
Schwalm, Schwalmstadt.)

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Fig 9-8 Position of the osteotomies when creating the transport segment during DO, which
are always trapezoidal in the frontal and horizontal planes. By avoiding undercuts, snagging
of the transport segment during upward movement is avoided. Due to the limited space
available in the anterior maxilla, it is often necessary to cut off one arm of the plate of the
distractor transport segment. The distractor post is then located laterally and posterior to the
upper lip.

Distractor types for vertical DO

Basically, there are external distractors, which are screwed to the outside of
the transport segment, and internal distractors, which run in a channel inside
the transport segment, as well as combination types. The internal distractors
are divided into removable distractors and distraction implants, which can
be used as a dental implants immediately after the distraction phase is
completed.

Clinical procedure (external distractor)

Distraction planning begins with a careful analysis of the
maxillomandibular relationship in the articulator with determination of the
vector. As a rule, the vector points to the vestibular edges of the opposing
dentition.

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Surgical procedure
The recommended incision for distraction osteogenesis is a midcrestal
incision, possibly slightly beveled on the outside, in order to preserve the
blood supply to the transport segment as much as possible. The vestibular
bone surface is exposed, the distractor is placed on a trial basis, and the
distraction vector is determined. If the vector is not correct, correction is
possible by bending the plates, by partial underlayment of shims, or by
removing bone. The distractor is then provisionally fixed with a few screws,
and the definitive osteotomy line is marked. Now the distractor is removed
again. The osteotomy should run trapezoidally in all directions
(buccolingual, coronoapical) to avoid undercuts, which would lead to
jamming of the segment during upward movement (Fig 9-8). This is best
done with oscillating saws, because these sacrifice little bone in the gap
created. Sawing and milling must not cause oral soft tissue perforation,
which would lead to subsequent nutritional disturbance of the segment. The
distractor is then reattached with at least two screws on each side. In the
functional test, the distractor is activated to detect and eliminate
disturbances in the course of the transport segment. The wound is then
closed with interrupted sutures, with the activation post emerging
transmucosally and terminating vestibularly in the oral cavity.

Latent phase
During the following 7 days, the soft tissue should heal until the sutures are
removed.

Activation phase
Distraction can then begin with 0.3 to 0.5 mm per day (one complete
revolution) depending on the distractor size and can be distributed into
several smaller steps. Activation is usually performed by the patient with a
screwdriver and is usually painless. During this time, the distraction post
should be supported on the temporary restoration, because soft tissue
traction always tends to cause the post to shift orally.

Consolidation phase

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When the desired final height is overcontoured by approximately 20%13 or
the transport segment abuts the opposing jaw, distraction ends, and the
consolidation phase begins. Even in this phase, soft tissue traction can still
cause an oral tilt of the transport segment, which is to be prevented by the
temporary restoration.

Distractor removal and implant placement

Surgical removal of the distractor is usually performed 12 weeks after the
start of distraction. It is recommended to place the implants together with
the distractor removal, because the implants then support the bone segment
vertically and prevent the transport segment from slipping back into the
callus. However, this does not always work, for example, if the soft tissue at
the distractor post was dehiscent or inflamed. One way of preventing
inflammation is to submucosally shorten the post at the end of the
distraction phase so that the mucosa can heal well.

Dangers and complications

Normally, DO is low in complications and very predictable, among other
things because there is no need for bone harvest surgery, and the
osteotomies can be performed quickly by a skilled surgeon. Vertical DO of
the alveolar ridge is often a compromise in the mandible. The more
atrophied the jaw, the more augmentation is indicated but also the thinner
the residual height of the remaining basal jawbone is after osteotomy.
Accordingly, mandibular fracture is a known complication. Another
complication is the displacement of the distraction vector in the
consolidation phase, especially in the edentulous anterior mandible, because
here the geniohyoid muscles exert a strong pull on the segment lingually.

Secondary lateral bone augmentation

The limitation of distraction osteogenesis is that the bone is only augmented
vertically and not horizontally. Therefore, in the esthetic field, an additional
horizontal augmentation is usually required after completion of the DO. The
DO makes it possible to preserve the attached gingiva vestibularly, so that

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soft tissue augmentation measures are often spared, especially when
overcompensating vertically.

9.5 Bone Ring Technique with Simultaneous Implant

Placement
Using standard reamers, autogenous trephine rings of compact bone can be
harvested from the chin prominence to fit precisely around the neck of a
dental implant. Such an augmentation then lies optimally and can be used
for single-stage vertical and horizontal augmentation in small defects. As
with all single-stage procedures, the risk is increased, in part because
dehiscence and infection can result in the loss of both the implant and the
bone graft. Special care must be taken to ensure that the hole in the ring for
the implant is an accurate fit; otherwise, the implant will split the ring in
two. Therefore, the procedure works best with implant types that are
smooth and do not have threads or reliefs in the coronal portion.
Because the chin as a donor site can cause complications (including
dropping lower lip and increased tooth exposure) and is limited to once-in-
a-lifetime harvesting, the suggestion has been made to use rings made from
allogeneic bone. Implant survival was 97.5% in a retrospective study of
allogeneic bone rings.14

9.6 Extraoral Tent-Pole Technique in the Anterior Mandible

and Lower Border Augmentation
Augmentation and simultaneous implant placement can be performed
extraorally in the anterior mandible via an incision in the submental fold
(Fig 9-9). This has the advantage of absolute sterility without dehiscence.
The implants serve as spacers. The technique is known as the tent-pole
technique and achieved between 94.4% and 100% implant survival in a
systematic review.15
Using the same approach, the lower border of the extremely atrophied
mandible can also be augmented with iliac bone blocks (lower border
augmentation), mainly for fracture prophylaxis.16

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9.7 Shell and Tent Techniques
An alternative strategy for dealing with bone blocks is the three-
dimensional construction of several veneers, both palatal and coronal, in the
desired ridge contour, which are then relined with cancellous bone.17 Very
thin bone block grafts from the external oblique ridge, which are split by
thin diamond cutting discs, are suitable for use as shell grafts.18 Using tent-
shaped coronally supported cortical shells for vertical elevation is called the
tenting technique; however, in one study only 1.6-mm elevation was
achieved with this approach.19 The use of resorbable polylactide plates as
shells has not yet progressed beyond the experimental stage.20

Fig 9-9 Extraoral tent-pole technique. a. Panoramic radiograph with anterior defect after
tumor treatment. b. Lateral cephalometric radiograph showing 10-mm symphyseal height. c.
Extraoral approach via a submental incision in the submental fold. The implants are placed
as tent poles.

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Fig 9-9 Extraoral tent-pole technique. d. Autogenous iliac cancellous bone was obtained
via trephine punches. The material is placed in rolls around the implants. e. After graft
placement, the intraoral soft tissues are closed. f. Postoperative lateral cephalometric
radiograph. g. After 3 months, remodeling of the pelvic cancellous bone is evident with

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formation of a cortical layer. h. Panoramic radiograph 3 months postoperatively. i. Intraoral
situation after placement of a bar support for the restoration.

Fig 9-10 Ridge switch graft on a narrow ridge. The disadvantage of the method is the loss
of ridge height.

Fig 9-11 Apical U-shape splitting technique in a maxillary lateral incisor region with an
undercut. The apical U can be split using a dental elevator.

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9.8 Ridge Switch Graft for a Narrow Ridge
The bone graft for lateral apposition in the edentulous mandible can also be
obtained by inverting a knife edge rige in the anterior mandible. Of course
this maneuver is at expense of its height. A full-thickness flap is raised
bilaterally at the apical ridge and then severed horizontally about 10 mm
below the ridge (Fig 9-10). This segment is resected and rotated 180
degrees. It is then screwed to the facial aspect of the residual alveolar
process as a free graft. The disadvantage of height loss is not so critical in
the edentulous mandible.

9.9 Apical U-Shape Splitting Technique

Because the superior alveolar process is oblique and an implant placed in
the prosthetic axis would show an apical fenestration defect, the apical U-
shape splitting technique was developed for undercut areas (Fig 9-11).
Here, a U-shaped corticotomy is performed on the basal superior alveolar
process. This area is exposed crestally with a chisel, and the implant is
placed at the same time.21

9.10 References
1. Roccuzzo M, Savoini M, Dalmasso P, Ramieri G. Long-term outcomes of implants placed after
vertical alveolar ridge augmentation in partially edentulous patients: A 10-year prospective
clinical study. Clin Oral Implants Res 2017;28: 1204–1210.
2. Hartmann A, Hildebrandt H, Schmohl JU, Kämmerer PW. Evaluation of risk parameters in bone
regeneration using a customized titanium mesh: Results of a clinical study. Implant Dent
2019;28:543–550.
3. Pellegrino G, Lizio G, Corinaldesi G, Marchetti C. Titanium mesh technique in rehabilitation of
totally edentulous atrophic maxillae: A retrospective case series. J Periodontol 2016;87:519–528.
4. Ciocca L, Lizio G, Baldissara P, Sambuco A, Scotti R, Corinaldesi G. Prosthetically CAD-CAM-
guided bone augmentation of atrophic jaws using customized titanium mesh: Preliminary results
of an open prospective study. J Oral Implantol 2018;44:131–137.
5. Ghanaati S, Al-Maawi S, Conrad T, Lorenz J, Rössler R, Sader R. Biomaterial-based bone
regeneration and soft tissue management of the individualized 3D-titanium mesh: An alternative
concept to autologous transplantation and flap mobilization. J Craniomaxillofac Surg 2019;47:
1633–1644.
6. Bäumer D, Zuhr O, Rebele S, Hürzeler M. Socket shield technique for immediate implant
placement—Clinical, radiographic and volumetric data after 5 years. Clin Oral Implants Res
2017;28:1450–1458.

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7. Gluckman H, Salama M, Du Toit J. A retrospective evaluation of 128 socket-shield cases in the
esthetic zone and posterior sites: Partial extraction therapy with up to 4 years follow-up. Clin
Implant Dent Relat Res 2018;20:122–129.
8. de Molon RS, de Avila ED, de Souza JA, et al. Forced orthodontic eruption for augmentation of
soft and hard tissue prior to implant placement. Contemp Clin Dent 2013;4:243–247.
9. Neumeyer S. The Tissue Master Concept (TMC): Innovations for alveolar ridge preservation. Int
J Esthet Dent 2017; 12:246–257.
10. Aldahlawi S, Demeter A, Irinakis T. The effect of implant placement torque on crestal bone
remodeling after 1 year of loading. Clin Cosmet Investig Dent 2018;10:203–209.
11. Marconcini S, Giammarinaro E, Toti P, Alfonsi F, Covani U, Barone A. Longitudinal analysis on
the effect of insertion torque on delayed single implants: A 3-year randomized clinical study. Clin
Implant Dent Relat Res 2018;20:322–332.
12. Zhao K, Wang F, Huang W, Wu Y. Clinical outcomes of vertical distraction osteogenesis for
dental implantation: A systematic review and meta-analysis. Int J Oral Maxillofac Implants
2018;33:549–564.
13. Reininger D, Rodriguez-Grandjean A, López-Quiles J. Analysis of resorption and need for
overcorrection in alveolar distraction osteogenesis. Int J Oral Maxillofac Implants 2016;31:865–
869.
14. Nord T, Yüksel O, Grimm WD, Giesenhagen B. One-stage vertical ridge augmentation and
dental implantation with allograft bonerings: Results 1 year after surgery. J Oral Implantol
2019;45:457–463.
15. de Groot RJ, Oomens MAEM, Forouzanfar T, Schulten EAJM. Bone augmentation followed by
implant surgery in the edentulous mandible: A systematic review. J Oral Rehabil 2018;45:334–
343.
16. Soehardi A, Meijer GJ, Berge SJ, Stoelinga PJ. Lower border bone onlays to augment the
severely atrophic (class VI) mandible in preparation for implants: A preliminary report. Int J Oral
Maxillofac Surg 2014;43:1493–1499.
17. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmentation in the posterior
maxilla: A 10-year clinical study. Int J Oral Maxillofac Implants 2019;34:471–480.
18. Yu H, Chen L, Zhu Y, Qiu L. Bilamina cortical tenting grafting technique for three-dimensional
reconstruction of severely atrophic alveolar ridges in anterior maxillae: A 6-year prospective
study. J Craniomaxillofac Surg 2016;44:868–875.
19. Novy LFS, Aguiar EG, de Arruda JAA, et al. Linear and volumetric gain after vertical bone
augmentation in the posterior mandible using an autologous cortical tenting method. Int J Oral
Maxillofac Surg 2019;48:1485–1491.
20. Iglhaut G, Schwarz F, Gründel M, Mihatovic I, Becker J, Schliephake H. Shell technique using a
rigid resorbable barrier system for localized alveolar ridge augmentation. Clin Oral Implants Res
2014;25:e149–e154.
21. Wu Q, Yang B, Gao S, et al. Apical U-shape splitting technique for undercut areas of the anterior
alveolar ridge: A prospective non-randomized controlled study. Int J Oral Maxillofac Surg
2019;48:388–394.

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 10
Extraction Socket Treatment

In nature, the healing of a tooth extraction defect is optimized for rapid,

bacteria-tight closure; for example, the bundle bone at the alveolar margin
is rapidly resorbed after tooth extraction so that the soft tissue can shrink
more easily over the defect. However, this natural optimization does not
coincide with the requirements of function and esthetics of dental implants.
Several therapeutic approaches exist with the goal of compensating for the
resorption of the bundle bone and facial bone lamella, thus fully
transferring the contour of the emergence profile of the natural tooth to the
implant reconstruction. These include immediate implant placement, ridge
preservation, and simultaneous contour augmentation by GBR.

10.1 Gentle Tooth Extraction and Surgical Treatment of the

Extraction Wound
Good conditions for undisturbed wound healing of the alveolus are
provided by atraumatic, preferably axial, extraction of the tooth. The
marginal gingiva should not be mobilized, because the detachment of a
periosteal flap leads to surface resorption of the underlying bone. Therefore,
surgical tooth extractions should be performed completely within the
alveolar socket rather than by raising a flap, if possible. Granulation tissue
and the inner marginal epithelium in the presence of marginal periodontitis
of the extracted tooth should be completely excised with sharp scalpel
blades. The blood coagulum can be stabilized at the entrance of the alveolus
by a piece of moistened collagen fleece, so that decomposition of the
coagulum by bacteria is prevented as much as possible.1 It is useful to adapt
the marginal gingiva over the collagen fleece with some sutures to stop the
bleeding as well. If these conditions are met, rapid soft tissue coverage by

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annular shrinkage of the buccal and interdental soft tissues over the bone
defect can be expected within about 3 weeks in healthy patients. Complete
bony consolidation takes about 3 months in the maxilla and often somewhat
longer in the mandible. Disturbances occur, for example, in the case of
inflammation due to plasmin activation by the urokinase plasminogen
activator (uPA), by bacterial streptokinase, or by endogenously induced
hyperactivity of fibrinolysis, eg, with oral contraceptives.2 The so-called dry
socket is a fibrinolytic alveolitis, ie, it results from secondary dissolution of
the blood coagulum.

Fig 10-1 Principle of ridge preservation. Replacement of the resorbed bundle bone with
socket grafting material.

10.2 Goals of Ridge Preservation

The aim of ridge preservation is to maintain the mid-buccal mucosal level
(MBML) for a subsequent dental implant. This goal is to be achieved by
influencing the facial socket wall. When a tooth is extracted, the marginal
bone resorbs physiologically, primarily by reducing the height of the facial
bone lamella. This is explained by the concept of bundle bone (see chapter
1), a type of bone at the insertion site of ligaments and tendons, in this case
the periodontal ligament. When the ligament disappears, the bundle bone
also shrinks. This shrinkage is physiologically preprogrammed and cannot
be stopped with the exception of the socket-shield technique (see also
section 9.2 in chapter 9 and section 10.8). The extent and speed of
resorption is variable between individuals.

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 The principle of ridge preservation is the early establishment of a
resorption-stable bone structure inside the alveolus, which can take over the
soft tissue support of the buccal gingiva internally before the bundle bone
shrinks (Fig 10-1). Thus, indirectly, the circular fiber system of the marginal
periodontium should also be prevented from collapsing, preserved, and
ideally transferred from the extracted tooth to the dental implant without
loss in soft tissue height and quality (keratinization; Fig 10-2). This is done
by filling the extraction socket with a bone graft or other bone substitute. In
the case of an alveolar defect, not only can resorption be reduced in this
way, but the defect can even be filled from the inside. This corresponds to
primary alveolar reconstruction (Fig 10-3).
One modification is ridge preservation together with guided bone
regeneration (GBR), in which bone substitute material and a membrane are
applied buccally to the alveolar wall. This is usually associated with flap
elevation, soft tissue scarring, and periosteal detachment, which would
contradict the actual goal of ridge preservation, which is why as little soft
tissue as possible should be mobilized.
With regard to the goal of transferring the soft tissue contour of the
extracted tooth to the implant reconstruction without loss of quality and
height, two other procedures compete with ridge preservation: immediate
implant placement and early implant placement with contour
augmentation.4 In immediate implant placement, the implant is placed at the
palatal alveolar margin, and the space between the implant and the buccal
wall is filled with a bone graft, similar to ridge preservation. Advantages are
that the implant can be immediately restored with a provisional restoration
and that the patient saves time and money. The disadvantage of immediate
implant placement is that the immediately placed implant still has the
remodeling phase of the extraction socket ahead of it, with uncertain
predictability of the extent of this remodeling. A meta-analysis showed a
higher implant loss rate with immediate implant placement than with early
implant placement.5 Remodeling, which cannot be well calculated, may also
result in soft tissue recession and esthetic failure, especially in a thin
gingival type.

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Fig 10-2 Feneis fiber apparatus. Original drawing from the article by Heinz Feneis
(anatomist, Tübingen).3 This work was the basis for the development of immediate implant
placement by Willi Schulte (oral surgeon, Tübingen).

Fig 10-3 Principle of primary alveolar reconstruction. Filling of a socket wall defect from the
inside.

In contrast, with early implant placement with contour augmentation,

after 8 weeks, most of the remodeling has already been completed, and the

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resulting loss of bundle bone can be assessed and compensated for under
visualization as needed with a stable bone graft with a low substitution rate.
This results in increased safety for the esthetics and function of the implant.
This discussion is currently ongoing.

10.3 Socket Grafting in Intact Alveoli

The aim of healing after tooth extraction from an implantology point of
view, especially in the esthetic field, is to preserve the bone volume of the
alveolar process. This is attempted in ridge preservation by filling the
alveolus with various graft materials. Ridge preservation involves not only
filling but also covering the extraction socket. Studies do not show that soft
tissue coverage by flap mobilization is beneficial, but rather the opposite:
bone resorption is increased by flap formation, and scars and flattening of
the vestibule and more bone loss occur than without flap formation.
The various filling materials have been scientifically compared largely
in randomized trials against unfilled spontaneous healing. In these studies,
the effect size is interesting for comparing the materials. Although the
buccal lamella also resorbs in ridge preservation, it resorbs less than in
spontaneous healing. This difference to spontaneous healing is the effect
size. In a large meta-analysis, the effect size of recombinant human bone
morphogenetic protein (rhBMP)-2 was highest with a 2.7-mm difference in
resorption from spontaneous healing.6 When filling materials were used,
xenogeneic bone graft substitute was the most effective in the included
studies, surpassed only by rhBMP-2. Alloplastic materials performed worse,
and leukocyte- and platelet-rich fibrin (L-PRF) showed only a small
additional effect over spontaneous healing. The mean of all studies showed
an average of 1.65-mm resorption reduction in the vertical direction and
1.62 mm in the horizontal direction.7 It has been scientifically proven with
moderate evidence from a Cochrane Report that ridge preseravtion is
basically useful for bone preservation, but no evidence was found for better
esthetics of the subsequent implant, and a reduced need for augmentation
was not established.8 Whether an intact alveolus should be filled with bone
substitute material, even if no defects are present, is quite controversial and
partially rejected.9 There is an argument that complete filling may also limit
the good natural bone healing tendency of the socket via obstruction of

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angiogenesis and is therefore only really useful in socket defects. In
addition, a systematic review pointed out the high rate of inflammation and
fibrous encapsulated bone substitute particles.10
In most studies, a barrier membrane was used for covering the graft,
which may or may not be resorbable. This membrane is intended to separate
the bone regeneration space of the bone graft from the bacterial influences
of the oral cavity for some time, so that vascularization and ossification of
the bone grafts can occur undisturbed. It is also possible to replace the
membrane with a piece of collagen fleece (Fig 10-4). It is advisable to place
a pontic-type provisional over the entrance to the socket so that the papillae
remain supported.

10.4 Socket Grafting with an Alveolar Defect

A clear indication for ridge preservation is an alveolar defect. Even in the
case of severe wall defects following marginal periodontitis, one study
showed that 91.2% of the alveolar bone volume could be regenerated.11 It is
scientifically elegant to plug defects of the buccal alveolar wall from the
inside and allow them to heal before the soft tissue collapses into the defect
(Fig 10-5).
This saves the patient possibly time-consuming subsequent secondary
reconstructions. This ridge preservation is also referred to as immediate
reconstruction of the alveolar process, analogous to immediate implant
placement.

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Fig 10-4 Ridge preservation. a. Initial situation with the maxillary left canine ready for
extraction with root resorption and buccal wall defect of the alveolus. b. Axial tooth
extraction without touching the marginal gingiva if possible. c. Scraper chips obtained at the
external oblique ridge. d. The alveolar socket is filled with purely autogenous scraper chips.
e. Bone substitute material mixed with scraper chips and venous blood. The material is
coagulated by polymerization of the fibrin. f. The entrance to the alveolar socket and buccal
wall defect is lined with a plug of the mixed bone substitute material.

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Fig 10-4 Ridge preservation. g. Collagen fleece (Resorba). h. The collagen fleece is
slightly moistened externally so that it does not stick to the instruments. i. Socket filled
above bone level for overcompensation. j. Sutured covering made of collagen fleece. k. A
provisional restoration is fitted with an ovate pontic that protrudes slightly into the alveolar
canal to provide provisional support for the papillae. l. Four months later, the buccal ridge
contour is maintained without significant denting and without significant palatal
displacement of the mucogingival border.

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Fig 10-4 Ridge preservation. m. On opening, a hard regenerate is visible, which provides
good primary support for the dental implant that is now to follow. n. Another 3 months later,
opening of the implant site by midcrestal incision and an apically displaced flap. o. Gingiva

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former in place and spontaneously well-attached gingiva without additional soft tissue
augmentation measures. p. Prosthetic restoration of the dental implant. q. Prosthetic
restoration immediately after insertion of the maxillary canine crown. r. Radiograph after
implant placement (left) and after placement of the crown (right). s. Panoramic radiograph
following ridge preservation.

Fig 10-5 Ridge preservation with a tissue punch graft. a. Initial situation: Radiograph
showing recurrence of apical periodontitis after apicoectomy. b. Schematic drawing of ridge
preservation with buccal primary wall reconstruction in the case of a buccal wall defect (left)
with the aid of an inserted collagen membrane (right). c. Careful intra-alveolar separation of
the root remnant in the axial direction with the Lindemann bur without touching the alveolar
walls. d. Luxation of the root halves against each other and into the channel of the drill
shaft. Buccal fistula visible. e. Palpation of the buccal defect by a probe. Defect is
approximately 12 mm deep. f. After carefully undermining the periosteal margins of the

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defect, a collagen membrane (Bio-Gide, Geistlich) is cut and placed under the flap. The
membrane is intended to prevent prolapse of the bone transplant under the buccal flap.

Fig 10-5 Ridge preservation with a tissue punch graft. g. Mixed graft of scraper chips
(from the external oblique ridge) and bovine bone substitute. h. The alveolus is filled tightly
to the level of the marginal bone. i. Obtaining a 5-mm tissue punch (Stiefel,
GlaxoSmithKline) on the hard palate on the inner side of the premolars. j. Circular incision.
k. Cutting off the tissue punch graft to a thickness of about 3 to 4 mm with the scalpel. l.
Tissue punch graft.

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Fig 10-5 Ridge preservation with a tissue punch graft. m. Suturing of the tissue punch
into the alveolar inlet. n. Use of a removable temporary splint with an ovate pontic, which
fits into the alveolar entrance and supports the papillae. o. When the sutures are removed,
part of the epithelium is desquamated due to temporary nutritional disturbance, but the
connective tissue of the tissue punch is healed, vital, and already vascularized. p. Four
months after ridge preservation, the circular outer margin of the punch is still visible in the
alveolar entrance. The transplant has prevented the centripetal shrinkage of the marginal
gingiva and thus preserved the Feneis fiber apparatus (Fig 10-2) in place. q. Radiograph
after alveolar grafting showing increasing consolidation of the graft. r. After 4 months,
minimally invasive opening along the borders of the tissue punch graft. s. Implant
placement using an index technique for immediate fabrication of the crown while the implant
is still healing. (Prosthetics by Prof. Dr. Stefan Wolfart.) t. After implant placement, a
cemented pontic was used as an esthetic provisional. u. Even 7 months after grafting, the
tissue punch is still clearly recognizable in the alveolar mucosa. Shrinkage of the papillae

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and marginal gingiva toward the center has been avoided. The papillae no longer have the
same height, but have been preserved in terms of vascularization and structure.

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Fig 10-5 Ridge preservation with a tissue punch graft. v. The punch graft should be
removed as excess tissue because otherwise unsightly bulges could result in the buccal
gingiva. It served its purpose at the time of implant exposure. w. Implant crown already
prepared by index technique. This means that no gingiva former is required. x. Implant
crown in place. Black triangles appear interdentally despite the previously described
measures to support the interdental papillae. y. Final result a few weeks later. The gingiva
has spontaneously regenerated interdentally to about 5.5 mm, which corresponds to the
Tarnow rule. It has been possible to transfer the architecture, shape, and color of the
marginal gingiva from the tooth to the implant reconstruction without loss

Fig 10-6 Natural alveolar healing after tooth extraction involves centripetal shrinkage of the
marginal gingiva in the direction of the arrows. In this process, the buccal and palatal
gingiva, which are still vertical on the tooth, flatten and lay horizontally. Secondly, the
interdental papillae flatten to about half their height and also shift their tissue to the
horizontal plane.

10.5 Primary Reconstruction of Extraction Socket Walls

Using Bone Blocks
Socket wall reconstruction by bone blocks requires secure coverage by a
mobilized flap. Such flaps from the vestibular aspect have esthetic and
functional disadvantages and thus contradict the goal of ridge preservation
to transfer an unaltered gingival margin from the tooth to the implant as far
as possible. In the anterior maxilla, however, there is the option of forming
an axial vascualrised flap from the palatal aspect to safely cover even high-
quality grafts. A corresponding case was presented in chapter 7 (Fig 7-24).

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10.6 Socket Seal Surgery
Ridge preservation focuses on immediately building up a bone structure to
support the curved architecture of the marginal gingiva, including the
interdental papilla, for a later ideal emergence profile of the restoration.
Socket seal surgery focuses on the soft tissue with the same goal, to
preserve the dentogingival attachment apparatus and its curved shape.
Rapid natural soft tissue alveolar closure occurs by centripetal (tobacco
pouch-like) shrinkage (Fig 10-6). During natural alveolar healing, the
dermal surface covering the alveolus originates from the erect papillae and
the erect gingiva on the tooth, which now flatten and spread horizontally
instead of vertically. This results in papilla loss and interdental black
triangles.
The goal of socket seal surgery is to stop centripetal shrinkage with an
epithelial graft. Generally, shrinkage of open wounds is most safely
contained by a dermal graft. The organism then lacks the incentive for
further scar contracture.
Various mucosal grafts can be applied to the extraction socket. The
simplest form of such a graft is the soft tissue punch from the hard palate or
tuberosity. This can be obtained from the tuberosity using disposable biopsy
circular blades of various sizes (4, 5, 6, or 8 mm; Stiefel; Fig 10-7) and
sutured into the socket entrance. Some patients have naturally occurring
fibromas in the tuberosity or thickened mucosal areas distomedial to the
second molars. One study showed an effect size of 0.6-mm higher mean
buccal soft tissue height at the implant for tuberosity grafts compared to
spontaneous healing.12 The thicker these punches are, the more likely there
is to be ingrowth of blood vessels over the lateral margins, so the thicker
tuberosity grafts should be preferred over punches from the palate. It is also
possible to insert combined soft tissue–connective tissue–bone punch grafts
(threelayer graft; see chapter 3, Fig 3-12) from the tuberosity into the
extraction socket in order to also heal the bone defect of the buccal alveolar
wall by means of an autogenous graft.13
A somewhat more complex procedure compared to the punch graft is
the transplantation of a connective tissue graft with a keratinized epithelial
island from the palate. This graft is obtained by a scalpel technique from the
hard palate medial to the premolars. This procedure is indicated in patients
with a very thin periodontal biotype in order to strengthen the biotype from

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the time of extraction. This is to prevent recession and graft resorption (Fig
10-8).

Fig 10-7 A punch graft should have a certain height because new blood vessels grow into
the tissue via these contact surfaces, or there is even microscopic anastomosis to the
existing blood vessels.

10.7 Augmented Immediate Implant Placement

Immediate implant placement can be risky due to the extent and speed of
remodeling, which cannot be predicted well. But immediate restoration with
a dental crown eliminates the need for socket seal surgery, and
individualized emergence profiles of dental crowns are advantageous over
rotationally symmetric gingiva formers.14 Temporary crowns eliminate the
shrinkage stimulus for soft tissues, as hemidesmosomes can form to the
abutment or crown material, sealing the underlying bony regeneration
space. Bone augmentation materials and soft tissue grafts can be placed in
this space. The insertion of xenogeneic bone substitute material into the
buccal gap produced different study results: sometimes an advantage,15
sometimes no significant increase in mean buccal soft tissue height.16
Placement of a connective tissue graft under the buccal gingiva resulted in
slightly increased bone resorption.17
If gingival recession occurs due to retraction of the buccal lamella, there
is a risk of esthetic failure or peri-implantitis due to the exposed roughened

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implant surfaces. Therefore, ridge preservation or waiting for remodeling
by early implant placement and contour augmentation are the safer options
that allow better control of the bony coverage of the buccal implant
shoulder. Studies have clearly shown that resorption of the buccal lamella
cannot be positively or negatively influenced by an immediate implant.18
Therefore, in augmented immediate implant placement, the implant is
placed against the palatal or lingual wall with the aim of building up a
second bone wall in the buccal gap (the so-called jumping distance) before
the outer alveolar wall resorbs. In augmented immediate implant placement,
an implant diameter smaller than the alveolar diameter is selected. This is to
ensure that a jumping distance of at least 2 mm width remains open on the
vestibular side. This gap is filled with bone graft and is then supposed to
ossify and permanently replace the resorbed buccal wall as soft tissue
support.
Augmented immediate implant placement often uses implant types that
have very sharp threads in the apical region and are screwed into the palatal
wall of the extraction socket with high torque. This is intended to achieve
high primary stability. This in turn allows immediate restoration with a
crown adapted to the emergence profile of the old tooth. This crown fits
exactly to the inner marginal epithelium of the extracted tooth in the
alveolar socket from the inside and leads to the formation of
hemidesmosomes. Thus, a bacteria-tight coverage of the buccal
regeneration space in the jumping distance is achieved, and the Feneis fiber
apparatus,3 together with the papillae elevations, can be transferred to the
restoration in an optimally supported manner.

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Fig 10-8 Socket seal surgery using a keratinized connective tissue graft. a. Maxillary
left central incisor ready for extraction after anterior trauma in a patient with recession
tendency and a thin periodontal biotype. b. Extensive bleeding of the extraction socket after
extraction. c. Perforations of the palatal wall to stimulate bleeding. d. Vigorous blood flow. e.
Insertion of collagen fleece into the alveolar entrance to stabilize the blood coagulum. f.
Stanched hemorrhage and stabilized coagulum.

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Fig 10-8 Socket seal surgery using a keratinized connective tissue graft. g. Fitting of a
connective tissue graft from the palate to thicken the buccal gingiva at risk of recession, in
conjunction with an epithelial island. h. Preparation of a fan-shaped recipient defect by
epiperiosteal preparation with a scalpel. The pocket should be prepared significantly larger
than the graft. i. The graft was sutured circularly with the epithelial island. Good contact with
the walls in the socket entrance should be sought so that vascular bridges can form quickly.
The connective tissue flap was pulled into the pocket with an absorbable pull-through suture
(polyglycolic acid [PGA] 5-0, Resorba) and spread flat without tangling. j. Two weeks after
soft tissue grafting, tissue swelling appears due to rapid vascularization and granulation
tissue formation. This is a sign of good healing of the graft. k. After 4 months, a dental
implant was placed, and the bone was augmented simultaneously with a bone block. This
was done safely under the reliable soft tissue coverage of the previous grafts. The
keratinized island is recognizable. l. Minimally invasive removal of the osteosynthesis screw
of the bone block is performed without repeated periosteal detachment from the bone and
without a new incision of the soft tissues.

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Fig 10-8 Socket seal surgery using a keratinized connective tissue graft. m. The
keratinized island has fulfilled its purpose and should be removed for implant exposure;
otherwise, gingival bulges may result on the buccal aspect. n. View of the abutment surface
after uncovering. Approximately 3-mm gingiva thickness can be seen in the soft tissue
access canal. This value is in line with the biologic width and should neither be undercut nor
exceeded. o. Irritation-free healing of the donor site of the keratinized connective tissue
graft. p Prosthetic restoration. Sufficient width of keratinized gingiva and absence of
recession of buccal gingiva at the left central incisor implant site despite thin periodontal
type. Largely absent interdental papilla adjacent to the neighboring implant in the lateral
incisor site. This is a hitherto unsolved problem in implantology. q. The occlusal view shows
soft tissue thickening compared to the neighboring right central incisor site. r. Radiograph
after prosthetic restoration showing remodeling. The preparation margins of the abutments
show the physiologic soft tissue heights. The implant shoulders are at the bone level of the
neighboring teeth.

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10.8 Socket-Shield Technique
The Hürzeler socket-shield technique,19 also called partial extraction20 or the
root membrane technique,21 is a form of ridge preservation and an
alternative to the previously mentioned bone grafts. This therapy is able to
avoid resorption of the facial bundle bone after tooth extraction by
preserving the Sharpey fibers at the coronal margin of the facial lamella by
retaining the associated root dentin. This technique is also described in
section 9.2 in chapter 9. The inner wall of the bony alveolus consists of
bundle bone, which loses its function after the associated Sharpey fibers
have been torn off and is always degraded, regardless of whether, for
example, an immediate implant is placed. This degree of bone resorption,
which can lead to a considerable risk to the buccal bone lamella, especially
in the case of thin alveolar walls (ie, thin periodontal biotype), can hardly
be influenced therapeutically after tooth removal.
The proposed solution of the socket-shield technique is the partial
extraction of the root by separating the tooth with a diamond bur so that a
crestal flat vestibular portion of the root is preserved vestibularly for bone
preservation until implant healing. However, according to previous data in
the literature, extrusion of the remaining tooth fragment and also purulent
complications22 occurred in about 19.5% of cases (see also Fig 9-4).

10.9 References
1. Kim JW, Seong TW, Cho S, Kim SJ. Randomized controlled trial on the effectiveness of
absorbable collagen sponge after extraction of impacted mandibular third molar: Split-mouth
design. BMC Oral Health 2020;20:77.
2. Xu JL, Sun L, Liu C, Sun ZH, Min X, Xia R. Effect of oral contraceptive use on the incidence of
dry socket in females following impacted mandibular third molar extraction: A meta-analysis. Int
J Oral Maxillofac Surg 2015;44:1160–1165.
3. Feneis H. Structure and function of normal gingival connective tissue. Dtsch Zahnärztl Z
1952;2:467–476.
4. Buser D, Halbritter S, Hart C, et al. Early implant placement with simultaneous guided bone
regeneration following single-tooth extraction in the esthetic zone: 12-month results of a
prospective study with 20 consecutive patients. J Periodontol 2009;80:152–162.
5. Cosyn J, De Lat L, Seyssens L, Doornewaard R, Deschepper E, Vervaeke S. The effectiveness of
immediate implant placement for single tooth replacement compared to delayed implant
placement: A systematic review and meta-analysis. J Clin Periodontol 2019;46(Suppl 21):224–
241.

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6. Bassir SH, Alhareky M, Wangsrimongkol B, Jia Y, Karimbux N. Systematic review and meta-
analysis of hard tissue outcomes of alveolar ridge preservation. Int J Oral Maxillofac Implants
2018;33:979–994.
7. Barootchi S, Wang HL, Ravida A, Ben Amor F, et al. Ridge preservation techniques to avoid
invasive bone reconstruction: A systematic review and meta-analysis: Naples Consensus Report
Working Group C. Int J Oral Implantol (New Malden) 2019;12:399–416.
8. Atieh MA, Alsabeeha NH, Payne AG, Duncan W, Faggion CM, Esposito M. Interventions for
replacing missing teeth: Alveolar ridge preservation techniques for dental implant site
development. Cochrane Database Syst Rev 2015;(5): CD010176.
9. Chappuis V, Araújo MG, Buser D. Clinical relevance of dimensional bone and soft tissue
alterations post-extraction in esthetic sites. Periodontol 2000 2017;73:73–83.
10. MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following
alveolar ridge preservation: A systematic review. Clin Oral Implants Res 2017; 28:982–1004.
11. Manavella V, Romano F, Corano L, Bignardi C, Aimetti M. Three-dimensional volumetric
changes in severely resorbed alveolar sockets after ridge augmentation with bovinederived
xenograft and resorbable barrier: A preliminary study on CBCT imaging. Int J Oral Maxillofac
Implants 2018;33: 373–382.
12. Zuiderveld EG, Meijer HJA, den Hartog L, Vissink A, Raghoebar GM. Effect of connective
tissue grafting on peri-implant tissue in single immediate implant sites: A RCT. J Clin
Periodontol 2018;45:253–264.
13. da Rosa JC, Rosa AC, Fadanelli MA, Sotto-Maior BS. Immediate implant placement,
reconstruction of compromised sockets, and repair of gingival recession with a triple graft from
the maxillary tuberosity: A variation of the immediate dentoalveolar restoration technique. J
Prosthet Dent 2014; 112:717–722.
14. Menchini-Fabris GB, Covani U, Crespi G, Toti P, Brevi B, Crespi R. Customized vs
conventional implant-supported immediate provisional crowns for fresh-socket implant: A
medium-term cone beam computed tomography study. Int J Oral Maxillofac Implants
2019;34:1505–1511.
15. Girlanda FF, Feng HS, Corrêa MG, et al. Deproteinized bovine bone derived with collagen
improves soft and bone tissue outcomes in flapless immediate implant approach and immediate
provisionalization: A randomized clinical trial. Clin Oral Investig 2019;23:3885–3893.
16. Bittner N, Planzos L, Volchonok A, Tarnow D, Schulze-Späte U. Evaluation of horizontal and
vertical buccal ridge dimensional changes after immediate implant placement and immediate
temporization with and without bone augmentation procedures: Short-term, 1-year results. A
randomized controlled clinical trial. Int J Periodontics Restorative Dent 2020;40:83–93.
17. van Nimwegen WG, Raghoebar GM, Zuiderveld EG, Jung RE, Meijer HJA, Mühlemann S.
Immediate placement and provisionalization of implants in the aesthetic zone with or without a
connective tissue graft: A 1-year randomized controlled trial and volumetric study. Clin Oral
Implants Res 2018;29:671–678.
18. Araújo MG, Silva CO, Souza AB, Sukekava F. Socket healing with and without immediate
implant placement. Periodontol 2000 2019;79:168–177.
19. Bäumer D, Zuhr O, Rebele S, Hürzeler M. Socket shield technique for immediate implant
placement—Clinical, radiographic and volumetric data after 5 years. Clin Oral Implants Res
2017;28:1450–1458.
20. Gluckman H, Salama M, Du Toit J. Partial extraction therapies (PET) part 2: Procedures and
technical aspects. Int J Periodontics Restorative Dent 2017;37:377–385.
21. Mitsias MM, Bratos M, Siormpas K, Pikos MA, Kotsakis GA, Root Membrane Group.
Longitudinal soft tissue changes during periodontal ligament-mediated immediate implant

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 placement with the root-membrane technique. Int J Oral Maxillofac Implants 2020;35:379–385.
22. Gluckman H, Salama M, Du Toit J. A retrospective evaluation of 128 socket-shield cases in the
esthetic zone and posterior sites: Partial extraction therapy with up to 4 years follow-up. Clin
Implant Dent Relat Res 2018;20:122–129.

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C
CLINICAL CHALLENGES AND
DECISION MAKING

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 11
Decision Making According to Defect
Stage

In the age of artificial intelligence, evidence-based medicine, and

guidelines, the decision in favor of a certain therapy path should be easy,
perhaps even possible by machine. In fact, however, the decision is also
becoming more difficult. The wealth of information and multiple
influencing patient-related factors (local, systemic) have to be reconciled.
The enormously variable genetics and epigenetics of patients are already
biologically opposed to all schemes, so that individualized medicine
represents the countermovement to automated decision making. In the
following chapters, an attempt will be made to structure therapy decision
making according to the criteria of defect stage and indication. The term
decision making is used synonymously with the medical term differential
indication.

11.1 Defect-Oriented Concept for the Differential Indication

of Augmentation Procedures
Clinically, the physician’s indication should always be based on the patient
and his or her individual clinical condition. The physician’s performance is
not based on techniques, materials, and methods. These were presented in
the previous section and are now to be classified clinically in terms of their
value. With regard to augmentations, this means starting from the defect
stage. In this chapter, a defect-oriented concept for the differential
indication of bone augmentations will be presented and further elaborated
with reference to the initial publication in the ITI Treatment Guide 7.1 This
concept is initially intended to propose universal solutions for all jaw

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regions. The following clinical chapters then present the specific indications
that require deviations from this concept, for example, large graft volumes
in the edentulous jaw that can not be managed with the intraorally harvested
external oblique ridge block graft.

Classification system
The classification system of the concept presented here is the resorption
stage of the jaw, based on the quarter classification (Fig 11-1; see chapter
1). This treatment scheme applies to single-tooth gaps, free-end situations,
and in principle also to edentulous jaws, but with the limitation of bone
graft volumes. Also, in the edentulous jaw, it is much easier to compensate
for a vertical deficit prosthetically than with augmentation because the
adjacent teeth are missing as a reference.

Fig 11-1 Decision making for an augmentation procedure depending on the defect stage.
GBR, guided bone regeneration.

Main technique and alternatives

For each stage of the defect, one procedure is suggested as the main
technique, along with an alternative. All four stages occupy equal space in
the table in Figure 11-1. In practice, however, the vast majority of cases are
in stage 1/4 and can therefore be treated satisfactorily with the least
complex technique.

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Outpatient feasibility
All augmentation procedures presented here can in principle be performed
on healthy patients on an outpatient basis under local anesthesia or, if
necessary, with sedation. This fact makes the concept suitable for the
private practice and for the patient means that bone augmentation remains
affordable and does not require inpatient treatment.

Healing time
For all procedures proposed here, the healing period is 4 months, either
until implant uncovering or until implant placement for two-stage
procedures.

11.2 Defect Stage 1/4

The 1/4 defect is the earliest stage of resorption of the alveolus, when a
large coronal portion of the buccal wall is missing a few weeks after tooth
extraction. Guided bone regeneration (GBR) cases usually make up the bulk
of patients in practice, because most patients and their dentists take care of
the tooth replacement issue soon after a tooth extraction. In stage 1/4, there
is still enough bone basally for primary implant stability (Fig 11-2). GBR
functions particularly reliably in contained defects of single-tooth gaps
within the envelope with preserved adjacent periodontium and bone walls.
The more elongated the defect, the further outside the envelope the implant
position is located, and the fewer adjacent teeth are present, the more likely
the bone block is to be considered as an alternative to GBR. This has a
higher regenerative potency and more inherent stability and buildup effect
than GBR. In addition, the block eliminates the overcontouring of the
particulate graft techniques, and the method is more precise than GBR.
Because in stage 1/4 the implants are usually placed in one stage, this
corresponds to “advanced” in the SAC (straightforward, advanced,
complex) classification.

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Fig 11-2 GBR technique for a 1/4 defect. a. Initial situation after implant placement and
perforation of the cortical bone. b. A Bio-Gide membrane (Geistlich) is cut into a tongue
shape. c. The tongue of the membrane is placed under the lingual flap margin and thus
fixed in place. d. Sterile venous blood is added to the bone substitute material (Bio-Oss,
Geistlich). e. The sterile blood should be drawn into all cavities of the bone substitute
material so that they do not attract contaminated saliva when applied in the mouth. f. During
all bone work (cortical perforation, implant osteotomy), the filter (Schlumbohm) is inserted
briefly into the aspirator in each case to collect the chips.

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Fig 11-2 GBR technique for a 1/4 defect. g. The chips are removed from the filter screen.
h. So far, the blood has not coagulated with the bone substitute material due to lack of
tissue thrombokinase. For this purpose, the filter bone is now mixed in at a ratio of 25% to
75%. i. After mixing in the bone, the blood coagulates, and easily manageable bone grafts
are formed at the appropriate thickness. j. The pieces can be placed in the defect. k. The
bone grafting material can be modeled in the defect. l. The still dry collagen membrane is
folded over the bone graft.

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Fig 11-2 GBR technique for a 1/4 defect. m. Moistening the membrane with a few drops
of saline solution causes it to soften and adhere relatively firmly to the graft like blotting
paper. The length of the soft tissue flap is checked with the single hook. n. A section of the
membrane is placed as a double layer. o. The flap is mobilized by periosteal release
incisions with the aid of the single hook and the scalpel. p. Due to the incision being made
in the center of the attached gingiva, only a few sutures are required at a relatively large
distance to close the wound tightly. This ensures blood supply to the flap margin. q.
Panoramic radiograph showing stable augmentation in the mandibular right first molar
region at the time of implant exposure. r. Stable clinical situation after prosthetic restoration.

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Fig 11-3 Single-stage bone block graft in a 2/4 defect. a. Baseline panoramic radiograph.
b. Baseline following coronectomy of the premolars, showing horizontal atrophy.

11.3 Defect Stage 2/4

Defect stage 2/4 appears later after tooth extraction than the aforementioned
stage, at the earliest a few months after tooth extraction, especially in jaws
with a narrow apical base. A wide apical base remains longer in the
aforementioned stage 1/4. The 2/4 stage may be congenital, such as in tooth
agenesis, and is then usually a board-like atrophy between adjacent teeth.
Bone block grafting is a universal method that suits almost any defect shape
and is used either with full screw retention or, in the shell technique, with
positioning screws (Fig 11-3). In defect stage 2/4, the implants are placed in
one or two stages. The decision is based on whether the residual alveolar
process still has enough bone for primary stability of the dental implant.
This is mainly a question of the width of the apical base and the prosthetic
axis of the implant. In case of doubt, it is better to proceed in two stages. If
the procedure is performed in two stages, it should be classified as
“complex” in the SAC classification. Basically, the two-stage procedure is a
safety measure, because the implant is placed secondarily in a vascularized
bone bed and, if the buildup volume is sufficient, the implant axis can then
be placed more freely than either single-stage method based on prosthetic
considerations.
Various special conditions make it possible to use bone splitting as an
alternative in stage 2/4. These include two splittable cortical lamellae
shown on the CBCT and an implant axis that is predetermined by the bone.
The brittleness of the mandibular bone makes a controlled procedure in the
posterior mandible difficult. In the mandible, splitting is therefore more

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successful in the anterior interforaminal region and certainly also in the
edentulous jaw. Brittleness also frequently occurs in the maxilla in
edentulous areas, which argues against splitting and in favor of an
appositional graft. Splitting has the disadvantage of poorly controllable
height resorption of the buccal lamella, which can be compensated for by
placing the implant more apically, but this is a disadvantage from an
esthetic point of view because it can result in crowns that are too long.
Splitting expands the envelope, and the implants placed at the same time
push the bone plate with soft tissue attachment outward. In addition,
splitting has an excellent healing tendency and requires hardly any foreign
material. These are major advantages for the procedure, making the overall
treatment more predictable and less expensive than block grafting.

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Fig 11-3 Single-stage bone block graft in a 2/4 defect. c. Implants scarcely have primary
stability. d. Marking of a bone block graft through the same incision but slightly more
posteriorly at the external oblique ridge. e. Osteotomy is strictly monocortical until the first
hemorrhage. The longitudinal section is pre-marked by dots. f. After the longitudinal incision
is completed, the apical incision is made through the half-submerged ball reamer. g. A
raspatory is inserted into the longitudinal slot. h. The cortical bone is detached from the
inner cancellous bone by twisting the raspatory.

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Fig 11-3 Single-stage bone block graft in a 2/4 defect. i. The external oblique ridge graft
is a purely cortical segment of approximately 3-mm thickness and variable length. j. The
block graft is placed buccal to the implants and further stabilized using lag screws. A block
graft is enormously stable due to the force of the osteosynthesis screws. k. Due to the
incision in the center of the attached gingiva, tight wound closure can be achieved with a
few stitches, leaving interstices free for blood circulation. l. Panoramic image after implant
placement and augmentation. m. Preparation of the prosthetic restoration with single
crowns. n. Lack of attached gingiva.

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Fig 11-3 Single-stage bone block graft in a 2/4 defect. o. Vestibuloplasty with a gingival
graft from the palate. p. Improved soft tissue situation. q. Mirror image of the prosthetic
restoration. r. Panoramic image after completion of treatment.

11.4 Defect Stage 3/4

Defect stage 3/4 occurs later, usually many years after tooth extraction.
However, it can also be the result of severe marginal periodontitis, an
accident, surgical tooth removal, or explantation. The shorter the tooth gap,
the better the chances of recovery. There is also a good chance of healing in
the posterior mandible if there is an anterior residual dentition without
vertical bone resorption.
The basic restoration is done by the universal method of the block bone
graft (Fig 11-4). In this situation, the block is to be used in the shell
technique. The block is inserted basally into the residual jaw in a milled
groove and is positioned coronally in a vertical overlap of the atrophic
ridge. The coronal block edge usually creates the future buccal bone
shoulder on the implant and should therefore be positioned from a
prosthetic point of view. In the posterior mandible, a defect-bridging long-
span block using a shell technique, with good overlap with the residual jaw

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at the limits of the depression, is suitable. In the posterior maxilla, a
tunneling preparation should be used to prevent dehiscence.2
Especially in the posterior mandible with long and relatively shallow
atrophies, the alternative of a swing osteotomy works better than an overlay
bone graft. Although this is technically more difficult to perform, as an
interpositional graft it is more reliable and less prone to infection (Fig 11-
5).

Fig 11-4 Two-stage block bone graft in a 3/4 defect. a. Initial situation: Dental computed
tomography scan showing loss of height on the buccal and lingual aspects. b. Exposed
defect with drilling of the groove and cortical perforation. c. Slightly more posteriorly in the
same incision, the block is lifted from the external oblique ridge. Here, the anterior and

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posterior corticotomies are performed, and the longitudinal section is pre-marked by dots. d.
The longitudinal section is completed. e. A raspatory is placed in the longitudinal slit and
twisted to loosen the cortical bone. f. In this case, resorbable osteosynthesis was performed
using Resorb X pins (KLS Martin) made of poly(D,L)-lactide. g. The resorbable pins are
made deformable by ultrasound with the aid of a sonotrode, moved into the final position,
and fused in. h. The pre-drilling is performed as described for lag screw osteosynthesis. i.
Resorbable osteosynthesis achieves lower strength values than titanium screws. The block
overlaps the defect vertically and therefore acts as a buccal covering. j. The height of the
block is slightly reduced according to the prosthetic requirements, leaving about 10 mm of
interocclusal space (3 mm for soft tissue passage and 7 mm for the crown height). k. A
large collagen membrane is cut so that a tongue grips under the lingual flap. l. Particulate
bone was collected in the filter during all bone drilling and mixed with the bone graft
substitute and venous blood. m. The space between the graft and the membrane is filled
with autogenous chips, if possible, and in the present case with a mixed graft. n. The
membrane becomes saturated with blood from the mixed graft, which forms fibrin bridges
and thereby fixes the membrane.

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Fig 11-4 Two-stage block bone graft in a 3/4 defect. o. Suturing in the attached gingiva in
the center of the alveolar ridge. p. Four months later, dental implants are placed in the now
consolidated bone. q. Detail of panoramic image showing regenerated bone and dental
implants in place. r. Spontaneous increase in attached gingival width caused only by bone
augmentation. s. Impression copings in place for prosthetic planning. t. Prosthetic
restoration (Dr. Preusse, Mölln).

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Fig 11-5 Swing osteotomy to treat a 3/4 defect. a. Baseline panoramic image. b. Buccal
corticotomy. Lingual corticotomy is performed with a chisel. c. Elevated segment with lingual
soft tissue attachment and perfusion. d. Bone substitute material is filled into the sandwich
gap. e. A collagen membrane is placed over the graft. f. Wound closure is achieved by
interrupted sutures, which can be relatively widely spaced because the attached gingiva can
be easily sutured in the center of the alveolar ridge.

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Fig 11-5 Swing osteotomy to treat a 3/4 defect. g. Osteotomy on the right side. h.
Elevated segment and osteosynthesis. i. The bone substitute material is interposed. j.
Coverage with a collagen membrane. k. Wound closure. l. Panoramic view after sandwich
interposition. m. Partially ingrown osteosynthesis plates at the time of material removal 4
months later. n. Implant placement in the left mandibular segment. Slight dehiscence at the
anterior implant due to an irregular shape of the transport segment. Bone chips are used to
compensate. o. Implant placement in the right mandible. p. Panoramic image after implant
insertion. q. Occlusal view of the prosthetic restoration. r. Prosthetic restoration on the left
side. s. Prosthetic restoration on the right side. t. Panoramic radiograph after prosthetic
restoration.

11.5 Defect Stage 4/4

Defect stage 4/4 is the almost complete loss of the tooth-bearing alveolar
process. Because of the large bone height deficits, simple onlay bone grafts
are no longer an option, as these only have a vertical effect up to about 3.7
mm. The sandwich technique can at least double this height.3 The term
sandwich technique refers to the mandible, which has quite pliable soft
tissue on the lingual side in the floor of the mouth that can tolerate vertical
displacements without disturbing the blood supply. In the posterior
mandible, the inferior alveolar nerve is the limiting structure. As a rule, at

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least 5 mm of bone should still be present above the nerve to safely form an
osteotomy segment. In the anterior mandible, anatomical limitations exist
due to the incisive nerve as an anterior extension of the mental nerve.
In the anterior maxilla, the method is usually not an option for vertical
defects because the palatal vascular pedicle is too rigid to be lifted
vertically. In this case, distraction osteogenesis is an alternative (Fig 11-6).
Here, the soft tissue pedicle is stretched slowly over weeks. Distraction
osteogenesis is also well suited for mandibular cases when, for example, the
soft tissues lack elasticity due to scarring.

11.6 References
1. Cordaro L, Terheyden L. Ridge augmentation procedures in implant patients. In: Chen S, Buser
D, Wismeijer D (eds). ITI Treatment Guide 7. Berlin: Quintessence, 2014.
2. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmentation in the posterior
maxilla: A 10-year clinical study. Int J Oral Maxillofac Implants 2019;34:471–480.
3. Geng YM, Zhou M, Parvini P, et al. Sandwich osteotomy in atrophic mandibles: A retrospective
study with a 2- to 144-month follow-up. Clin Oral Implants Res 2019;30:1027–1037.

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Fig 11-6 Distraction osteogenesis in a 4/4 defect. a. Panoramic image with marginal
periodontitis at the maxillary right central and lateral incisors. b. Panoramic image with
vertical bone defect in the same region after tooth extraction. c. The soft tissue tends to
camouflage the vertical defect of approximately 12 mm in the bone. d. The distractor is
screwed in on a trial basis and then removed again. The osteotomy of the transport
segment is now performed. The distractor is then reattached in the existing screw holes in a
reproducible manner. e. With the screws tightened, the distractor is activated a bit on a trial
basis to check the completeness of the osteotomy and the mechanics. f. The distractor post
with the activation screw protrudes a little from the gingiva. The patient places the
screwdriver here daily and activates the distractor by one turn, which amounts to an
increase of 0.3 to 0.5 mm, depending on the distractor size. g. Panoramic image after
activation of the distractor. h. The distraction has resulted in a vertical increase, but not in a
widening of the ridge. This step is performed simultaneously with implant placement. i. Filter
bone is placed onto the implant surface. j. The particulate bone is compacted by pressing it
with a moist swab.

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Fig 11-6 Distraction osteogenesis in a 4/4 defect. k. A bone block graft from the external
oblique ridge is adapted. It is aligned in height as a new buccal bone shoulder at the level of
the bone on the adjacent teeth. Fine adjustment is made exactly 3 mm below the

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prospective gingival height of the planned prosthesis. l. Osteosynthesis of the block graft.
m. As resorption protection and to increase precision in the esthetic area, the block is
covered with bone substitute particles. n. A collagen membrane is cut to size. o. It is
clamped under the palatal flap. p. Moistening makes the membrane pliable, and it conforms
to the bone graft. q. Wound closure after implant placement. r. Fixed provisional restoration
with cemented pontics. s. For exposure, the old multiple-use ridge incision is reopened. t.
Gingiva formers are screwed in. u. Initially, the prosthetic restoration shows a gingival
margin that is too apical and interdental black triangles. v. After a few weeks, the gingiva
has grown coronally to approximately 3 mm above the bone block. Interdentally, the gingiva
even manages to reach 6 mm. As a result, the planned gingival conditions have been
achieved spontaneously, triggered by the correct positioning of the bone block. w.
Posttreatment clinical image (prosthetics by Prof. Wolfart, Aachen). x. Radiograph taken 12
years later with correct marginal bone closure after remodeling of the soft tissue attachment
apparatus.

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 12
Decision Making in the Anterior
Esthetic Region

Compared to standard protocols, implant placement in the esthetic field

requires increased precision and predictability of augmentation thickness
and height over long periods of time to provide a reliable basis for
subsequent soft tissue attachment and pink esthetics. One desires a
permanent 1- to 2-mm thick labial bone wall up to the implant shoulder to
avoid the gray color of the titanium showing through the gingiva. Recession
due to graft resorption is counterproductive. Prosthetic gingiva, ie, pink
ceramic, or vestibular acrylic shields as gingival substitutes are a second
choice but can usually be avoided by correct bone augmentation. The
gingival transition of mandibular teeth is usually not in the direct view of
others, but because patients can look directly at their own mandibular
anterior teeth and the associated gingiva in the mirror, patient satisfaction
should also be promoted here by an esthetic replacement.

12.1 Special Anatomical Features of the Anterior Maxilla

The oblique position of the superior alveolar process has consequences (Fig
12-1). Implant axes placed in the direction of the bone usually create a
screw opening on the labial surface or require prosthetic compensation.
Implant axes placed in the prosthetic direction, with the screw channel on
the palatal surface of the crowns, then require augmentation. Vertical bone
atrophy always has a sagittal component due to the oblique position of the
alveolar process, which leads to recession of the atrophied alveolar ridge. In
order to compensate for occlusion, the implant axes and the denture are
often tilted forward in a fan shape, resulting in a mechanically unfavorable

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canting of the prosthetic denture (ridge lap design). This compensation
results in eccentric implant loading. Therefore, the bone should be
augmented vertically and horizontally to achieve an esthetic and
functionally resilient result. In general, sagittal discrepancies such as
pseudoprognathism and true dysgnathia cannot be compensated
prosthetically, not even with the help of dental implants. In healthy patients,
surgical correction by augmentation and, if necessary, jaw realignment is
the best option. Furthermore, unlike in the posterior region, vertical losses
cannot simply be compensated by long dental crowns. If the latter aspects
are not taken into account, the result is so-called horse teeth: long anterior
crowns that, starting from the small apical base of the maxilla, fan out and
tilt forward.

Fig 12-1 The atrophied edentulous maxilla has two disadvantages: vertical loss and the
recession of the alveolar ridge causing an anterior oblique angle. If these problems are not
recognized, long protruding anterior crowns (ie, horse teeth) will result.

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12.2 Anatomical Features of the Anterior Mandible
The anterior partially edentulous mandible very often shows an extremely
narrow apical base with a bulb shape in sagittal section. While in the
posterior region a certain buccolingual angling of the implant axes to adapt
to the opposing dentition is usually possible, this is rarely possible in the
anterior mandible because of the narrowness of the apical region. CBCT
diagnostics and, if necessary, navigated implant placement is also
advantageous because of the narrow tooth gaps (Fig 12-2). Problems are
sometimes caused by a very prominent incisive nerve, injury to which
should be avoided because neuropathic pain conditions associated with
dental implants are known in this area (Fig 12-3).1

Fig 12-2 Digital volume tomogram with ampullary mandibular cross-section with an
indentation inferior to the anterior teeth.

12.3 Gingival Biotype

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According to clinical experience, thick and thin gingival biotypes2 mainly
influence the bone thickness of the facial lamella and the recession
tendency of the gingiva3,4 on the dental implant, even though this cannot be
proven with certainty on the basis of scientific data.5 The soft tissue
thickness figures given in chapter 7 were quoted without taking the gingival
type into account and must therefore be individually adjusted.6 A thick
gingival type is more forgiving of deficiencies in bone augmentation than a
thin biotype. In short gaps, the gingiva of the thick biotype hangs like a stiff
curtain, attached to the adjacent periodontium. The problems of the thick
biotype are scarring at incisions of the gingival margin and the tendency to
pockets with associated peri-implantitis risk, which can remain unnoticed
for a long time. The thin biotype responds to deficiencies in bone
augmentation with recession and exposed implant margins. Undesirable
gray discoloration of the metal implant is also possible. Therefore, there is
an increased need for bone and soft tissue augmentation to reinforce the
gingiva of this biotype. On the other hand, the risk of peri-implantitis is
lower because the gingiva “moves away” from the infection and does not
form pockets with pathological bacterial flora in the first place.

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Fig 12-3 Digital volume tomogram. The incisive nerve can be seen in the anterior
interforminal mandible, which would be at risk in the event of implant placement.

12.4 Gingival Height and Reverse Planning

The esthetics and height of the gingiva of an implant restoration in the
anterior region should be clearly planned by anticipating the final result
digitally or in a wax-up and discussing it with the patient (Figs 12-4a and
12-4b). Reverse planning is the calculation backwards from this treatment
objective. In other words, the prospective gingival morphology is first
determined in the wax-up on the basis of the esthetic proportions and the
gingival height of existing neighboring teeth. The decisive factor for the
subsequent attachment and pattern of the gingival attachment is the bone,
because the soft tissue follows the bone passively.

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Fig 12-4 a. Trial set-up of a maxillary anterior dentition. b. Transfer to a drilling template by
duplicating in clear acrylic. c. Starting from the drilling template, the average numbers
shown here can be used to precalculate the required bone height and then generate it by
augmentation.

As a rule of thumb, the soft tissue height (chapter 7) in the edentulous

region is 1.5 mm. If the gingiva can rest on one side against a crown on the
vestibular surface, it rises to 3 mm, which corresponds to the average value
of the biologic width (Fig 12-4c). If the gingiva can support itself between
two teeth on both sides, then with a probability of 95% it rises about 6 mm
coronal to the bone.7 However, between two adjacent dental implants only 3
to 4 mm of soft tissue height can be expected, which is why this situation
should be avoided as much as possible in the anterior region by inserting
pontics or bridge attachments. These dimensions are therefore subtracted
from the specified prospective gingival height, which gives the bone level
required for the reconstruction. The bone is precisely built up to this height
by augmentation using autogenous blocks.8 In augmentation procedures
such as guided bone regeneration (GBR), which are prone to height
resorption, the amount of shrinkage must be factored in and compensated
by overcorrection.

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12.5 Precise Augmentation by Avoiding Resorption
Especially when augmenting simultaneously with implant placement,
precise and low resorption healing of the augmentation is required to
accurately adjust the labial soft tissue height with the bone graft. Resorption
protection of bone block grafts was discussed in chapter 2 and consists of
using hard bone graft types such as external oblique ridge blocks,
membranes, and bone graft substitutes such as xenogeneic bone graft
substitute to cover the block graft. In contrast to the former methods, the
additional use of a bone graft substitute in the wound also has
disadvantages because it increases the amount of foreign material and
creates infection risks due to interfaces for possible biofilm formation
directly under the suture.

12.6 Implant Positioning

Vertical
As a rule, implants with a raised rough-smooth border and platform
switching, so-called bone-level implants, are used in the esthetic field.
However, this name does not suggest that the implants are placed at the
level of the existing bone, but rather at the level of the prospective bone
after augmentation. The implants are therefore planned with their rough-
smooth border in the vertical plane at the prospective bone height
corresponding to the prospective gingival height. There is little tolerance in
the vertical dimension. It is true that dental technicians like to place the
implant somewhat more apically, because a longer emergence profile can
then better compensate for implant misplacements. However, if the implant
is placed too deep, the biologic width will be violated. In a single-tooth gap,
where the gingiva is attached to the healthy adjacent periodontium, an
implant placed too apically would create a pseudopocket and a loss of
attachment to the adjacent periodontium because the body strives to comply
with the law of biologic width. Thus, an implant placed too apically in a
single-tooth gap will produce iatrogenic damage to the adjacent tooth. In a
larger gap, if the implant is placed too apically, the entire gingival margin
will be established more apically, resulting in interdental black triangles and
food retention.

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Mesiodistal
The implant diameter should be selected so that there is a 1.5- to 2-mm
distance from the neighboring teeth in a gap. If one places the implant
closer to the neighboring tooth, the soft tissue attachment apparatus will not
have enough space. The so-called biologic width should actually be called
biologic height, but this structure also has a space requirement in its width.
If this space requirement is not met in the mesiodistal direction, iatrogenic
damage occurs due to loss of attachment to the neighboring teeth with the
formation of a more apical papilla tip. If the horizontal minimum distances
are not observed between two implants, the papillae also lose height with
the formation of interdental black triangles. In very narrow gaps, for
example, in mandibular anterior teeth and some maxillary lateral incisors,
eg, in the case of gaps caused by agenesis, it is sometimes necessary to go
slightly below these minimum distances. If at least one platform-switched
implant is used, the distance of the platform switch can be added to the
horizontal biologic width. This results in a minimum gap width of 5 mm for
a 2.9-mm implant with a 2.2-mm abutment diameter, for example. If the
gap is even smaller, one should rather think about the option of the single
retainer resin-bonded prosthesis.

Orofacial
Augmentation success and also long-term preservation of the alveolar
process is initially best achieved within the envelope. There are
augmentation techniques that can offset the envelope, such as extended
splitting or a long bone block. But for the single implant position, the goal
should be that it should always be within the buccal contour line of the
alveolar process. If the opposing dentition suggests a different implant
positioning, eg, in the case of dysgnathia or pseudoprognathism, then it
should be remembered that dysgnathia should not be compensated
prosthetically but skeletally by appropriate surgery. If the reason is
pseudoprognathism, then the occlusal height must be corrected and not the
orofacial implant position (see chapter 14). Basically, a simple rule applies
to the orofacial implant position in both jaws. Place the implant in contact
with the palatal wall. The prerequisite is that this wall has been clearly
visualized by soft tissue detachment and can be assessed intraoperatively. If

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this wall is missing, it should be built up by augmentation (see section 11.4
Defect Stage 3/4 in chapter 11).

Fig 12-5 Esthetic complication management. a. Infraocclusion due to implant placement

at young age before the pubertal growth spurt. Vestibular fistula. b. Panoramic radiograph
with approximately 7-mm infraocclusion, after an attempt at compensation by an overlong
abutment. c. Bone defect largely concealed by the soft tissue after explantation. d. After
opening, the extent of the bone defect is shown. e. Treatment of the bone defect by
autogenous bone block from the external oblique ridge. f. Panoramic radiograph showing
osteosynthesis screws.

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12.7 Augmentation for Dental Agenesis and Adolescents
The alveolar process grows throughout life by further eruption of the teeth.
This growth can be seen when an anterior implant moves into
infraocclusion with the adjacent teeth over time, especially in patients with
a vertical growth pattern (Fig 12-5).
The greatest growth is to be expected in childhood up to 12 years of
age, with up to 23.7 mm vertical growth, which results from the deepening
of the palatal arch (dentoalveolar growth) and the drift of the maxilla in the
vertical development (craniofacial growth) of the midface9,10 (Table 12-1).
An ankylotic dental implant would not follow this drift and would therefore
be in infraocclusion by this amount in relation to the occlusal plane. In
adolescence from 12 to 18 years, the addition of dentoalveolar and
craniofacial growth results in mean infraocclusions of about 3.1 mm for an
implant placed in adolescence, but in the most unfavorable individual case,
taking into account the observed data spread, up to 7.9 mm.11 Beyond the
age of 18, no further craniofacial growth can be assumed, but there is still a
vertical development of the alveolar process by eruption of the teeth, with a
mean 1.7-mm and maximum 5.8-mm infraocclusion of a dental implant.
Beyond the age of 31, there are data of a mean of 0.3 mm of further
infraocclusion, which is probably clinically tolerable. However, in
individual cases, in 6.25% of patients, the infraocclusion was significant
enough that crowns had to be remade. No exact values have been reported
in studies,12,13 but the author assumes that crown remaking is performed for
an infraocclusion >1 mm, which is considered to be the maximum value for
the older adult age group.

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Fig 12-5 Esthetic complication management. g. Soft tissue contour after healing of the
bone block. h. Reentry. The bone block had partially integrated 4 months later. i. Panoramic
view after implant placement in the bone block. j. Implant uncovering as an interim
outcome. k. Documentation of stability 7 years later. The patient has moved to another
location and kindly took a photo with his cell phone camera.

Table 12-1 Mean and maximum infraocclusion and implant survival in the maxillary anterior
region with implant placement during growth14,16

Mean infraocclusion Maximum Implant survival (%)

(mm) infraocclusion (mm)
Children up to 12 M 17.4 – F 14.0 M 23.7 – F 20.3 72.4
years

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Adolescents (12–18 3.1 7.9 93
years)
Young adults (18–31 1.7 5.8 97.4
years)
Adults (>31 years) 0.3 >1 up to 100
M, male; F, female.

Contrary to what may have been initially expected, implant prognosis

improves with age, which may be related to the improved bone supply and
reduced immune response of the elderly to foreign bodies.14
Girls go through the pubertal growth spurt, recognizable by menarche,
at around 13 years of age, and boys later at around 15 years of age. After
that, alveolar process growth slows down. If an implant restoration is
planned, then waiting for the pubertal growth spurt is the best compromise
between the threat of implant infraocclusion and increased psychologic
stress.15 Taking into account the individual psychologic stress, augmentation
and implantation can then also be performed before the age of 18 according
to the Association of Scientific Medical Societies in Germany (AWMF)
guidelines, if necessary with 1 to 2 mm epicrestal positioning as a secutity
surcharge, because further growth of the adjacent dentition can be expected
until the age of 30 years and beyond.16 An orthodontic gap opening in the
case of dental agenesis should take place immediately before implant
restoration so that the created edentulous area does not atrophy horizontally
due to inactivity and trigger greater augmentation requirements. The most
elegant way to solve these bone deficiencies in the adolescent is by soft
tissue–covered bone splitting, taking advantage of the elasticity of
adolescent bone. However, it must be taken into account that sometimes the
bone in edentulous regions due to agenesis cannot be split due to fusion of
the vestibular and oral compact bone. In this case, the two-stage block graft
is usually preferred.

12.8 Vertical Augmentation to Preserve Adjacent Teeth

As one can see from the concept of the envelope, the periosteum is working
toward making the bone contour as smooth as possible. Protrusions are
remodeled and leveled in the long run. This is a good thing in a dislocated
comminuted fracture, for example. In terms of vertical bone defects in the

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dentition, however, this tendency means severe damage to neighboring
teeth. If vertical atrophy or a vertical defect in the dentition is not
augmented and the implant is placed deeper, then bone resorption and
attachment loss of the adjacent neighboring teeth will occur.17 As a result,
these teeth develop gingival recession or, root caries or may become loose.
Therefore, in the case of trauma causing a vertical defect, the primarily
uninvolved neighboring teeth are often secondarily threatened by
inadequate restoration and later have to be extracted.
In the author’s experience, vertical augmentation in these cases supports
the periodontal tissue on the adjacent teeth, which in some cases slowly
creeps back up the roots over a period of months (creeping attachment).
This effect works particularly well if the augmentation is not carried out
abruptly, but gradually over weeks through distraction osteogenesis.

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Fig 12-6 Esthetic complication management. a. Defect after a bicycle accident, with
subsequent treatment in another office with an allogeneic bone graft and implant placement,
and eventual implant and augmentation loss. The adjacent right central incisor and left
canine show recession and were planned for extraction by another practitioner. b. Fistula
and chronic wound after allogeneic bone graft. c. Segment osteotomy and installation of a
TRACK 1.0 distractor (KLS Martin). d. Panoramic image before activation. e. Panoramic
image after about 10 days of activation . f. Implant placement 3 months after the start of
distraction osteogenesis, waiting for the consolidation phase.

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Fig 12-6 Esthetic complication management. g. Panoramic image after implant
placement. h. Connective tissue graft placed during implant exposure. i. Augmentation of
the labial gingiva. j. Placement of the crowns. k. Patient’s photo (taken with a cell phone
camera) a few months later shows some creeping attachment at the right central incisor and
left canine. The teeth are stable and fully preservable.

12.9 Implant Treatment of Vertical Defects in Periodontally

Compromised Dentition
Implants should only be placed after decontamination of periodontitis.
However, even after rehabilitation and supportive therapy, there is a risk of

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recurrence of marginal periodontitis and a failure of dental implants.
There are different opinions about the use of dental implants in
periodontally damaged edentulous regions. Apart from the increased risk of
periimplantitis, after periodontal bone loss the implants are inevitably
positioned too apical in the gaps relative to the neighboring teeth, so that an
uneven dentition with different bone heights results. If periodontitis then
progresses and further teeth are lost, the end result is often a ridge with
implants from various manufacturers distributed more or less haphazardly,
which can hardly be reasonably useful from a prosthetic standpoint. With
this in mind, conventional dental prostheses in the edentulous region would
be more reasonable. Vertical augmentations in small tooth gaps are difficult
in this situation with conventional abutment techniques, because the
periodontally damaged neighboring periodontium does not contribute any
healing support (ie, wall thickness) and rather creates infection risks.

Fig 12-7 Vertical augmentation in periodontally damaged dentition. a. Vertical defect

after periodontitis-related tooth loss in the mandibular anterior region. b. Panoramic image
in initial position with defect. c. Segment osteotomy and installation of a TRACK 1.5
distractor (KLS Martin). d. Panoramic radiograph after activation of the distractor.

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 On the other hand, dental implants provide perioprosthetic stabilization
for the remaining teeth so that, with good hygiene and consistent
periodontal supportive therapy, the natural teeth become stronger again and
can be preserved in the long term. The image of the picket fence can be
used here, where individual damaged pickets are renewed, but the fence
remains in place for life. The indication for implant restoration in sites with
periodontal damage depends on the prognosis of the dentition and the
patient’s cooperation.
If the canines still look relatively good after anterior tooth loss in the
maxilla or mandible, the temptation is great to place two implants in the gap
for a two-on-two anterior partial denture. Most often, this results in
overlong dental crowns. In this situation, vertical augmentation by
distraction osteogenesis (Fig 12-7) or interpositional bone grafting is
indicated (Fig 12-8) to raise the bone level to match the rest of the dentition.

12.10 Treatment of Bone Defects in the Anterior Maxilla

The restoration of the esthetic region in the maxilla does not deviate from
the treatment concept in chapter 11. However, it should be extended to
include the aspects of gap length, bony walls (healthy neighboring
periodontia), and position in the envelope (Fig 12-9).
The earlier the resorption stage, the shorter the gap, the better
surrounded by intact teeth with intact periodontia, and the further in the
envelope the defect is located, the more likely GBR is to be considered.
Thus, in the case of 2/4 defects in single-tooth gaps, GBR is sufficient,
deviating from the overall treatment concept (Fig 12-10). In single gaps,
even in the case of deep vertical defects (4/4), meshes (Fig 12-11) or bone
blocks (Fig 12-12) can be used successfully. This is because the 3.7-mm
angiogenesis distance from the walls of the defect in healthy neighboring
periodontia also counts in the horizontal dimension.

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Fig 12-7 Vertical augmentation in periodontally damaged dentition. e. Distractor after
activation with exposed upper attachment plate and soft tissue dehiscence without negative
consequences. f. After consolidation phase and implant placement in the distraction
segment. g. Panoramic image after implant exposure 3 months later showing consolidated
bone. h. Prosthetic restoration (Dr Merk, Bad Nauheim).

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Fig 12-8 Vertical augmentation in periodontally damaged dentition. a. Panoramic
image with periodontally damaged mandibular anterior dentition. b. Vertical defect after
extraction of all four incisors. c. Sandwich Interposition bone graft for vertical elevation.

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Fig 12-8 Vertical augmentation in periodontally damaged dentition. d. Panoramic
image after sandwich bone graft. e. Implant placement 4 months later. f. Prosthetic
restoration. g. Panoramic radiograph after prosthetic restoration.

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Fig 12-9 Decision-making process from chapter 11 extended for the esthetic area by the
factors gap size, defect walls, and envelope.

The higher the resorption stage (4/4), the greater the gap, the less
enclosed by intact periodontia, and the further outside the envelope the
defects are, the more likely distraction osteogenesis (DO) is indicated.
Simple interpositional bone grafting without distraction has a maximum
limitation of 3 to 4 mm in the anterior maxilla because of the rigid palatal
soft tissues and is therefore not indicated, because this height can be
obtained by simpler procedures, eg, the GBR with mesh technique. GBR
and DO thus represent extremes in the spectrum of indications. The space in
between can be filled by autogenous bone block grafts, which are thus quite
universally applicable.

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Fig 12-10 Deviation from the treatment concept in a maxillary lateral incisor. a.
Anterior tooth trauma at the maxillary right lateral incisor. b. Surgical removal of the root
remnant a few days after trauma. Ridge preservation with collagen fleece in the socket. c.
Defect situation 6 months later. d. Incipient 2/4 defect at implant drilling, defect within the
envelope. e. Implant in 2/4 defect. f. Tongue-shaped Bio-Gide membrane (Geistlich). g.
Tongue of the membrane tucked under the palatal flap. h. Mixed bone graft of Bio-Oss bone
graft substitute (Geistlich), drill bone chips, and venous blood after coagulation. i. Lateral
augmentation, processing of the bone graft substitute in a malleable piece thanks to the
coagulation of the autologous blood. j. Covering with the help of the Luniatschek gauze
packer. k. Membrane in a double layer. l. Moistening the membrane so that it adheres and
sticks like blotting paper.

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Fig 12-10 Deviation from the treatment concept in a maxillary lateral incisor. m. Flap
mobilization by periosteal incisions using a Gillies single hook retractor and fresh 15c
scalpel. n. Wound closure is possible with relatively few stitches thanks to the midcrestal
incision (Supramid 5-0, Resorba). o. Implant implant uncovering. p. Radiograph after
exposure. q. Intermediate result after prosthetic restoration.

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Fig 12-11 Deviation from the treatment-planning concept: vertical defect treated with
a GBR mesh technique. a. Panoramic radiograph with vertical defect at the maxillary left
second premolar. The adjacent second and third molars were already scheduled for

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extraction due to bone deficiency. b. Construction of the individual Yxoss Mesh (ReOss). c.
Defect after exposure. d. Exposed sinus membrane during lateral window sinus elevation.
e. After high dissection, accidental membrane perforation at the site of the small septum
visible in the panoramic image in the maxillary left first molar region. f. Moistened collagen
fleece (Kollagen Resorb, Resorba). g. Insertion of the collagen fleece into the sinus to cover
the membrane perforation with the Luniatschek gauze packer. h. Collagen fleece in situ.

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Fig 12-11 Deviation from the treatment-planning concept: vertical defect treated with
a GBR mesh technique. i. Exposed left external oblique ridge with tracks left by bone
harvesting with the scraper. j. Bio-Oss bone substitute. k. SafeScraper (Geistlich) with filled
container. l. Filling with fresh venous blood as a safely sterile liquid. m. Wetting of all
cavities of the porous material with sterile liquid so that it does not become saturated with
contaminated saliva during application in the mouth. n. Scraper bone is added in a ratio of
25% bone to 75% bone substitute; the blood has not yet coagulated. o. The mixture
coagulates due to the tissue thrombokinase of the bone. p. Filling of part of the graft into the
sinus floor. Due to coagulation, there is little risk of dislocation of individual particles into the
sinus through the membrane perforation. q. The mesh after sterilization. r. The mesh is filled
with the bone graft mixture. The clotted blood holds all particles together in place. s.
Inserted mesh with good fit due to customized printing technique. t. The Bio-Gide
membrane is cut to a tongue shape. u. Moistening of the membrane in situ with saline
solution. v. Wound closure with 4-0 single interrupted and interdental sutures.

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Fig 12-11 Deviation from the treatment-planning concept: vertical defect treated with
a GBR mesh technique. w. Healed mesh without premature exposure. x. After 4 months,
exposure of the mesh for removal. y. Section of a panoramic image with mesh in situ. z.

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Implant insertion into the regenerated bone. aa. Section of a panoramic image with implant
as a preliminary result; prosthetic restoration has been performed by the general dentist.
bb. Panoramic image (section) after prosthetic restoration. cc. Prosthetic restoration. (Dr K.
Schlichter, Offenbach an der Queich).

Fig 12-12 Deviation from the treatment-planning concept: 4/4 vertical defect treated
with a bone block. a. Panoramic image with vertical defect at the maxillary left premolars.
b. Exposed defect. c. Thick defect-matched bone block from the external oblique ridge. d.
Osteosynthesis. e. Covering with mixed particulate graft (bone substitute, venous blood,
and 25% filter bone) for resorption protection and contour augmentation. f. Tongue-shaped
membrane with retention behind posterior teeth.

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Fig 12-12 Deviation from the treatment-planning concept: 4/4 vertical defect treated
with a bone block. g. The membrane holds automatically due to the capillary effect
(surface tension of the fluids). h. Tight wound closure, despite fewer sutures, because the
incision was made in the middle of the attached gingiva. This leaves plenty of room for flap
margin perfusion. i. Panoramic image with block in situ. j. Dental implants placed after 4
months. k. Prosthetic restoration. l. Panoramic radiograph 4 years later with stable bone
level in the maxillary left premolar region.

Splitting is a special indication group for the 2/4 defect, which is linked
to special conditions (splittable lamellae, axial deviation, and risk of height
resorption of the buccal lamella; Fig 12-13). Due to the height resorption of
the buccal lamella during splitting, it is advisable to perform splitting in two

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stages in large gaps in the anterior maxilla and wait for remodeling for 4
months (Fig 12-14).

Fig 12-13 Bone splitting with 2/4 defect. a. Initial situation with narrow alveolar ridge with
sufficient height. b. The CBCT shows a spongy bone structure of the anterior maxilla with 5-
mm residual width and little corticalization. The anterior maxilla is not very oblique, rather
vertical, which is a good condition for bone splitting. c. Exposure of the defect via midcrestal
incision so that the ridge is exposed but the vestibular bone is not denuded. d. Measuring
the width of the ridge with the calipers: 5 mm. e. Midcrestal incision of the ridge using the
diamond flame bur. Starting from the incision, subperiosteal vertical relief osteotomies were
made laterally toward the vestibule so that the labial segment can move in a controlled
manner. f. The blade chisel is entered to approximately the level of the nasal floor to swing
out the labial segment.

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Fig 12-13 Bone splitting with 2/4 defect. g. The dental implants are clamped in the gap
and show hardly any primary stability due to the elasticity of the labial bone wall. Because of
the expected resorption, they tend to be placed slightly more apically than normal. h.
Wound closure can only be adaptive, leaving a gap, because the flap was not mobilized to
avoid scarring and keep the bone segements pedicled. i. The removable provisional can
continue to be worn, but because of the additional volume of the splitting, the vestibular
flange must be separated or greatly reduced. j. Panoramic image with implants in situ. k.
Prosthetic restoration.

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Fig 12-14 Combination blocks and splitting. a. Nearly edentulous maxilla. b. Lateral
cephalometric radiograph shows the severe bialveolar protrusion as a difficulty. c. Two-
stage bone augmentation by bone splitting in the incisor region and bone blocks in the

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canine–first premolar region on both sides. d. Healed augmentation and temporary implants
(IPI, Nobel Biocare) in situ. e. Panoramic image after augmentation with IPI implants. f.
Lateral cephalometric image showing augmentation gain. g. After 4 months, the implants
are placed. h. Panoramic image after implant placement.

Fig 12-14 Combination blocks and splitting. i. Lateral cephalometric image with straight
implant axes; compare to Fig 12-14b. Block augmentation allowed axial correction. j.
Implant uncovering. Because the incision was always made midcrestal, a ring of firmly
attached gingiva automatically results around the implants without additional gingival
grafting or other complex soft tissue management. k. Digital planning of the prosthesis. l to
n. Prosthetic restoration (Dr Volmar, Espenau).

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Notes on the differential indication: GBR versus autogenous block
graft in the esthetic region
Because of the tendency toward height resorption of particulate bone grafts,
which achieve only 80% defect coverage on average, at least 2 mm should
be overcorrected in all directions. For this purpose, a 4-mm thickness
should be built up. Vertical overcontouring by 2 mm should also be
performed, eg, by working against a short gingiva former instead of the flat
implant cover screw. In the onion-shell technique, augmentation is built up
layer by layer. Vital autogenous bone chip material (from the bone scraper)
is first placed on the implant. A mixture of bone substitute material can be
placed on coronally to fill the defect, and pure bone substitute material can
be placed labially for overcontouring. A material with a low substitution
rate (eg, Bio-Oss) secures the volume gained for years.18 A collagen
membrane is placed as resorption protection. The augmentation can also be
modified with thickened variants of collagen membranes (Bio-Gide
Compressed) or collagen membranes with extended service life, up to the
combination of polytetrafluoroethylene (PTFE, ie, Teflon) membranes for
service life with collagen membranes for tissue compatibility. As the final
layer, the uninjured periosteum of the full-thickness flap follows. Here,
suturing has to be done very carefully, because a partial loss of
augmentation on the labial surface of the implant would lead to dehiscence
of the soft tissues with an esthetic failure.
The single-stage autogenous bone block augmentation was superior to
GBR in augmentation efficacy in a direct comparison in a randomized
trial.19 Autogenous materials have a high value in the esthetic field in terms
of increasing the predictability of an augmentation. A bone block can be
used to adjust the gingival height very precisely, even over larger gaps (see
Fig 12-14). If the neighboring periodontium is already damaged, this is
more in favor of a block graft and against a GBR. Contour gaps between the
block, implant, and residual bone are bridged with particulate autogenous
material (scraper bone), and the relatively indefinite overcontouring of
GBR is omitted with the block. Revision situations with scarring speak in
favor of the block graft (Fig 12-15). Similarly, exposed teeth at the border
of or outside the envelope can be treated with a block (Fig 12-16).
However, block grafting is more complex than GBR and may result in more
severe complications.

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Notes on vertical defects in larger gaps
Vertical defects in the anterior maxilla and mandible occur after trauma and
after marginal periodontitis. The most important aspect of vertical
augmentation in the esthetic field as opposed to posterior teeth is the
avoidance of long dental crowns (colloquially known as “horse teeth”).
These make patients look older and give the impression of chronic
periodontitis to the observer. For the treatment of vertical deficits in the
esthetic area, attached bone blocks in the shell technique have proven
successful in cases of small gap width (see section 11.4 Defect Stage 3/4 in
chapter 11).
In the case of large vertical defects, the indication for inpatient
treatment with iliac bone graft placement should not be delayed. However,
this method has the disadvantage of resorption that is sometimes difficult to
predict. If a transport segment can still be formed under the nasal floor,
distraction osteogenesis is the method of choice. It allows a slow gradual
stretching of the rigid palatal tissue. A vertical overcorrection of about 20%
of the displacement distance is recommended. It must often be
supplemented by lateral augmentation to widen the ridge (Fig 12-17).
Reverse planning with trial setup of the teeth prior to treatment is helpful
for planning the augmentation requirements.

12.11 Treatment of Bone Defects in the Anterior Mandible

Early defect stages 1/4 to 3/4 in smaller gaps can be treated well by GBR.
Block grafts are rarely indicated for partially edentulous patients in the
anterior mandible because of the small distances involved and because the
canines are usually still in place. Small vertical defects can be compensated
by longer crowns. For 2/4 defects, bone splitting is often possible. For large
vertical 4/4 defects involving the entire anterior mandible, eg, after tumor
defects or trauma, interpositional bone grafting is the method of choice for
alveolar bone augmentation (Fig 12-18). If scarring is present, distraction
osteogenesis is more suitable (Fig 12-19).

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Fig 12-15 Longitudinal defect in the anterior maxilla. a. Deviation from the treatment-
planning concept: single-stage procedure for 1/2 defect. Augmentation by block graft from
the external oblique ridge on both sides; purely autogenous procedure in a shell technique
without bone substitute. b. Panoramic image with single-stage augmentation. c. Removable
prosthetic restoration on galvano-telescopic copings. d. Mirror view. e. Mirror view of the
copings. f. Frontal view of the copings.

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Fig 12-16 Single-stage bone block in 1/2 defect after previous surgery. a. Severe
scarring after previous incision in the vestibulum in another office. Condition after implant
loss. b. Horizontal defect of the bone. c. Panoramic view of the initial situation. d. Gingival
margin and midline incision of the alveolar ridge. Here pilot drilling was complicated by
missing vestibular bone. e. The trial post already shows the future dehiscence defect. f. The
last trial abutment of the Straumann BL System is inserted.

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Fig 12-16 Single-stage bone block in 1/2 defect after previous surgery. g. Machine
implant placement in a straight line without wiggling to avoid multiple threading. h. The
insertion depth of the bone-level implant is the bone shoulder of the adjacent teeth. i. 1/2
defect with >50% implant exposure. j. Placement of the retromolar bone block from the
external oblique ridge. k. Osteosynthesis. The curve of the external oblique ridge graft is
placed crestally. The block is 3 mm apical to the prospective gingival height and precisely
defines the subsequent esthetics because it resorbs very little or not at all. l. Gap-free
joining of the block so that the cutting cores can enter without interference and the block
integrates quickly. m. Mixed bone graft for further contour filling. n. The Bio-Gide membrane
is cut to a tongue shape. o. It is placed under the palatal flap with Luniatschek gauze
packer. p. The membrane is held in place here and requires no further fixation. q. Blood
coagulation allows the mixed bone graft to be transferred in one piece. r. In the defect, it is
first pressed into the contour gaps. s. A larger carpet-like piece is placed vestibularly as
resorption protection. t. The membrane is folded over and moistened.

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Fig 12-16 Single-stage bone block in 1/2 defect after previous surgery. u. Flap
mobilization, performed with a single hook retractor and scalpel, is complicated by previous
surgery, unfavorable previous incision placement, and scarring. v. There is considerable
disfiguration of the vestibule because the flap has lost its natural elasticity due to scarring.
w. Occlusal view of soft tissue coverage with primary wound closure. x. After 4 months, the
vestibule has already deepened spontaneously without further soft tissue management. y.
Panoramic view with vertical implant position at the height of the adjacent teeth. z.
Uncovering of the implant within the midline incision of the alveolar ridge with positioning of
the vestibular gingiva and slight apically positioned flap.

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Fig 12-16 Single-stage bone block in 1/2 defect after previous surgery. aa. Minimally
invasive osteosynthesis material removal by a stab incision to avoid surface resorption due
to periosteal detachment, which would result in gingival recession and compromised
esthetics. bb. Inserted gingiva former. The slight blanching of the gingiva improves after a
few minutes. Otherwise, the gingiva former would have to be removed and the flap better
mobilized. cc. Panoramic image after implant exposure with correct bone level at the
implant. dd. Prosthetic restoration (Dr Klatt, Kassel). ee. Frontal view with esthetic
impairment due to scarring. ff. Detail showing the correctly adjusted gingival height through
the bone block.

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Fig 12-17 Bone block in 1/4 defect. a. Initial situation: maxillary left central incisor located
prominently outside the envelope. b. Panoramic radiograph: apical periodontitis and
incomplete root filling at the maxillary left central incisor. c. After extraction of the maxillary
left central incisor, ridge preservation is performed with a gingival tissue punch graft from
the palate. d. Sutured tissue punch graft. e. Very active healing of the tissue punch graft
after rapid vascularization after one week. f. Result a few weeks after tissue punch graft
insertion. g. Panoramic image: initial situation before augmentation. h. Defect opening via
gingival margin and alveolar ridge incisions. i. Stage 1/4 defect with exposed implant
shoulder. j. Bone block from the external oblique ridge placed 3 mm apical to the
prospective gingival height and covered with a collagen membrane. k. Only autogenous
filter bone was used for contour filling. l. A section of membrane is also placed under the
palatal flap in a double layer with the Luniatschek gauze packer. m. The double layer in this
case should provide maximum security against biofilm formation on the bone in case of
possible dehiscence. n. Wound closure is possible with only a few sutures to leave plenty of
room for flap margin perfusion.

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Fig 12-17 Bone block in 1/4 defect. o. Panoramic radiograph after single-stage implant
placement. p. Minimally invasive removal of the osteosynthesis material is performed 4
months later to avoid risking surface resorption of the block. q. For exposure, only the
previous midcrestal incision is reopened without the need for major soft tissue
management. r. At the gingiva former, the slightly epiperiosteal to buccal flap is established
at a 3-mm height (corresponding to biologic width). s. Prosthetic restoration (Dr Pindur,
Frankfurt am Main).

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Fig 12-18 Mandibular anterior sandwich interposition bone graft. a. Baseline with
extensive vertical defect after cyst removal surgery in another office. b. Panoramic image of

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the baseline situation. c. The initial CBCT shows a favorable, relatively deep nerve position.
This allows a large securely pedicled bone segment. d. Segment osteotomy after exposure
of the defect via a midcrestal incision. e. Osteosynthesis after elevation of the transport
segment with 2.0 Mini plates (KLS Martin). f. Interposition of a mixed bone graft (Bio-Oss).
g. Panoramic image after augmentation.

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Fig 12-18 Mandibular anterior sandwich interposition bone graft. h. Panoramic
radiograph after implant placement 4 months later. i. Another 3 months later, at the time of
implant exposure. Lack of attached gingiva is evident. j. Incision for a thick, box-shaped

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gingival graft from the hard palate. k. Vestibuloplasty with epiperiosteal preparation to
create a vascular recipient bed for the gingival graft. l. Sutured gingival graft. m. Prosthetic
restoration (Dr Trohorsch, Frankfurt am Main). n. Panoramic image after prosthetic
restoration.

Fig 12-19 Mandibular anterior distraction osteogenesis. a. Panoramic radiograph

showing the initial situation with a vertical defect after a motorcycle accident with treatment
performed in a different office. b. Segment osteotomy and formation of a voluminous
transport segment with distractor fixation (TRACK 1.5, KLS Martin). c. Activated distractor
after about 3 weeks. d. Toward the end of distraction, soft tissue dehiscence often occurs
over the upper attachment plate without negative consequences. e. Panoramic image after
implant placement in the transport segment after completion of the consolidation phase. f.
Prosthetic restoration (Dr Kuhlmann, Kassel).

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Fig 12-19 Mandibular anterior distraction osteogenesis. g. Panoramic radiograph after
prosthetic restoration. h. Follow-up 10 years later without bone recession.

12.12 References
1. Politis C, Agbaje J, Van Hevele J, et al. Report of neuropathic pain after dental implant
placement: A case series. Int J Oral Maxillofac Implants 2017;32:439–444.
2. Olsson M, Lindhe J, Marinello CP. On the relationship between crown form and clinical features
of the gingiva in adolescents. J Clin Periodontol 1993:20:570–577.
3. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants
Res 2008:19:73–80.
4. Nisapakultorn K, Suphanantachat S, Silkosessak O, Rattanamongkolgul S. Factors affecting soft
tissue level around anterior maxillary single-tooth implants. Clin Oral Implants Res
2010:21:662–670.
5. Akcalı A, Trullenque-Eriksson A, Sun C, Petrie A, Nibali L, Donos N. What is the effect of soft
tissue thickness on crestal bone loss around dental implants? A systematic review. Clin Oral
Implants Res 2017;28:1046–1053.
6. Thoma DS, Mühlemann S, Jung RE. Critical soft-tissue dimensions with dental implants and
treatment concepts. Periodontol 2000 2014;66:106–118.
7. Roccuzzo M, Roccuzzo A, Ramanuskaite A. Papilla height in relation to the distance between
bone crest and interproximal contact point at single-tooth implants: A systematic review. Clin
Oral Implants Res 2018;29(Suppl 15): 50–61.
8. Chiapasco M, Tommasato G, Palombo D, Del Fabbro M. A retrospective 10-year mean follow-
up of implants placed in ridges grafted using autogenous mandibular blocks covered with bovine
bone mineral and collagen membrane. Clin Oral Implants Res 2020;31:328–340.
9. Thilander B. Dentoalveolar development in subjects with normal occlusion. A longitudinal study
between the ages of 5 and 31 years. Eur J Orthod 2009;31:109–120.
10. Antoun JS, Cameron C, Sew Hoy W, Herbison P, Farella M. Evidence of secular trends in a
collection of historical craniofacial growth studies. Eur J Orthod 2015;37:60–66.
11. Yoon SS, Chung CH. Comparison of craniofacial growth of untreated Class I and Class II girls
from ages 9 to 18 years: A longitudinal study. Am J Orthod Dentofacial Orthop 2015; 147:190–
196.
12. Andersson B, Bergenblock S, Fürst B, Jemt T. Long-term function of single-implant restorations:
A 17- to 19-year follow-up study on implant infraposition related to the shape of the face and
patients’ satisfaction. Clin Implant Dent Relat Res 2013;15:471–480.

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13. Bergenblock S, Andersson B, Fürst B, Jemt T. Long-term follow-up of CeraOne™ single-
implant restorations: An 18-year follow-up study based on a prospective patient cohort. Clin
Implant Dent Relat Res 2012;14:471–479.
14. Terheyden H, Wüsthoff F. Occlusal rehabilitation in patients with congenitally missing teeth-
dental implants, conventional prosthetics, tooth autotransplants, and preservation of deciduous
teeth—A systematic review. Int J Implant Dent 2015;1:30.
15. Terheyden H, Tetsch J. S3 guideline dental implant restorations in multiple tooth nonunions and
syndromes. Z Zahnärztl Implantol 2019;35:190–194.
16. Terheyden H. Implant restorations in children, adolescents and young adults. Indication and
timing. Implantology 2018;26:115–122.
17. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implants in
adolescents: A 10-year follow-up study. Eur J Orthod 2001;23:715–731.
18. Sanz M, Vignoletti F. Key aspects on the use of bone substitutes for bone regeneration of
edentulous ridges. Dent Mater 2015;31:640–647.
19. Benic GI, Eisner BM, Jung RE, Basler T, Schneider D, Hämmerle CHF. Hard tissue changes
after guided bone regeneration of peri-implant defects comparing block versus particulate bone
substitutes: 6-month results of a randomized controlled clinical trial. Clin Oral Implants Res
2019;30: 1016–1026.

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 13
The Posterior Regions: Free-End
Situations

In the posterior regions, too, the decision-making process for augmentation

procedures follows the treatment-planning concept in chapter 11. In the
posterior regions, bone can thus be reliably built up horizontally and
vertically. The topic of this chapter is predominantly the differential
indication for augmentation alternatives. In the posterior regions, the
regenerative approach must be weighed against prosthetic tissue
replacement. In the posterior mandible, for example, a vertical deficit can
usually be compensated by short implants and long crowns without major
esthetic disadvantages. In the posterior maxilla, for example, there are
efforts to avoid sinus elevation surgery.

13.1 Clinical Considerations in Free-End Situations

The basic approach of this chapter is to compensate for bone defects in
partially edentulous patients with free-end situations in order to create
conditions that mimic natural bone for dental implants and dentures. This is
also the best prophylaxis for the atrophied adjacent teeth, which are
otherwise prone to periodontal overload, gingival recession, and root caries
(Fig 13-1). In general, the adequate restoration of a free-end situation is, to
a certain extent, a conservative treatment, because the restoration of the
occlusal support zones protects the temporomandibular joint and either
prevents or is a prerequisite for the functional treatment of
temporomandibular joint problems by occlusal splints. The perioprosthetic
stabilization of the residual dentition by implant restoration of free-end
situations should also be mentioned. If an anterior residual dentition has to

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bear the same chewing force as the previous dentition with 14 occlusal
pairs, periodontal tooth migration and tooth loosening due to overloading
are possible. Restoration of the supporting zones by means of bone
augmentation and dental implants can prevent this tendency and thus
preserve a compromised dentition. Finally, the esthetic and functional (eg,
angular cheilitis) effect of an increase in bite height via reconstruction of
the supporting zones by means of augmentation and dental implants should
be mentioned, because in the case of free-end situations there has usually
been a reduction in dimension of occlusion beforehand due to abrasion and
tooth migration. In the ideal situation, ie, with bone augmentation and
dental implants, the patient is restored to the youthful condition of a full
dentition. Such a regenerative approach is, of course, associated with
expense and surgical interventions. A large part of this chapter deals with
the coordination of the treatment aims and the extent to which compromises
can be made to this ideal.

Fig 13-1 Vertical augmentation, to a certain extent as a conservative service. Remodeling

adjacent to a vertical defect leads to gingival recession and root caries on the distal tooth.
Augmentation removes the stimulus for bone resorption at the distal tooth. This prevents
root caries and attachment loss.

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Fig 13-2 Illustration of why augmentations in the posterior mandible usually heal well. The
scar tissue attached to the ascending mandibular ramus and the periodontium of the most
distal tooth tends to migrate cranially during shrinkage and thus cover the augmentation.

13.2 Comparison of Soft Tissue Healing in Free-End

Situations in the Maxilla and Mandible
In the posterior mandible, conditions are more favorable for soft tissue
healing than in the maxilla. A scar always has a tendency to shrink, and a
flap has a tendency to retract. In the maxilla as a whole, the retraction
tendency works in the direction of exposure of the augmentations because
the soft tissue behind the tuberosity is attached behind the tuberosity
relatively far cranially, and the convex arch shape, which protrudes in
relation to the narrow apical base, tends to create tension in soft tissue flaps.
More favorable conditions exist in the posterior mandible. Here, the soft
tissue is attached to the ascending ramus and the cranially attached
pterygomandibular raphe. Therefore, together with an elevated anterior
residual dentition, scarring pulls the soft tissue over the concave jaw shape
of the posterior mandible and tends to cover the augmentation with flap
tension (Fig 13-2). The posterior oral vestibule is also not as deep in the

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mandible as in the maxilla. More favorable conditions for bone graft
healing are present, lending credence to the reports of guided bone
regeneration (GBR) exceeding the 3 to 4 mm of bone formation that would
otherwise occur.1 In the posterior jaws, flap retraction can be countered by
tunneling techniques so that no midcrestal incision is made at all, but
instead a subperiosteal posterior preparation is made via a vertical relief
incision in the canine region.2

13.3 General Information on Short Versus Regular Implants

The length of natural tooth roots, between 10 and 14 mm, was for a long
time the model for the length of dental implants. This overlooked the fact
that tooth roots in the periodontal ligament are movably attached in contrast
to implants. Lower transmission lengths of the masticatory force to the bone
are sufficient for the osseointegrated fixed bond. It looks strange for an
expirienced clinician, but according to prospective studies, long single
crowns for mandibular molars can be anchored on implants of 4-mm length
with only 3-mm osseointegration length.3 Even the maxilla, with its reduced
cortical structure compared with the mandible, could be successfully
restored with long single crowns on 4-mm implants according to
prospective data.4 It should be noted that prospective data on ultra-short 4-
mm implants have so far covered only short time periods of up to 2 years.5
Prospective data on short implants between 6 and 8 mm in length with up to
8 years of follow-up are available.6 As a result of the learning process
mentioned above, implants from 8 mm in length are now considered normal
length, and implants shorter than 8 mm are considered short implants.
Splinting for prosthetic compensation of short endosteal implant lengths
in the maxilla7 is also a prosthetic concept adopted from experience with
periodontally anchored teeth. Whether this principle also applies to dental
implants remains to be seen, as the survival rates of nonsplinted single
crowns on short implants in the mandible are very good.8

Load-bearing capacity and type of abutment connection for short and

reduced-diameter implants

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If occlusal rehabilitation is considered to be a sustainable overall medical
treatment, and if it is also indicated in some studies that the bone level on
osseointegrated implants may remain stable for life, then the mechanics of
the implant-abutment connection should also be adapted to this potentially
lifelong function.
When two alternately loaded parts are joined, micromovements and
elastic deformations occur. This also applies to the cone, which is
considered to be the best pairing of two parts from a mechanical standpoint.
But under the constant alternating load during mastication, the inner cone
can slip further into the outer cone of the abutment connection over time
with just a small amount of material removal and thus gain a small degree
of freedom by rotating around the abutment screw. Elastic deformations of
the abutment connection are also known from detailed synchroton
radiographic studies of implant connections under high load,9 especially in
the case of reduced-diameter implants.10 All of these micromovements can
expand into macromovements over the years with hundreds of masticatory
contacts per day. Then the failure of the component or the breakage of the
abutment screw is not far away. Mechanical failure of the abutment
connection results in a defective osseointegrated implant that can only be
removed at great expense, also in terms of tissue loss.
This suggests that, to protect the patient, clinicians should prefer to use
thicker and more stable implants and perform bone augmentation if
necessary to accommodate them, as long as this is feasible to do while
staying in compliance with the biologic rules of distance from adjacent
teeth.
Short implants often have flat connections with an external hexagon,
which have worse mechanical properties than the regular tapered internal
connections.11 Implants with internal connections are available from
different lengths: Camlog from 9 mm, Straumann BL from 8 mm, Conelog
(Camlog) from 7 mm, and Astra EV (Dentsply Sirona) from 6 mm. The
vertical space requirement resulting from the screw, anti-rotation device,
and cone does not allow for shorter versions. One exception is the ultra-
short 4-mm Straumann TL implant, which is largely hollow on the inside,
but still maintains the normal coupling of TL implants because of the tulip
shaped transgingival portion (Fig 13-3). The other exception is Bicon
implants, whose connection works by wedging a very steep taper without
screwing and without an antirotation element, and which also use the same

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internal connection type for all implants down to the shortest implants of 5
mm. The abutment connection compromises may speak for avoiding short
implants and instead augmenting the bone vertically and using regular
implants.

Peri-implantitis and short implants

In prospective studies, bone loss is always about 1 mm less in short
implants than in regular implants in comparable situations.12,13 But in
relation to the total osseointegrated length, for short implants even a small
bone loss is higher in percentage than in regular impalnts. Also a small bone
loss may therefore become critical for an ultrashort dental implant.

Fig 13-3 The minimum implant length is determined by the space needs for the internal
tapered connection, anti-rotation device, and screw threading. Most very short implants can
only solve this by stepping back to external hex connections. An exception is the 4-mm
Straumann TL implant, in which the internal taper connection is accommodated by its tulip
shape and which therefore has the same proven coupling as, eg, 14-mm implants.

If inflammatory bone resorption is then added, a short implant is

quickly lost. The usual pocket depth in peri-implant lesions that can lead to
the establishment of pathogenic pocket flora, is about 6 to 8 mm. At this

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depth, a short implant has long since been lost; it cannot withstand any
degree of peri-implantitis. A regular implant, however, is still functionally
stable, if it retains an apical 4 mm of osseointergated length.
Therefore, a rescue attempt by surgical periimplantitis therapy is also
worthwhile for regular implants. The success rate of short-term infection
elimination with surgical peri-implantitis therapy is almost 100%, and more
than two-thirds of all infected implants can be retained long-term after
periimplantitis therapy (see chapter 15). This is an argument for vertical
augmentation and use of implants of regular length.

13.4 General Information on Narrow- Versus Regular-

Diameter Implants
Implants with a diameter less than 3.5 mm are defined as narrow-diameter
implants.14 This is mainly for loading reasons,15 because in implants with
internal connections, the wall thickness will eventually fall below the
critical range as they become narrower. An implant with an internal
connection and/or platform switching must be drilled hollow to serially
accommodate the elements of the connection, anti-rotation device, and
screw threading. This problem is further exacerbated with tapered internal
connections, where the taper as a wedge exerts an explosive effect on the
implant. Implants with a diameter of less than 3 mm are referred to as mini-
implants. For reasons of space, many of these no longer have an abutment
connection and are used in one piece. An exception is the Straumann 2.9-
mm BL implant, which has a conical internal connection.
The problem of diameter reduction is the risk of implant fracture. This
occurred in a large sample of over 10,000 mixed implant types at a rate of
0.44% (about 1 every 200 implants), mostly between 2 and 8 years after
placement. One millimeter of diameter reduction compared to a standard
diameter brought a 96.7% increase in the risk of fractures. Harder titanium
alloys were able to compensate for this effect with a 72.9% risk reduction.
There was a twenty-fold increase in risk in the presence of bruxism.16
When it comes to molar replacement, narrow-diameter implants not
only reach the limits of load-bearing capacity; due to the large diameter of
molar crowns (about 10 mm), such small implants also create a flat
emergence profile with a corresponding impediment to oral hygiene (Fig

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13-4). Based on this premise, molars should rather be restored with
implants of increased diameter (wide platform), which are around 5 mm in
diameter. In addition, tissue-level implants, such as the Straumann TL
implant, have the added benefit of a connection that gradually widens
toward the platform (tulip shape), resulting in favorable loading values and
harmonious emergence profiles with wide-platform implants. A 5-mm
implant requires at least 1 mm, preferably 2 mm, of bone vestibularly and
orally, meaning that a minimum ridge width of 7 to 9 mm is required for
safe placement. If this bone is not present in the site, it can be built up by
augmentation.

Fig 13-4 In the case of pronounced crown overhangs with an inconsistent emergence
profile, paths for interdental brushes (hygiene access, red) should be planned. Sometimes it
is more hygienic to place the implant eccentrically in a very wide gap and create hygiene
access with a pontic. The most favorable solution is an implant with a diameter adapted to
the crown (crown-down concept, far right). (Modified from Wolfart.17)

13.5 Pros and Cons of Vertical Augmentation in the

Posterior Mandible

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Prospective data on short implants in sufficient bone initially show equally
good survival as for regular implants, in some cases even better. However,
after 5 years, the statistics shifted in favor of regular implants; longer
periods have not yet been studied.12 A recent meta-analysis by the author of
randomized prospective studies on short implants versus vertical
augmentation followed by regular implants in the posterior mandible13
showed the same picture. Again, short implants initially performed better in
terms of implant survival, marginal bone resorption, and complication rates,
but there was a trend in favor of regular implants with increasing time in
function (Fig 13-5). Vertical mandibular augmentation had its price not only
in terms of treatment duration, discomfort, and cost, but also in terms of
complications. Short implant placement is a much less complicationprone
procedure than vertical augmentation of the posterior mandible. But after 5
years and even more clearly after 8 years, more short implants were lost
than regular implants, with about 90% survival in this indication.
Short implants are a predictable path for the patient to receive fixed
prostheses, with lower costs, less stress, fewer office visits, and lower risk
of complications compared to vertical augmentation and regular implants.
However, it is foreseeable that regular implants and vertical augmentation
may be the more sustainable path. One must watch the study data in the
coming years, but it is likely that short implants will be lost even with
minor peri-implant bone loss. Regular implants can remain osseointegrated
longer in the case of peri-implantitis, so that they can be successfully
decontaminated and preserved in the long term.
There is a tendency for many consumer goods to have a shortened
service life, which is contrary to sustainable economic practices. Some
technical devices last only a little longer than the warranty period and then
have to be disposed of and replaced, consuming resources. This strategy of
the consumer goods world is called planned obsolescence and has been
criticized because, although it benefits the economy, it harms the
environment and the consumer.
However, the human organism is not a technical object and masticatory
functional rehabilitation is not a consumer good but a medical therapy. The
patient should be aware of the advantages and disadvantages of both
procedures: low complication rates and surgical burden but shorter life span
of short implants versus higher complication rates and surgical burden but
greater longevity of regular implants in augmented bone. The problem of

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short-lived implants is that they leave a site that has already undergone
surgery with associated scars and bone defects. It is known from
retrospective data that repeated implant placement at the same site
progressively worsens the prognosis of the subsequent implant. In a recent
study of over 5,000 dental implants, the survival rate of the first implant
placement was 95.4%. A second implant after loss of the first had 77.4%
survival; the third implant had 72.4% survival; the fourth implant had 50%
survival.18 Unlike engineered devices that can be replaced, the biologic
potency of the implant site suffers after implant losses,19 which may be due
to reactions to metal particles or soft tissue scarring, among other factors.
Repeated surgical procedures at the same site place a psychologic burden
on patients, which is unlikely to increase their willingness to undergo
subsequent implant placement later in life. So it pays to do everything right
the first time an implant is placed and to work for its survival, even if
inflammatory complications arise. In contrast to the developments in
technology and the consumer goods industry, the physician should strive for
sustainability so that the implant treatment is curative and designed for life.
This means that implant length and diameter are more likely to return to the
model of the natural tooth root, which sometimes requires appropriate bone
augmentation. This way, as so often in life, is a bit more tedious, but
probably healthier in the end. For the general dentist and the patient,
augmentation occasionally means referral to specialized colleagues for co-
treatment.

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Fig 13-5 A meta-analysis by the author analyzed randomized studies comparing vertical
augmentation with regular implants versus short implants in the atrophied posterior
mandible. Here, the tendency toward more tooth implant losses with increasing study
duration can be seen for short implants.

13.6 Pros and Cons of Sinus Elevation in the Posterior

Maxilla
In the maxilla, the discussion of the differential indication between short
implants and vertical augmentation followed by regular implants is
somewhat different. In the maxilla, vertical augmentation by sinus elevation
is technically much easier than sandwich bone grafting in the mandible; in
addition, there is no nerve in the vicinity. The decision to use regular
implants versus short implants is therefore easier than in the mandible,

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given the good healing tendency and low complication rate of the sinus
elevation.

Fig 13-6 Bicortical anchorage of 8-mm implants in the posterior maxilla with 6- to 7-mm
residual bone height.

First, the interocclusal distance in the model analysis in the articulator

should be used to clarify whether the bone deficiency is due to external
alveolar ridge atrophy or, more frequently, to internal atrophy caused by
expansion of the maxillary sinus (see Fig 8-4).
The maxilla does not have the firm cortical structure of the mandible, so
the argument for ultra-short implants in order to avoid sinus elevation is not
as strong as for the posterior mandible. Apart from study situations, a
minimum length for maxillary implants of 8 mm is currently clinically
accepted.19 Thus, a discussion of pros and cons for sinus elevation may exist
for residual bone heights at the sinus floor of 5 to 7 mm for placement of 6-
mm implants; however, at 4 mm and less, the indication for sinus elevation
is undisputed if one does not prefer other therapies altogether. However, if
the bone is augmented, it should be sufficient for at least 10-mm implants.20

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 Jaw resorption by pneumatization of the alveolar bone of the maxillary
sinus proceeds relatively quickly after tooth extraction, so that many
patients do not even present at the stage of 5- to 7-mm residual bone, but
only appear when the bone is reduced to less than 2 mm. Then sinus
elevation avoidance by short implants is no longer an option in the free-end
situation.
Sinus elevation avoidance strategies include implants in the pterygoid
process of the sphenoid bone or in non-atrophic maxillary bone of the
pterygomaxillary fissure.21 These solutions often represented prosthetic
compromises because, for example, these implants were not in the center of
the masticatory functional load, and implants in the third molar region are
not easy for the patient to reach during oral hygiene procedures without
gagging. These techniques for sinus elevation avoidance have recently been
revived by “all-on-four” concepts in which the implants are placed in the
intersinus bone and project slightly posteriorly (ie, tilted implants), allowing
arch support up to the second premolar region in favorable cases.
Studies show that short implants (≥5 mm and <8 mm) heal reliably at
the sinus floor,22 especially if they are anchored bicortically, ie, in the
crestal and apical cortices (Fig 13-6). Nevertheless, sinus floor
augmentation is such a small additional expense compared with the incision
made anyway for implant placement, even with bone heights between 5 and
8 mm, that the sinus elevation is frequently made to anchor 10- to 12-mm
implants. This is especially true for highly loaded distal prosthetic
abutments in long-span free-end situations. The advantages for this can be
seen in the following chapter. Sinus floor augmentation is not only used to
achieve osseointegration in free-end situations with low bone height in the
posterior maxilla. In the extremely atrophied edentulous maxilla, sometimes
sinus elevation is the easiest way to create bone support anywhere at all. As
a rule, sinus floor augmentation is indicated when atrophy has occurred due
to pneumatization of the maxillary sinuses. If the outer ridge contour is
reduced or if the interocclusal distance between ridges becomes too great,
Le Fort I interpositions or overlay grafting may be indicated. Sinus
elevation avoidance by tilted intersinus implants is discussed in the next
chapter.

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13.7 Conclusion on Differential Indication for Augmentation
Versus Modified Implants in the Posterior Region
The prerequisites for a decision in favor of or against augmentation and in
favor of or against short, narrow, or tilted (SNT) implants are that the
patient is medically capable of undergoing augmentation surgery and that
the costs have been clarified. If a dental clinic is incapable of performing
augmentation surgery, it is nevertheless obliged to provide information
about the risks and benefits of augmentation and, if necessary, to refer the
patient to a specialized center. The prosthetic restoration and subsequent
follow-up care are then usually carried out again in the referring practice.

13.8 Differential Indication for Bone Augmentation in the

Posterior Mandible
Augmentation of the narrow posterior mandible
For the posterior mandible, a single-stage GBR is very effective for 1/4
defects in single-tooth gaps as well as elongated gaps over the entire
posterior region. Due to the soft tissue situation, GBR works better in the
posterior mandible than maxilla. Two-stage block grafts are more
recommended for the higher resorption stages (2/4 and 3/4). Reduced-
diameter implants are of no real help in horizontal mandibular atrophy,
because even a 3.3-mm implant requires at least 5.3 mm of bone, and most
atrohpic ridges are narrower, board thin or even razor thin. Therefore, it
makes sense to augment enough bone so support a regular implant. In older
patients with full edentulism and increasing atrophy, the mandibular
alveolar process bone is so brittle that bone splitting results in
microfracturing and shards, so it is rather discouraged. In younger patients
and with sufficiently cancellous alveolar processes, bone splitting is often
possible in free-end situations (Fig 13-7).

Morphology of the mandibular defect

The shorter and steeper a defect in the posterior inferior alveolar process,
the more likely it is that it can be bridged by a bone block graft from the
external oblique ridge using the shell technique with relatively little effort

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(Fig 13-8). This defect then lies fully in the envelope and is surrounded by
healthy bone walls on two sides. Only long-standing defects of two or more
tooth widths require more complex surgical measures.

Sandwich bone graft in the posterior mandible with less than 3 mm

of residual bone above the nerve
With at least 5 mm of residual bone above the nerve, sandwich bone
grafting with a 2-mm safety distance to the inferior alveolar nerve is
possible. With only 3 mm of residual bone above the nerve, one can try to
form a transport segment for a sandwich interposition by lifting off the
osteotomized segment with exposure of the nerve canal (like a bone flap).
This approach is risky and may be associated with temporary or permanent
impairment of the alveolar nerve. However, this maneuver is still less
traumatic to the nerve than completely dislodging the nerve from the canal
in a nerve lateralization.

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Fig 13-7 a. Bone splitting in the posterior mandible is complicated by the brittleness of the
bone. Here, two regular implants are in the gap. b. Exposure of the implants via the
midcrestal incision results in the formation of a nice cuff of soft tissue around the implant. c.
Healing of the implants without loss of height of the buccal compact bone. d. Prosthetic
restoration.

Fig 13-8 Differential indication for bone augmentation procedures in the posterior mandible
according to gap length and defect depth.

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Fig 13-9 Nerve lateralization. A bone lid was temporarily lifted off in the posterior mandible
to expose the nerve without damaging the bone.

Indication for nerve lateralization

The main problem of nerve lateralization is the almost 100% occurrence
rate of temporary loss of sensation23 and the nutritional disturbance of the
mandible due to removal of the central vessel (Fig 13-9). The nutritional
disturbance is considered to be the reason for the frequent delayed
spontaneous fractures.24,25 Technically, nerve lateralization (or
medialization26) is distinguished from nerve transposition. In nerve
lateralization, a long cortical lid is lifted laterally off the nerve canal, the
nerve is luxated from its bed, the implant is placed, and the nerve is
repositioned. This maneuver is associated with a 1.56% occurrence rate of
permanent loss of sensation in the lip region.26 During nerve transposition,
the nerve canal is exposed, and the nerve is extracted, starting from the
mental foramen and moving in a posterior direction. The extension of the
inferior alveolar nerve into the anterior mandible, the incisive nerve, is
severed. This distalizes the mental foramen. This maneuver is more
traumatic than nerve lateralization and is associated with 12.12% permanent
loss of sensation.27 From the author’s point of view, augmentation treatment
options are simpler and less likely to cause complications than nerve
lateralization approaches. Therefore, nerve lateralization is used by the
author only in rare special cases.

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Indication for iliac bone grafting in the posterior mandible
If sandwich osteoplasty is not possible due to insufficient bone height over
the inferior alveolar nerve, the indication is for elevation and grafting of a
monocortical bone block from the iliac crest (Fig 13-10). This technique
can often be performed with tunneling to avoid wound dehiscence.

Bone grafting in Vicryl mesh for posterior mandible

If iliac bone grafting is not possible, the old technique of the Vicryl Mesh
Bag (Ethicon) can be used (Fig 13-11).28 This technique is also known as
the “Kiel sausage” or English sausage technique. In this technique, an
absorbable Vicryl mesh is sutured over a disposable syringe to form a bag.
The front part of the syringe is then cut off, the plunger withdrawn, and the
syringe filled with particulate augmentation material. This should contain a
high proportion of autologous bone, eg, a 25%/75% mixture. The tip is then
inserted into the mesh bag and squeezed out. Preparation in the posterior
mandible is carried out via a vertical incision in the canine region, with
careful protection of the nerve, generously tunneling subperiosteally to the
posterior. The lingual and buccal periosteum must be stretched to create
sufficient space. A long needle holder is used to guide out an absorbable
pull-through suture in the wisdom tooth region. This thread now pulls the
filled mesh bag into position on the alveolar ridge. The thickness of the bag
and thus the augmentation height must be approximately twice that of the
bone height required later, because the particulate materials resorb to a high
extent.

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Fig 13-10 Iliac bone graft. a. Panoramic image with free-end situation and less than 3 mm
residual bone above the nerve on both sides of the mandible. b. The lateral cephalogram
shows the enormous interocclusal distance that would have to be bridged with a long dental
crown on short implants. c. Panoramic image after ilaic bone graft placement using lag
screw osteosynthesis. d. Lateral cephalogram showing correction of interocclusal distance.
e. Restoration with dental implants. f. Prosthetic restoration.

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Fig 13-11 Vicryl mesh bag technique. a. Panoramic image showing the initial situation of
pronounced alveolar ridge atrophy (Cawood class VI) in the mandible. b. Tunneling
preparation starting from a vertical incision anterior to the mental nerve. c. Filling of the
Vicryl bag with a mixed bone graft. d. The Vicryl mesh bag is introduced into the
subperiosteal soft tissue canal with the help of a posteriorly protruding pull-through suture.
e. Panoramic image showing the grafted lateral defects. Overcorrection was performed to
compensate for resorption. f. Panoramic image 4 months later with ossified augmentation
material. Height reduction has occurred due to resorption of the particulate material.

13.9 Differential Indication for Bone Augmentation in the

Posterior Maxilla

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Lateral and crestal atrophy with change of occlusion
Because the posterior maxilla narrows cranially with a narrow apical base,
crossbites are to be expected with crestal height reduction, which is also
referred to as centripetal atrophy of the maxilla. A careful analysis of the
interocclusal space and, if necessary, a model analysis can help to identify
this circumstance. However, even without a vertical atrophy component the
maxillomandibular relationship can change, because after tooth extraction a
narrow apical base quickly results in horizontal ridge atrophy, especially in
the premolar region anterior to the maxillary sinuses, which is also referred
to as the piriform rim of the maxilla. The sinus elevation alone, however
obvious and quickly performed, should be supplemented in these cases by
horizontal and vertical crestal augmentation if the implant-supported
prostheses are to be in correct occlusion.

Horizontal augmentation of the lateral maxilla

The horizontally narrow jaw in the premolar region before a lateral sinus
elevation corresponds to the 2/4 situation and should therefore be treated
with a bone block according to the treatment-planning concept presented in
chapter 11 (Fig 13-12). However, this can often be performed in one stage
together with implant placement, along with a single-stage sinus elevation.
According to the treatment-planning concept and clinical experience, the
exclusive use of bone substitute material is not sufficient for the 2/4 defect
in the posterior maxilla. Alternatively, bone splitting in the premolar region
should be considered (Fig 13-13). Whether this is feasible depends on how
steeply the maxillary sinus floor rises. If the maxillary sinus extends
anteriorly into the first premolar range, the block graft is indicated. If the
maxillary sinus floor already rises cranially at the second premolars, the
area anterior to it can be augmented via bone splitting.

Vertical augmentation of the posterior maxilla

Vertical augmentation of the posterior maxilla with bone blocks from the
external oblique ridge is difficult because the soft tissue tends to dehisce.
This can be prevented by a tunnel preparation, but this then makes a
simultaneous sinus elevation more difficult.

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 In the posterior maxilla, there is a good indication for customized
titanium mesh filled with particulate materials, which initially provides
good contour and stability. If there is partial loss of the particulate graft
material due to soft tissue dehiscence, this is not so problematic because
part of the vertical distance can also be compensated by longer dental
crowns. Therefore, the usual augmentation height that can be achieved with
particulate materials can be exceeded in the posterior maxilla by using
titanium mesh if partial loss of the augmentation can be accepted because of
the low esthetic relevance.

Indication for iliac bone grafting in the posterior maxilla

In the case of long-standing defects such as complete free-end situations
with a vertical deficit of approximately 1 cm or more, the indication for
placement of an autogenous monocortical iliac crest block should not be
ignored. Allogeneic bone block grafts are risky in free-end situations in the
posterior maxilla because of their tendency toward dehiscence and infection
with such large augmentation heights. An autogenous iliac bone block, on
the other hand, can heal secondarily even in the presence of dehiscence.

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Fig 13-12 Single-stage block augmentation for a 2/4 defect. a. Sinus floor defect with
typical narrow jaw in the premolar region. b. Resorbable osteosynthesis (Resorb X, KLS
Martin) of block grafts from the external oblique ridge. c. Contour augmentation and
resorption protection using a mixed bone graft. d. Coverage with a collagen membrane. e.
Similar initial situation on the opposite side. f. Resorbable osteosynthesis of block grafts. g.
Contour augmentation and resorption protection by a mixed bone graft. h. Coverage by
collagen membrane. i. Postoperative panoramic radiograph. j. Preparation of the fixed
prosthetic restoration (Prof Wolfart, Aachen). k. Placement of the prosthetic restoration. The
augmentation in the premolar region allows the premolars to be overlapped in the dental
arch and avoids crossbites or tilting of the implants. l. Facial view 12 years later. m. Left
view 12 years later. n. Right view 12 years later.

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Fig 13-13 Single-stage bone splitting in 2/4 defect. a. Panoramic image with rising
maxillary sinus floor and space for splitting in the first premolar region. b. After the ridge has
been longitudinally slit, entry is made with the blade chisel to the maxillary sinus floor. Prior
to this, the sinus membrane was prepared and elevated. c. Careful expansion of the
splitting gap using bone elasticity with a Flohr root elevator. d. Trial posts in place after
implant drilling. e. Implant placement into the splitting gap and the sinus floor. A reduced-
diameter 3.3-mm implant was used in the splitting gap. This was covered with a particulate
bone graft during the sinus elevation. f. Mirror image after prosthetic restoration (Dr
Schaumburg, Baunatal).

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Fig 13-13 Single-stage bone splitting in 2/4 defect. g. CBCT 2 months after sinus
elevation surgery. h. Position of the first premolar implant with the tip in the sinus, well
covered by the walls of the splitting gap and the particulate bone graft.

13.10 References
1. Malik R, Gupta A, Bansal P, Sharma R, Sharma S. Evaluation of alveolar ridge height gained by
vertical ridge augmentation using titanium mesh and novabone putty in posterior mandible. J
Maxillofac Oral Surg 2020;19:32–39.
2. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmentation in the posterior
maxilla: A 10-year clinical study. Int J Oral Maxillofac Implants 2019;34:471–480.
3. Rokn AR, Monzavi A, Panjnoush M, Hashemi HM, Kharazifard MJ, Bitaraf T. Comparing 4-mm
dental implants to longer implants placed in augmented bones in the atrophic posterior
mandibles: One-year results of a randomized controlled trial. Clin Implant Dent Relat Res
2018;20:997–1002.
4. Bolle C, Felice P, Barausse C, Pistilli V, Trullenque-Eriksson A, Esposito M. 4 mm long vs
longer implants in augmented bone in posterior atrophic jaws: 1-year post-loading results from a
multicentre randomised controlled trial. Eur J Oral Implantol 2018;11:31–47.
5. Torassa D, Naldini P, Calvo-Guirado JL, Fernández-Bodereau E. Prospective, clinical pilot study
with eleven 4-mm extra-short implants splinted to longer implants for posterior maxilla
rehabilitation. J Clin Med 2020;9(2):357.
6. Felice P, Barausse C, Pistilli R, Ippolito DR, Esposito M. Short implants versus longer implants
in vertically augmented posterior mandibles: Result at 8 years after loading from a randomised
controlled trial. Eur J Oral Implantol 2018;11:385–395.
7. Pieri F, Caselli E, Forlivesi C, Corinaldesi G. Rehabilitation of the atrophic posterior maxilla
using splinted short implants or sinus augmentation with standard-length implants: A
retrospective cohort study. Int J Oral Maxillofac Implants 2016;31:1179–1188.
8. Esposito M, Buti J, Barausse C, Gasparro R, Sammartino G, Felice P. Short implants versus
longer implants in vertically augmented atrophic mandibles: A systematic review of randomised
controlled trials with a 5-year post-loading follow-up. Int J Oral Implantol (New Malden)
2019;12:267–280.
9. Rack T, Zabler S, Rack A, Riesemeier H, Nelson K. An in vitro pilot study of abutment stability
during loading in new and fatigue-loaded conical dental implants using synchrotron-based

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 radiography. Int J Oral Maxillofac Implants 2013;28:44–50.
10. Nelson K, Schmelzeisen R, Taylor TD, Zabler S, Wiest W, Fretwurst T. The impact of force
transmission on narrowbody dental implants made of commercially pure titanium and titanium
zirconia alloy with a conical implant-abutment connection: An experimental pilot study. Int J
Oral Maxillofac Implants 2016;31:1066–1071.
11. Semper W, Heberer S, Mehrhof J, Schink T, Nelson K. Effects of repeated manual disassembly
and reassembly on the positional stability of various implant-abutment complexes: An
experimental study. Int J Oral Maxillofac Implants 2010;25:86–94.
12. Ravidà A, Wang IC, Barootchi S, et al. Meta-analysis of randomized clinical trials comparing
clinical and patient-reported outcomes between extra-short (≤6 mm) and longer (≥10 mm)
implants. J Clin Periodontol 2019;46:118–142.
13. Terheyden H, Meijer G, Raghoebar G. Vertical bone augmentation and regular implants versus
short implants in the vertically deficient posterior mandible—A systematic review and meta-
analysis of randomized studies. Int J Oral Maxillofac Surg 2021;50:1249–1258.
14. Schiegnitz E, Al-Nawas B. Narrow-diameter implants: A systematic review and meta-analysis.
Clin Oral Implants Res 2018;29(Suppl 16):21–40.
15. Velasco-Ortega E, Flichy-Fernández A, Punset M, Jiménez-Guerra A, Manero JM, Gil J. Fracture
and fatigue of titanium narrow dental implants: New trends in order to improve the mechanical
response. Materials (Basel) 2019;12(22):3728.
16. Chrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. Factors influencing the fracture of dental
implants. Clin Implant Dent Relat Res 2018;20:58–67.
17. Wolfart S (ed). Implant Prosthodontics: A Patient-Oriented Strategy. London: Quintessence,
2016.
18. Agari K, Le B. Successive reimplantation of dental implants into sites of previous failure. J Oral
Maxillofac Surg 2020; 78:375–385.
19. Moy PK, Aghaloo T. Risk factors in bone augmentation procedures. Periodontol 2000
2019;81:76–90.
20. Lundgren S, Cricchio G, Hallman M, Jungner M, Rasmusson L, Sennerby L. Sinus floor
elevation procedures to enable implant placement and integration: Techniques, biological aspects
and clinical outcomes. Periodontol 2000 2017;73:103–120.
21. Araujo RZ, Santiago Júnior JF, Cardoso CL, Benites Condezo AF, Moreira Júnior R, Curi MM.
Clinical outcomes of pterygoid implants: Systematic review and meta-analysis. J
Craniomaxillofac Surg 2019;47:651–660.
22. Palacios JAV, Garcia JJ, Caramês JMM, Quirynen M, da Silva Marques DN. Short implants
versus bone grafting and standard-length implants placement: A systematic review. Clin Oral
Investig 2018;22:69–80.
23. de Campos CG, Francischone CE, Souza Picorelli Assis NM, Devito KL, Sotto-Maior BS.
Neurosensory function and implant survival rate following implant placement with or without an
interposed bone graft between the implant and nerve: Prospective clinical trial. Int J Oral
Maxillofac Implants 2019;33:1450–1456.
24. Kan JY, Lozada JL, Boyne PJ, Goodacre CJ, Rungcharassaeng K. Mandibular fracture after
endosseous implant placement in conjunction with inferior alveolar nerve transposition: A patient
treatment report. Int J Oral Maxillofac Implants 1997;12:655–659.
25. Kablan F, Abu-Sobeh A, Lorean A, Levin L. Spontaneous mandibular fracture as a complication
of inferior alveolar nerve transposition and placement of endosseous dental implants in the
atrophic mandible: A review of the literature and a report of two cases and their nonsurgical
conservative management. Quintessence Int 2020;51:230–237.

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26. Sharifi R, Beshkar M, Mobayeni MR, Hasheminasab M. Inferior alveolar nerve medialization for
dental implant placement: Case report with the introduction of a new technique. Int J Oral
Maxillofac Implants 2018;33:e113–e115.
27. Palacio García-Ochoa A, Pérez-González F, Negrillo Moreno A, et al. Complications associated
with inferior alveolar nerve reposition technique for simultaneous implant-based rehabilitation of
atrophic mandibles. A systematic literature review. J Stomatol Oral Maxillofac Surg
2020;121:390–396.
28. Härle F, Kreusch T. Augmentation of the alveolar ridges with hydroxylapatite in a Vicryl tube.
Int J Oral Maxillofac Surg 1991;20:144–148.

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 14
The Atrophic Edentulous Jaw

Augmentations in an atrophied edentulous ridge have some peculiarities

compared to the treatmentplanning concept in chapter 11. Augmentations
and prosthetic procedures affect not only dental esthetics but also the entire
face and perioral skin. The defect size and graft volumes sometimes require
extraoral donor regions and inpatient conditions under general anesthesia.
The transition from a natural to a prosthetic dentition is a psychologically
significant threshold in life for patients, which is respected by careful
planning and execution of the dental prosthesis. Careful consideration of
conventional as well as augmentation and augmentation-free implant-
supported restoration options is required. Great haste and promises of new
teeth in a few hours contradict this.

14.1 Function (Mastication and Speech) and Alveolar Ridge

Atrophy
The process of alveolar ridge atrophy is physiologic and in this sense not a
disease; however, the result—the resorbed alveolar ridges and the limited
chewing ability of the edentulous person—must be considered a serious
loss of organs, in this case of the masticatory organ. Imagine what an
unpleasant experience it is when, in company, the mandibular denture slips
into the cup while drinking tea, or what danger can be involved when, while
eating in a social situation, an edentulous person tries to swallow unchewed
meat out of shame and suffers respiratory distress and possible choking. A
study of the chewing ability of test food revealed that patients with
overdentures on atrophied ridges had only about 20% of the chewing ability
of edentulous patients or patients with fixed dentures (Fig 14-1).
Overdentures on dental implants also did not achieve much more chewing

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ability (40%) than complete dentures, except that the dentures were
positionally stabilized.1 It has been clearly demonstrated that a sufficient
number of dental implants increases masticatory strength and masticatory
efficiency, both for single-tooth gaps2 and for implant-supported complete
dentures.3 In patients with atrophied alveolar ridges, implant restoration and
masticatory rehabilitation also improved speech function and articulation.4

Fig 14-1 Chewing ability was experimentally determined in a study by having participants
chew a tough test food (cured impression silicone) and recording the number of chewing
cycles and the resulting size of the particles using graduated sieves. This showed that with
an overdenture on two implants in the mandible (overdenture on implants), there was only a
slight difference in particle size and no advantage at all in chewing duration compared to
patients with full dentures on atrophied ridges. Therefore, to be able to chew like dentate
patients again, more elaborate prostheses on more than two implants are necessary for
edentulous patients. (Adapted from Fontijn-Tekamp.1)

14.2 Nutrition and Alveolar Ridge Atrophy

Most denture wearers with atrophied alveolar ridges intuitively respond to
the question of whether they can chew well that they could eat anything and
have hardly any restrictions. This only shows how adaptable people are and
how gradually the process of chewing loss occurs. A closer look then
reveals that the food is previously divided into small bites on the plate, is
gulped down more or less unchewed, and the diet as a whole is very
carbohydrate-dominated. Contrary to expectations, patients with poor

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chewing function are usually not underweight, but rather overweight due to
malnutrition. Humans need a certain amount of minerals (eg, calcium and
iron) and vitamins and intuitively feel this. If the spectrum of food shifts
due to a lack of chewing ability,5 if the diet contains fewer fresh vegetables
and meat but more mashed potatoes and creamed soups, and if more
bananas are consumed instead of apples and carrots, then one has to eat
more overall in order to get out of the nutrient-poor diet the required daily
amount of nutrients. Lack of exercise reinforces this even further, because if
in the past it was possible to extract the nutrients from 3,000 calories per
day with physical work, in today’s modern world 1,500 calories per day
must suffice as the amount of food required due to a lack of exercise. This
does not adequately succeed and is part of the explanation for the high rate
of osteoporosis, among other things. Nutrient undersupply is a drive to
caloric oversupply, and this is one of the causes of obesity in modern
society. Nutrition as a whole suffers from a lack of chewing ability when
food cannot be adequately broken down and the food spectrum shifts.6 In a
comparative study, 22% of denture wearers suffered from malnutrition
versus 0% of dentate participants.7
A gradual shift in the edentulous person’s food spectrum toward soft
carbohydrates may also increase the likelihood of onset of or exacerbate
type 2 diabetes. Timely masticatory rehabilitation can therefore prevent
nutritional disorders and contribute to general health.

14.3 Dementia and Alveolar Ridge Atrophy

Chewing ability is not a question of old age, but a question of dental status.8
It has been known for a long time that the onset of dementia is statistically
associated with the loss of chewing ability,9 whereby a neuromuscular
causal relationship is frequently discussed.10 In any case, it is plausible that
a person with poor masticatory function due to alveolar ridge atrophy may
not be able to eat well and may become socially withdrawn, resulting in
cognitive deterioration. Timely masticatory rehabilitation may help prevent
dementia.

14.4 Quality of Life and Alveolar Ridge Atrophy

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There is clear evidence that dental implant-supported restorations improve
the quality of life of edentulous patients with alveolar ridge atrophy.11 In a
recent study, an Oral Health Impact Profile (OHIP) score improved from
15.89 to 6.18, but not only oral-related quality of life improves with dental
implants, but also general health-related quality of life in parallel.12 The
quality of life after augmentation by iliac bone grafts was at a similar
favorable level of 8.4, which highlights the good tolerability of the bone
augmentation method in edentulous patients with alveolar ridge atrophy.13

14.5 Facial Esthetics and Alveolar Ridge Atrophy

The vertical: Occlusal and lower face height
There are many influences over the course of life that lead to a decrease in
vertical occlusal dimension. These include abrasion and attrition, intrusion
and tooth migration, and orthodontic and other tooth extractions. The
reduced occlusal height has consequences. The lower face height decreases,
and the face appears wider. The lower face soft tissues, which are sized for
a certain bone frame, compress, resulting in thin lips as well as a sharp
supramental fold and deepened nasolabial folds. The retracted lips also
cause a slightly negative mouth rounding (ie, ).
The positive effect of the bite elevation can already be simulated during
the initial consultation by placing cotton rolls on the mandibular dentures of
the edentulous patient and blocking the bite by one to two centimeters
during the planning consultation. In addition, the lips can be supported from
the inside with a little Flexaponal wax (Dentaurum) to simulate the
functional and esthetic gain of dental treatment (Fig 14-2). It can be
observed whether the lips become fuller and the mouth rounding becomes
positive (ie, ).

The horizontal: Pseudoprognathism

In this way, it is also possible to check whether a true prognathism or a
pseudoprognathism, which disappears during bite elevation, is present (Fig
14-3). This is because the final occlusal reduction is a consequence of the
loss of the last teeth and the subsequent alveolar ridge atrophy. The
mandible rotates around the axis of rotation in the temporomandibular joint.

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This causes the chin and mandibular alveolar ridge to move anterior to the
maxilla, resulting in protrusion of the chin and a Class III bite:
pseudoprognathism. The muscles of facial expression, often called the
mimic muscles, lose their tension in the resting position. This may develop
into salivary incontinence with oral angular cheilitis and candidiasis.

Mimic muscles
Atrophy following tooth loss causes the attachment points of the mimic
muscles to diminish. Loss of retention of the mentalis muscle, which
normally inserts at the root level of the mandibular anterior teeth on the
vestibular alveolar ridge, causes the chin soft tissue to descend, which is
referred to as chin droop, chin ptosis, or witch’s chin. This deformity cannot
be corrected by dental prosthetic measures because the muscle attachment
cannot be restored by denture acrylic. The preliminary stage of chin ptosis
is greater exposure of the mandibular teeth, which is observed in many
elderly people due to a decrease in lip tension. The smile muscles of the
upper lip also lose their attachment and tension, so pouting of the lips is
eliminated, and the lip becomes narrow and collapsed. The lack of lip
support due to alveolar bone and tooth loss leads to fine vertical wrinkling
of the upper lip skin in early stages and sagging of the cheek soft tissues
into the oral cavity in late stages. This in turn results in a relative protrusion
of the nose with lowering of the nasal tip, which then looks oversized
compared to the rest of the face.

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Fig 14-2 Improvement of masticatory function by increasing the number of implants.
a. Initial situation in a 67-year-old patient with atrophic and flabby ridge. b. Existing
restoration with overdenture and two dental implants in the mandible. c. Initial situation with
curled lips and compressed soft tissues due to the missing lip support from teeth and the
alveolar ridge. There is salivary incontinence of the corners of the mouth with a tendency to
angular cheilitis. The perioral skin folds are deepened, and the oral fissure shows negative
rounding. d. Panoramic radiograph showing Cawood class V atrophy. e. Lateral
cephalometric radiograph with especially atrophied anterior alveolar ridge as a combination
syndrome due to the hard anterior occlusion with the two mandibular implants. These lead
to constant tilting of the maxillary prosthesis with transformation of alveolar bone into flabby
tissue. When planning the two mandibular implants, the maxilla could have been included in
the implant planning to prevent the combination syndrome. f. Planning simulation of bite
elevation and bone augmentation using cotton rolls on the dentures and Flexaponal wax
strips on the dentures for lip relining. This causes the red of the lips to roll outward, the
perioral wrinkles to disappear, and a positive rounding of the mouth.

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Fig 14-2 Improvement of masticatory function by increasing the number of implants.
g. Panoramic radiograph after maxillary alveolar ridge augmentation by LeFort
interpositional bone grafting. h. Lateral cephalometric radiograph after augmentation. i.
Intraoperative image: LeFort I bone graft with interposition of bone substitute material and
additional lateral apposition of monocortical autologous iliac bone grafts. j. Panoramic
image after implant restoration. k. Lateral cephalometric radiograph after implant
restoration. l. Exposed implants before prosthetic restoration.

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Fig 14-2 Improvement of masticatory function by increasing the number of implants.
m. Panoramic image after restoration with bar prosthesis in the maxilla (Dr Rauch,
Melsungen). n. Extraoral image after prosthetic restoration.

Fig 14-3 Improvement of function and facial esthetics by augmentation. a. Initial

situation: atrophied maxillary alveolar process with insufficient denture retention in a 55-
year-old female patient. b. Lateral cephalometric radiograph showing pseudoprognathism of
the mandible.

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Fig 14-3 Improvement of function and facial esthetics by augmentation. c. Panoramic
image with atrophy of Cawood class V in the maxilla and class IV in the mandible. d.
Intraoperative image: LeFort I osteotomy with interposition of bone graft substitutes and
additional lateral and anterior apposition of monocortical autogenous iliac bone grafts. e.
Panoramic image after maxillary alveolar ridge augmentation by LeFort interpositional bone
grafting. f. Lateral cephalometric radiograph after augmentation. Pseudoprognathism is
already reduced due to the improved vertical occlusal dimension. g. Osteosynthesis
material removal 4 months after Fig 14-3f shows rounding of the edges of the bone grafts
and normal low surface resorption, recognizable by the exposed screw heads. h.
Augmentation enables prosthetic-friendly, tooth-axis-compliant, and parallel alignment of the
maxillary dental implants so that they can later be axially loaded without angled abutments.

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Fig 14-3 Improvement of function and facial esthetics by augmentation. i. Panoramic
radiograph after implant uncovering 3 months after Fig 14-3 h. j. Lateral cephalometric
radiograph after implant uncovering. k. Conical double crowns as retaining elements in the

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maxilla. l. Same retaining elements in the mandible. m. Prosthetic restoration with
overdenture in the maxilla (Dr M. Braun, Kassel). n. Before and after images in profile.
Reduction of the pseudoprognathism and unfolding of the lips are noticeable. o. Before and
after facial views. A stretching of the facial shape through improved occlusal height as well
as a smoothing of the supramental fold and improvement of the lip fullness is recognizable.

All these developments can be reversed by careful dental prosthetic

therapy. Cosmetic measures such as permanent makeup to widen curled
lips, lip injections, skin resurfacing, facelifts, and the like do not address the
problem from the root cause and are therefore usually relatively
unsuccessful. At best, they should be performed following occlusal
rehabilitation.

14.6 Dental Prosthetic Features in Severe Alveolar Ridge

Atrophy
In most cases, dental implants and augmentations are necessary for
satisfactory masticatory functional rehabilitation of edentulous patients with
ridge atrophy. A conventional denture is often not sufficient.

Maxilla
In the maxilla, support is required for unfolding of the skin around the lips.
This usually requires the maxillary anterior and posterior teeth to be
positioned anterior or lateral to the alveolar ridge, because the centripetal
atrophy of the maxilla has made it too small relative to the mandible.
Because of this unfavorable overhang, conventional dentures without
implant anchorage would be quickly dislodged. Dislodging of the denture
occurs especially with protrusion and guidance contacts, even with a fully
balanced tooth setup, resulting in flexing of the anterior maxillary alveolar
ridge. This results in increased atrophy of the anterior maxilla with the
formation of a rubber-like flabby crest. This influence is particularly
extreme in the combination syndrome when a mandibular residual dentition
meets a soft tissue-supported full denture in the edentulous maxilla (Fig 14-
4). Even more at risk for such a syndrome is the combination of four
implants in the mandible with a conventionally rehabilitated maxilla. In
these cases, alveolar ridge atrophy is sometimes seen in the anterior region
down to the nasal floor, with the alveolar process still present laterally. The

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final stage of ill-fitting maxillary dentures is usually inflammation of the
oral mucosa, chronic pressure sores, and irritation fibromas. Truly effective
lip support results only from bone augmentation of the alveolar processes,
in which case the mimic muscles find their natural attachment points again
and receive proper tension. The alveolar process volume and the sagittal
position of the alveolar processes are more important for the lip appearance
than the position of the teeth.

Mandible
In the mandible, the problem of increasing alveolar ridge atrophy is initially
poor positional stabilization of the denture against shear and pull-off forces.
If dental implants are not an option, this problem can be eliminated down to
at least 15 mm symphysis height (seen on lateral cephalometric radiograph)
by a combination of lowering of the floor of the mouth and coverage by a
split-thickness skin graft. These procedures are considered as relative
heightening of the ridges, in contrast to a bone augmentation, which is
considered absolute heightening of the ridge. After this soft tissue surgical
measure, which has unfortunately been largely forgotten in many countries,
a mandibular denture usually holds satisfactorily. However, the hold that
can be achieved is not comparable with the comfort gain provided by dental
implants. In the period of preprosthetic surgery, the indication for an
absolute ridge augmentation was below 15 mm. Without dental implants,
however, all absolute augmentation measures by bone grafts and visor and
sandwich osteotomies were only of short duration, because the amount of
elevation disappeared again within a few years due to continued jaw
atrophy. Only the combination of bone augmentation measures with dental
implants has brought about a real halt to alveolar ridge atrophy, which is
referred to as the bone-protective effect of dental implants. However, it is
also true for the mandible that the lip appearance is characterized more by
the alveolar processes than by the tooth position, because the mimic
muscles do not find any attachment points on denture acrylic.

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Fig 14-4 Return to a fixed dentition in a case of severe maxillary atrophy. a. Initial
situation: 59-year-old female patient with a flabby ridge in the anterior maxilla with
inadequate denture fit. b. Panoramic radiograph showing initial situation with combination
syndrome due to an almost full dentition in the mandible. The maxilla is severely atrophied
anteriorly, which appears as local osteolysis. The posterior maxilla shows a lower degree of
atrophy. c. Section of lateral cephalometric image showing negative stepping of the lips and
retroposition of the maxilla in relation to the mandible. d. Intraoperative image with LeFort I
interpositional osteoplasty under advancement and interposition of bone graft substitute. In
addition, lateral and anterior apposition of autogenous iliac bone blocks with corresponding
osteosynthesis. e. Panoramic image after augmentation. Two temporary dental implants
can be seen for positional stabilization of the provisional prosthesis. f. Section of lateral
cephalometric radiograph. The maxillary retroposition has been eliminated.

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Fig 14-4 Return to a fixed dentition in a case of severe maxillary atrophy. g. Four
months after Fig 14-4d, the dental implants were inserted parallel to each other and in the
correct axis for the subsequent prosthetic restoration enabled by augmentation. h.
Panoramic image after implant placement with parallel alignment. Without augmentation,
the implants would be divergent according to the narrow apical base of the natural maxilla
(similar to a bouquet of flowers). i. Section of lateral cephalometric radiograph after implant
placement. j. Even before implant uncovering, there is marked improvement in the amount
of attached gingiva compared to Fig 14-4a. The flabby ridge has been filled from inside. k.
Because the incisions were always made midcrestally and the soft tissue was never
detached from the palatal bone during the interpositional bone grafting, in contrast to an
onlay osteoplasty, the implants can emerge in that place where already the primary and
permanent teeth had erupted. Additional surgical soft tissue management is unnecessary. l.
Panoramic image after implant exposure. Bone level up to the implant shoulder is shown.

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Fig 14-4 Return to a fixed dentition in a case severe maxillary atrophy. m. The
impression copings are parallel in the prosthetic phase thanks to the straight implant
alignment. Therefore, little elastic deformation of the impression materials and thus low
impression error can be expected. In principle, it would be possible to work with impression
plaster as was historically done. n. Fixed prosthesis in crown-bridge technique without
acrylic or gingival imitations (Dr J. Tetsch, Münster, Germany). o. Fixed prosthetic
restoration after previous extreme atrophy. In a sense, the biologic clock of the ridge has
been turned back to the time before edentulism. p. Occlusal view of the prosthesis. q. Smile
image. r. Panoramic radiograph 1 year after prosthetic restoration without signs of marginal
bone resorption. The prosthetic restoration was modified again, using partial dentures.

A special feature of the atrophic mandible can be the painful pressure on

the mental nerve, when the mental foramen seeminigly migrates to the crest
over the course of severe atrophy. Here, chronic irritation due to the

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pressure of the denture and a chronic pain syndrome can occur, which can
only be satisfactorily eliminated by bone augmentation.
Another feature of severe alveolar process atrophy of the mandible is
the risk of fracture, especially in connection with drilling for dental
implants.14

14.7 Step 1: Differential Indication for Implant-Retained

Overdenture Versus Implant-Supported Denture
This differential indication is predominantly a question of chewing
performance and chewing habits with the previous restoration. It is also
important to assess patients’ previous situation. Do they still have their own
teeth, are they already used to removable dentures, or have they been
wearing full fixed dentures for a long time? Patients coming from a
conventional full denture or overdenture will most likely continue to be
satisfied with this solution, with the improvement that a palate-free
overdenture can be achieved with dental implants. Patients who previously
had their own teeth and until recently were able to chew relatively well
would probably be disappointed by a full denture, even if only as a
provisional solution. Such patients are more likely to be advised toward
implant-supported dentures.
Age and age-related dexterity for hygiene measures as well as wishes
for social participation, such as eating food that is difficult to chew in
company, also influence the decision. No sharp line can be drawn here, but
for those over 80 years of age, the overdenture should at least be seriously
considered. However, it should also be mentioned that an overdenture has
hygienic disadvantages, because it cannot be rinsed underneath, and severe
therapy-resistant denture stomatitis due to candida overgrowth often
develops in the covered mucosal areas.
However, the decisive factor for the choice of implant-retained
overdentures versus implantsupported dentures is the desire for chewing
ability. Edentulous patients with ridge atrophy can first be asked what they
can currently eat, followed by the question of what they would like to be
able to chew. If there is then no great additional desire for chewing
function, the therapy tends to go in the direction of position-stabilized
mandibular dentures with two implants and a palate-free overdenture

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retained on four implants in the canine and first molar positions (Fig 14-5).
Sinus elevation also allows secure stabilization in this case and brings many
advantages over an overdenture retained on four implants in the intersinus
region, because such a solution requires a very wide posterior denture base
to absorb the tilting moments. According to the German Society for
Implantology (DGI) guidelines, two implants are always too few in the
maxilla. In a prospective study, overdentures retained on four mini-implants
did not provide any gain in chewing ability compared to conventional full
dentures, but only stabilized the position of the denture.15 Implant-retained
or -supported restorations should be recommended in both arches, with a
minimum two implants in the mandible and four in the maxilla. If, for
reasons of cost, only the mandible is restored with implants, there is a risk
of combination syndrome, ie, increased atrophy of the anterior maxilla with
formation of a flabby ridge due to the strong occlusive forces in that area.
The abutments against the masticatory force should be approximately
equally strong in both articulating partners, as in the case of scissors, in
order to effectively crush the food.
The chewing comfort of overdentures does not match the chewing
power of natural teeth. If the desire is to bite off bread crusts and apples or
to eat tough meat, then more effort is required. Then the restoration goes in
the direction of a fixed or removable implant-supported prosthesis on at
least four interforaminal implants in the mandible and at least four,
preferably six, implants in the maxilla.

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Fig 14-5 Procedure for implant-retained overdentures. a. Initial situation: denture-
incompetent atrophied maxilla in a 74-year-old female patient. b. Panoramic image showing
Cawood class V atrophy of the maxillary alveolar process. c. The lateral cephalometric
image shows the relatively voluminous bone in the symphysis of the mandible. d.
Panoramic image after LeFort I interpositional bone grafting. e. Lateral cephalometric image
after augmentation showing bone gain. f. Four months after Fig 14-5d, implant placement
takes place. The insertion posts show the prosthetically friendly parallel alignment of the
implants.

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Fig 14-5 Procedure for implant-retained overdentures. g. The panoramic image shows
the recommended number and location of implants for overdenture restorations. h. Because
the incisions were always made midcrestally and there is no lateral displacement of the
mucosa as with onlay grafts, the implants break through in their original position in the linea
alba and do not require augmentative soft tissue management. i. The lateral cephalometric
image shows a harmonious lip profile and good utilization of the augmented bone by the
dental implants with a high anteroposterior abutment spread. j. Large support polygon due
to large anteroposterior abutment spread. k. Restoration with implant-retained overdentures
(Dr Stephan Heine, Kassel, Germany). l. A photograph 10 years later shows the stability of
the restoration, but also the redness typical under overdentures. This is denture stomatitis
caused by candida fungi, which mostly grow in and on the denture because it is not
flushable underneath, when in place.

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14.8 Step 2: Differential Indication for Fixed or Removable
Implant-Supported Dentures
In the case of removable dentures and fixed approaches, bone augmentation
has at best the goal of creating sufficient bone for the osseointegration of
implants. The actual tissue replacement is performed by the acrylic
prosthesis. “All-on-four” solutions differ from removable dentures in that
the former must end apical to the smile line because the transition line of
the acrylic denture must be hidden behind the lip. For this to work, there
must either be pronounced atrophy, or it must be created by radical bone
resection. This is not a tissue-friendly procedure, nor does it compensate for
the advantage of immediate loading of the implants. This is one reason why
so called “all-on-four” solutions should be mentioned in the consultation
but, from the point of non nocere, are often not a gentle alternative. More
physiologic is a removable denture that elevates the transition zone above
the smile line far into the vestibule with a vestibular acrylic shield. Then the
full height of the bone behind the labial shield can be preserved. Removable
dentures usually rest palate-free on six implants at the central incisor,
canine, and first molar positions with sinus floor augmentation and ridge
widening by splitting or blocks in the anterior maxilla and use bars or
telescopic copings as connecting elements (Fig 14-6). Such prostheses feel
like the patient’s own teeth and allow full masticatory function. Some
prosthodontists do not want implants in a central incisor position because
they may interfere with esthetic denture morphology if the position is
unfavorable. However, this is a question of correct surgical implant
positioning, which should be carried out by augmenting the bone if
necessary. The advantage of implants in a central incisor position over
posterior implants is the full-arch support of the prosthesis against occlusal
forces. With full-arch support in place, the prosthesis can be made lighter
and more delicate and therefore more comfortable than prostheses on
posterior implants that protrude over the anterior region. Another alternative
to the above concept is implants in the lateral incisor, first premolar, and
first molar positions, depending on where better bone is found.
The alternative to the above-mentioned removable prosthesis in need of
clarification is a fixed prosthesis in a crown-and-bridge technique (Fig 14-
7). If fixed dentures in a crown-and-bridge technique are desired, the bone
structure must not only allow osseointegration but also provide a natural

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emergence profile for the implants, including symmetric support for the
attached gingiva (pink esthetics). In this form, the emergence profiles of the
crowns are within the patient’s own gingiva. This implies much higher
precision requirements for implant position and more effort in bone
augmentation than with removable prostheses, where the resin compensates
for much. Ideally, eight implants are placed at the bilateral central incisor,
canine, first premolar, and first molar positions (see Fig 14-7). These can
then be restored with four repair-friendly short partial dentures, which are
easier to fabricate than long-span dentures because of lower framework
stress. The opposing dentition in the mandible receives six implants at the
bilateral canine, first premolar, and first molar positions, which are then
also restored with three short partial dentures. The dental technical costs of
crown-and-bridge restorations are often lower than those of some
removable prostheses. Fixed partial denture restorations can also be
fabricated on six implants with a denture restoration divided in two in the
middle. The crux of the fixed restoration in the crown-and-bridge technique
is the length of the tooth crowns as well as their anterior inclination in the
case of a receding alveolar ridge. The appearance of long “horse teeth”
quickly occurs in the case of vertical bone loss, because very few patients
have lost the last permanent teeth without vertical bone loss. In other words,
when deciding together with the patient on the fixed prosthesis using the
crown-and-bridge technique, the topic of vertical augmentation should be
discussed during patient education.

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Fig 14-6 Implant-supported removable maxillary restoration on six implants. a. Initial
situation: 33-year-old female patient with Cawood class V atrophy of the edentulous maxilla.
(Artifacts due to non-removable earrings.) b Lateral cephalometric radiograph showing
marked atrophy but no recession of the maxilla. c. Intraoperative image. LeFort I
interpositional bone grafting, with construction of a frame using autogenous bone graft strips
from the iliac crest. d. The interpositional gap and all cavities are filled with bone substitute
mixture to minimize iliac bone harvesting. e. Panoramic radiograph after augmentation. f.
Lateral cephalometric radiograph after augmentation.

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Fig 14-6 Implant-supported removable maxillary restoration on six implants. g. Four
months after Fig 14-6f, the implants are placed. h. Prosthetic restoration. i. Occlusal view of
the palate-free prosthesis. j. Double crowns as connecting elements. k. Balanced smile
appearance created by augmentation. l. Panoramic photograph 5 years postoperatively.

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Fig 14-7 Implant-supported fixed restoration with short partial dentures. a. Initial
situation: 50-year-old patient with periodontal bone loss and desire for a fixed restoration
using the crown-and-bridge technique. Loss of approximately 7 to 10 mm of alveolar ridge
height due to periodontitis. b. Panoramic view after extraction; temporary dental implants
(IPI, Nobel Biocare) secure the provisional prostheses for a patient who is not used to full
dentures. c. Lateral cephalometric radiograph 3 months after extraction with Cawood Class
IV apical ridge atrophy in both jaws. d. Intraoperative image showing construction of a
frame using autogenous iliac bone grafts for ridge widening and rapid bridging of the
interpositional gap. e. Sandwich interpositional bone grafting in the mandible. f. In the
mandible, the gap is filled with a bone substitute material mixture.

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Fig 14-7 Implant-supported fixed restoration with short partial dentures. g. Covering of
the graft with collagen membranes (Bio-Gide, Geistlich). h. Wound closure in the mandible
using continuous sutures. i. Panoramic image after vertical augmentation in both arches. j.
Lateral cephalometric image after augmentation with height gain of approximately 10 mm in
the maxilla and approximately 7 mm in the mandible. k. Osteosynthesis material removal in
the maxilla 4 months after Fig 14-7 h. l. Osteosynthesis material removal in the mandible.

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Fig 14-7 Implant-supported fixed restoration with short partial dentures. m. There are
only small tolerances in implant positioning, since a crown-and-bridge restoration is
planned. n. Panoramic image after implant placement. o. Lateral cephalometric radiograph
after implant placement. p. Prosthetic restoration (C. Schmieder, Eggersdorf). q. The
panoramic radiograph shows the split restorations with seven short partial dentures.

14.9 Step 3: Differential Indication Based on Pros and

Cons of Vertical Augmentation
The option of fixed prostheses in a crown-and-bridge technique with
vertical bone augmentation is also a question of age, because young patients

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still remember the chewing comfort of their own teeth more vividly, and a
very long service life of the prosthesis can be expected. This justifies a high
expenditure. The option of removable or fixed restorations is not only a
question of the patient’s wish, but of course also of the anatomical
conditions and, among other things, the hygiene capabilities in the years to
come. One should inquire about the desire for fixed teeth in a crown-and-
bridge technique in order to communicate the resulting bone augmentation
needs.
If this results in a need for bone augmentation, the question of bone
origin should be clarified. For example, iliac bone harvesting is prohibited
in patients with walking disabilities. Patients should be asked whether they
would like to have bone grafts from deceased or living donors from a bone
bank instead and whether they would like to bear the additional costs for
this.
When the goal is clear, it is checked whether the patient prerequisites
are present. The medical history is carefully reviewed and checked for
contraindications to major augmentations, such as the use of
bisphosphonates. Risk factors such as smoking and diabetes mellitus are
pointed out to the patient. The patient’s ability to undergo general
anesthesia is then checked. This is followed by cost clarification via a cost
estimate.
Vertical augmentation of the edentulous maxilla and mandible has many
advantages. In addition to perfect implant positioning and compensation of
pseudoprognathism through jaw advancement, Le Fort interpositional bone
grafting results in, among other things, bony lip support at the alveolar
process level and support of the paranasal skin with flattening of the
nasolabial folds. Together with the automatic elevation of the nasal tip due
to better bone support at the nasal spine, this makes the patient looks
younger and more attractive. In the mandible, the alveolar process can be
elevated by sandwich interpositional osteoplasty. This has the advantage
that the mental muscle automatically finds a more cranially located
attachment point. As a result, the mandibular tooth exposure is reduced and
the drooping chin disappears. Furthermore, the lower lip receives support at
the alveolar process level, unfolds through attachment points for the mimic
musculature, and becomes fuller as the supramental fold becomes flatter.
Such an improvement has its price. First of all, there is an inpatient stay
as well as an surgery under general anesthesia, which, including iliac bone

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harvesting, requires 2 hours for one arch and about 3 hours for both arches.
The differential indication for removable dentures is therefore mainly based
on the willingness and ability to undergo surgery and the assumption of the
costs for this.
In the author’s experience, alternative augmentation techniques such as
onlay bone grafts with iliac bone blocks or skull bone grafts are reserved for
special situations. Interpositional bone grafts have innumerable advantages
over onlays, but are technically more difficult to perform than onlay
techniques.

Fig 14-8 Treatment of a Cawood class VI atrophy with interpositional bone grafting. a.
Initial situation with pronounced alveolar process atrophy of both arches in a 69-year-old
female patient. The mandibular alveolar ridge is inferior to the floor of the mouth; there is no
attached gingiva left. In the right first molar region there is pachyderma due to chronic
pressure points. b. The maxilla is also atrophied. c. Panoramic radiograph showing 8-mm
symphyseal height. d. Intraoperative image, horizontal osteotomy of the anterior
interforaminal region of the mandible.

14.10 Extreme Atrophy

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Extremely atrophied mandibles are such a special situation, especially if
osteoporosis is present, because there is a risk of fracture when sectioning
the mandible for a sandwich bone graft or when drilling for dental implants
(Fig 14-8). Although the first short implant studies, performed in the
extremely atrophied anterior mandible, showed that short implants in the
interforaminal region can achieve good long-term results,16 there is a strong
case for augmentative treatment of the pronounced mandibular atrophy.
Depending on the study, the probability of fracture due to implant drilling is
about 2% of at this degree of atrophy.17 Such fractures are difficult to treat
due to the lack of bone surface for reattachment and should be avoided. If
the mandibular arch fractures bilaterally, there is even a risk of life-
threatening respiratory distress due to tongue and airway collapse.
Augmentation can therefore certainly be indicated for fracture prophylaxis.
Surgical errors such as notch stresses due to pointed osteotomies or too
forceful chisel insertion lead to fracture. On the other hand, even an 8-mm
mandible can still be treated with the sandwich technique if the procedure is
carried out carefully, which offers enormous advantages compared to onlay
or lower border augmentation.
A common reason for augmentation of the atrophied mandible is also
pressure pain or even a chronic pain syndrome associated with an exposed
inferior alveolar nerve. The mental foramen moves to the top and even
toward the midline of the mandibular ridge with increasing atrophy. In
Cawood class VI atrophy, the nerve may even be completely exposed and
emerge posteriorly.

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Fig 14-8 Treatment of a Cawood class VI atrophy with interpositional bone grafting. e.
The interposition gap has been filled by a bone graft–bone substitute material mixture. f.
Intraoperative image in the maxilla, where a frame of thin strips of autogenous iliac crest
grafts was built up after LeFort I osteotomy and advancement of the maxilla. g. The
interposition gap, the sinus floors, and all voids were filled with a bone graft-bone substitute
(Bio-Oss, Geistlich) mixture (25%/75%), then the grafts were covered by a collagen
membrane (Bio-Gide). h. Panoramic radiograph after augmentation and placement of
temporary dental implants in the maxilla. i. The lateral cephalometric radiograph illustrates
the height gain of 9 mm in the mandible and 10 mm in the maxilla. j. At the time of
osteosynthesis material removal, the bone edges have rounded compared to Fig 14-8f, and
the former block grafts have become vascularized.

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Fig 14-8 Treatment of a Cawood class VI atrophy with interpositional bone grafting. k.
The position indicators show the parallel prosthetic-friendly alignment of the dental implant
osteotomies in the maxilla. l. Panoramic image after implant exposure. At this point, the last
provisional implant (at the maxillary right first premolar position) is also removed. m. Lateral
cephalometric radiograph after implant uncovering. n. Locator abutments in the mandible
(Dr J. Schwalm, Schwalmstadt). The spontaneous return of the attached gingiva compared
to Fig 14-8a without soft tissue management is interesting. o. Locator abutments in the
maxilla. p. Preparation of the prosthetic restoration.

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Fig 14-8 Treatment of pronounced alveolar ridge atrophy with interpositional bone
grafting. q. Palate-free overdentures. r. Prosthetic restoration (Dr J. Schwalm,
Schwalmstadt). s. Occlusal view of mandibular prosthesis. t. Occlusal view of maxillary
prosthesis. u. Panoramic radiograph 1 year after prosthetic restoration. There is no
marginal bone resorption. v. Lateral cephalometric image 1 year after prosthetic restoration
with stable maxillary position. w. Profile and facial images with correct lower face height and
beautiful lip appearance despite previous extreme atrophy. x. Local vestibuloplasty to
improve the attached gingiva in the mandibular left canine region. y. Paper template for
accurate measurement of a gingival graft from the hard palate. z. Gingival graft secured
with periosteal sutures and alveolar ridge sutures. aa. Improved gingival situation at
mandibular left canine region compared to Fig 14-8n. bb. Panoramic radiograph 5 years
after prosthetic restoration. Stable situation without marginal bone resorption or alveolar
ridge resorption. cc. Panoramic radiograph 10 years after prosthetic restoration. Continued
stable situation.

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Fig 14-9 Interpositional grafting after periodontal bone loss in a Cawood class IV. a.
Initial situation with hopeless dental status despite years of periodontal treatment in a 49-
year-old female patient. b. Lateral cephalometric radiograph showing a reduced occlusal
height due to periodontal tooth migration and loss of supporting bone. c. Panoramic
radiograph 3 months after tooth extraction. d. Lateral cephalometric radiograph showing
significant reduction in jaw height 3 months after tooth extraction.

The severely atrophied mandible is usually the deepest part of the oral
cavity, deeper than the floor of the mouth. Accordingly, the hygiene under
dentures is poor when the alveolar ridge is no longer a ridge but a valley.
This leads to food impaction. Augmentation can raise the ridge again.
The mentalis muscle attaches the chin soft tissue. If a cranial attachment
is restored to this, chin droop and exaggerated mandibular tooth exposure
can be reversed. A purely prosthetic restoration, eg, in the context of all-on-
four solutions, does not ameliorate this point.
Extreme maxillary atrophy can also be treated with Le Fort interposition
bone grafting as long as a palatal wall is available, so that large amounts of
graft volume can be saved compared to overlay bone grafts. This makes the
surgical procedure much more tolerable. The indication for microsurgically
anastomosed bone grafts is very rare in preprosthetic surgery because the
effort and the surgical burden are very high (Fig 14-10).

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Fig 14-9 Interpositional grafting after periodontal bone loss in a Cawood class IV. e.
Intraoperative detail showing sandwich interposition gap filled with mixed bone graft
material. f. LeFort I interposition gap filled with mixed bone graft. A monocortical iliac strip
graft was attached to both canine regions like cornerstones, which also overlaps the
interpositional gap cranially and is thus intended to cause rapid fusion of the segment with
the maxillary base. g. Covering of the bone grafts with collagen membranes. h. Wound
closure in the maxilla with a minimal sutures. The fissuring and scarring after periodontally
induced tooth loss is still visible. i. Panoramic radiograph after augmentation. j. The lateral
cephalometric radiograph shows the height gain of about 7 mm in the mandible and 10 mm
in the maxilla after augmentation to compensate for the periodontitis-related loss.

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Fig 14-9 Interpositional grafting after periodontal bone loss in a Cawood class IV. k.
Panoramic radiograph with good utilization of the newly gained height due to sufficiently
long dental implants 4 months after augmentation. l. Lateral cephalometric image with
prosthetically parallel, aligned dental implants and correct maxillomandibular relationship.
m. Exposure of the implants 3 months after placement via a midcrestal incision. As a result
of the interposition technique, the soft tissue was never detached from the oral side of the
alveolar ridge. Therefore, the implant emerges at the same site as the previous primary and
permanent teeth. No additional soft tissue management is required to form a cuff of gingiva.
n. Exposure in the maxilla by midcrestal incision and a slightly apically shifted flap. o. Trial
framework in the maxilla. p. Zirconia framework.

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Fig 14-9 Interpositional grafting after periodontal bone loss in a Cawood class IV. q.
Mandibular removable restoration on double crowns. r. Maxillary cemented prosthetic
restoration (Dr B. Simon, Hamburg-Harburg). Avoidance of long crowns by prior vertical
bone augmentation. s. Panoramic image 1 year after prosthetic restoration. t. Panoramic
image 11 years after prosthetic restoration without signs of bone resorption at the implants
or in the augmented areas. u. Panoramic radiograph 16 years after prosthetic restoration
with continued stable situation. v. Youthful skin appearance, correct lower face height, and
unfolded lips.

Fig 14-10 Conventional complete restoration with sinus elevation. a. Baseline situation
of a 52-year-old patient with a long history of restorative work in the dentition. b. Teeth were
extracted under sedation, and the previously prepared full dentures were placed as a
provisional restoration. Three months of healing was allowed; subsequently two-stage sinus
floor augmentation and lateral augmentation were performed (a total of 4 months after initial
contact and the start of planning).

14.11 Differential Indication for Augmentation-Free

Restoration and Immediate Loading on Oblique
Implants (All-on-Four Methods)
The indication for the “all-on-four” methods exists at an earlier stage than
the actual cases in this book chapter, which deals with patients who have
already become edentulous. Patients who have a long history of
conservative and periodontal treatment in the second dentition are the main
ones who consider all-on-four methods. In this case, the cost and time
investment associated with a conventional restoration with sinus elevation
(Fig 14-10) versus a convenient immediate solution under general
anesthesia plays a role; fear of treatment is also often a factor.
The “all-on-four” method takes advantage of the fact that in the anterior
maxilla there is still a relatively large amount of bone in the residual
dentition apical to the premolars. Because the floor of the maxillary sinus

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rises obliquely toward the anterior, it is often possible to get long dental
implants with sharp threads inserted so tightly along this slope that even
prostheses projecting posteriorly into the first molar regions can be loaded
immediately due to a splayed polygon of support.
In the atrophied mandible, it is hardly possible to achieve an additional
gain from the support polygon by tilting the implants because the position
of the mental foramen becomes closer to the ridge with increasing degree of
atrophy. In this case, classical axial interforaminal implant placement in
conjunction with a bar with distal cantilevers is often sufficient for an
implant-supported replacement up to first molar regions.

Sacrifice of healthy teeth and alveolar bone

The “all-on-four” method is usually performed under general anesthesia,
and the promise found in relevant full-page newspaper advertisements is
that patients will go into anesthesia with painful and destroyed teeth and
wake up with strong and healthy teeth. Such messages naturally entice
doctors and patients to sacrifice many a tooth worth preserving and, above
all, plenty of alveolar bone for the sake of convenience, because the
transition line of the screw-retained prosthesis must be placed apical to the
smile line for the system to work. It is not written in the advertising
messages that the fixed teeth are often only a plastic temporary denture that
still has to be replaced later at additional cost.

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Fig 14-10 Conventional complete restoration with sinus elevation. c. Placement of the
dental implants 6 months after initial patient presentation. In the mandibular molar region,
very soft bone still existed in the extraction sockets 5 months after extraction. d. Implants in
the bilateral first molar regions did not heal correctly and had to be replaced after a total of 9
months. At this time, exposure of the maxillary implants was performed after 3 months of
healing time. e. and f. Fourteen months after initial presentation, the definitive prostheses
were placed in the mandible (Dr M. Braun, Kassel) and maxilla. The patient therefore had to
make do with a removable provisional denture for 14 months. g. Panoramic radiographic
image after prosthetic restoration. The restoration has been under function for 1 year and
shows no functional or hygienic problems. An all-on-four immediate restoration would
probably have required a similar period of time for the definitive prosthetic placement after
final implant healing, albeit with a fixed provisional restoration.

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Augmentation and sinus elevation avoidance
The other promise of the “all-on-four” methods, especially to non-specialist
dentists, is to avoid augmentation and sinus elevation using inclined
implants. Apart from the fact that sinus elevation is so minimally invasive
that it should be sought rather than avoided, sinus elevation avoidance is
associated with limitations and subsequent risks. In “all-on-four”
restorations, implants are intentionally placed at an angle at the anterior
margin of the maxillary sinus, where the sinus floor rises at an angle.
However, a small sinus elevation is necessary to find this location, unless
fully guided implants are placed. In the author’s experience, however, this
is not advisable, because with fully guided oblique implant placement one
loses the feeling for the drilling resistance of the bone. It is no longer
possible to respond well to the cancellous bone of the maxilla by partially
undersizing preparation in parts of the implant osteotomy, which then
frequently leads to unstable implants that can no longer be loaded
immediately. This means that the promise of immediately fixed teeth can no
longer be kept. Many maxillary sinuses are extended far forward, so that
even with tilted implants a support polygon can only be achieved as far as
the premolar region.

Immediate loading and patient satisfaction

In order to be able to use at least the immediate loading of the “all-on-four”
method in the aforementioned situation, it is indicated to combine the tilted
implants with sinus floor augmentation.18 All concerns are compensated by
the proven high satisfaction of most patients and doctors with the
immediate masticatory function19 and the convenience of the complete
treatment with one anesthesia and a single trip to the dental office. The
latter probably plays a role more in countries where patients have to travel a
great distance to visit a dentist and nationwide high-quality dental care is
not a matter of course. However, the experience of such health care systems
strongly influences the scientific literature and thus also the professional
opinion in countries with good dental care being commonplace and
available at short travel distances. In the latter situation, sustained treatment
success in family care over generations is more important than the pleasure
of immediate masticatory function.

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Complications of tilted implants
In contrast to an axially placed implant, a tilted implant in the sagittal
direction often has one implant shoulder that is higher and one that is lower
compared with the bone level. At a 45-degree tilt, this accounts for 2 mm of
height discrepancy mesially and distally for a 4-mm implant. The biologic
width is about 3 mm, so the discrepancy due to remodeling leads mesially
to exposure of roughened implant components or distally to marginal bone
loss and a pseudopocket. Both situations are theoretically associated with an
increased risk of peri-implantitis.20 In practice, however, this situation
seems to be well compensated by the body, as no increased bone loss21 and
no increased peri-implantitis rates22 were observed on angled implants, at
least in the short term up to 1 year. However, more mechanical
complications and higher marginal bone loss were observed on angled
abutments than on straight abutments.23

Hygiene difficulties of screw-retained full dentures

In the author’s experience, keeping screw-retained full dentures clean, as in
the “all-on-four” method, is very difficult. This only works if the
undersurface of the prosthesis is pontic-like and brush channels to the
implants have been incorporated. However, this contradicts esthetics.
Because the transition line has to lie above the smile line, these brush
channels are rather deep in the mouth and difficult to find. The
compromises made in practice lead to food accumulation under the rather
bulky prostheses. In principle, it is advantageous in reconstructive medicine
to work as delicately as possible and to keep the amount of material placed
in the body as small as possible. Some clunky “all-on-four” prostheses
contradict this rule. The problem of the lack of hygiene access can be
countered by a removable design of the “all-on-four” prosthesis, eg, on a
bar, but then one has made so many compromises compared to the
abovementioned promises that one might as well work conventionally with
sinus elevation and implants placed axially in the ideal prosthetic position.

14.12 Differential Indication for Augmentation-Free

Restoration of the Maxilla with Zygoma Implants

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Zygoma implants are an alternative for restoring the atrophied Cawood
class V maxilla. These are surgically demanding to place under general
anesthesia but create a stable prosthetic bed. Care should be taken to avoid
contact of the metal with the air space of the maxillary sinus by means of
sinus elevation preparations and extrasinus guidance of the implants,
because otherwise chronic sinusitis and fistulas occur within 1 year in about
10% of cases.24–26 Exposed metal can also promote mold growth and
sinusitis.27
There are randomized prospective data comparing zygoma implants to
conventional implants combined with augmentation in 71 edentulous
patients with alveolar ridge atrophy.28 The time to a fixed prosthesis was
444 days in the conventional group and 1.3 days in the zygoma group.
About twice as many complications occurred in the zygoma group (28 of 35
patients) as in the conventional group (14 of 31 patients), which was mainly
due to sinusitis and fistulae in the zygoma group and compromised
osseointegration in the conventional group. In this study, the augmentations
were performed with animal block materials as onlays rather than
autogenous iliac bone, which would have been a better material selection in
this indication. Under these conditions, implant survival at 1 year was 85%
for the augmentation group and 97% in the zygoma group. Despite the
somewhat unfair study conditions with the use of a complication-prone
augmentation material in the control group, it can nevertheless be stated
that zygoma implants were suitable in this study to avoid major surgery
with extraoral bone harvesting. Long-term survival in a meta-analysis of
mainly retrospective studies of up to 18 years of follow-up was 95.1% at 12
years.29 When low-grade augmentation under local anesthesia is not
sufficient for Cawood class IV to V (eg, bilateral sinus elevation and
autogenous block grafts in the anterior region), zygoma implants are worth
considering as an alternative to extensive augmentation with iliac bone.
However, zygoma implants should be placed by experienced surgeons
because significant malpositioning into the orbit30,31 and even into the
cerebrum32 has been reported.

14.13 Differential Indication for Augmentation-Free

Restoration of Cawood Class V to VI Atrophied
Mandible with Short Implants

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In the mandible, even in cases of extreme atrophy with only a few
millimeters of bone height, there is the alternative of interforaminal short
implants with an overdenture, which are very helpful, eg, for patients taking
antiresorptive or anticoagulant medications. A randomized prospective
study showed the lowest loss rates after 10 years for the group with short
implants, compared to transmandibular implants and augmented
situations.33 In this study, 30% of patients with transmandibular implants,
5% of patients with augmentations, and none of the patients with short
implants required a repeat surgical procedure. The trade-off for
augmentation stems from fracture prophylaxis, esthetics, and the desire for
a restoration above the standard of the overdenture. Augmentation is not
necessary in the mandible for osseointegration and overdenture anchorage.

14.14 Differential Indication for Augmentation-Free

Restoration with Subperiosteal Implants
The latest augmentation-free restoration alternative for severely atrophied
ridges is patient-specific subperiosteal implants additively manufactured by
CAD/CAM methods (eg, IPS Implants Preprosthetic, KLS Martin). This
type of implant achieves excellent primary stability by fixation using
osteosynthesis screws and does not require any bone augmentation because
it is fixed in areas of the midface that are not subject to atrophy (Fig 14-11).
Not much can be said yet about long-term survival due to lack of data; only
case series with a short observation period are available.34,35 Basically,
subperiosteal implants have the disadvantage that they probably have no
bone-protective effect and do not stop physiologic jaw atrophy, so that long-
term restorations lose bone support over time.36 This type of restoration is
still at the trial stage.

14.15 Recommendations for Augmentative Treatment of

Atrophied Edentulous Ridges
In the case of larger augmentations, final implant planning should only be
performed after the augmentation has healed. After augmentation, the bone
volume achieved can be assessed quite well after the onset of remodeling,

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about 3 months postoperatively. Then the question of fixed or removable
dentures can be discussed and planned in detail. A wax-up can be made on
the alveolar ridge as a method of reverse planning, which takes into account
facial esthetics, dental esthetics, and feasibility based on bone conditions.
This wax-up is transferred to a provisional prosthesis, which the patient can
check under function and at rest. Intraoperatively, the provisional prosthesis
serves as a drill guide and is further used postoperatively as a temporary
denture until the definitive implant restoration is completed. Digital
planning helps the novice with their first cases, but with some experience it
is safe to use the conventional drill guide. There is seldom a real need for
navigated implant placement, because the ridge has to be exposed anyway
for osteosynthesis material removal after augmentation, and then implant
placement can be performed under direct vision.

Radiographic diagnostics in edentulous patients

At an early stage of the initial consultation, a panoramic radiograph and a
lateral cephalometric radiograph are recommended for edentulous patients
with ridge atrophy. This shows the lower symphysis height and the occlusal
relation. A three-dimensional radiographic examination by CBCT is not
absolutely necessary at this stage.
In the lateral cephalometric radiograph, one can also see the upper lip
length and assess the vertical and sagittal augmentation requirements in the
maxilla. The natural tooth exposure (incisal point) is about 2 mm at lip rest.
From the planned incisal point 2 mm inferior to the lip, measure in a
straight line to the residual bone of the maxillary alveolar process. From the
measured distance, subtract 10 mm for the height of an anterior crown and
3 mm for the soft tissue emergence profile of the implant (ie, 13 mm is
subtracted). The rest of this line is the vertical bone augmentation
requirement. If this line is more oblique than 20 degrees to the masticatory
plane, an additional advancement of the maxillary alveolar process is
required. This is done in combination with horizontal placement of iliac
bone blocks, preferably with Le Fort I interpositional bone grafting.

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Fig 14-11 Augmentation-free restoration with digitally fabricated subperiosteal
implant. a. Initial situation: 65-year-old patient after tumor treatment in the maxilla with
bone defect covered by radialis flap. b. Panoramic image of the initial situation with an old
blade implant, which has an 8-mm pocket and bleeding upon probing, but is otherwise
under function. c. Digital 3D planning of the patient-specific IPS Preprosthetic implant based
on computed tomographic data together with the engineers of KLS Martin. After medical
approval of the design, the titanium implant is printed from titanium powder using the
selective laser melting process. d. Intraoperative image: after soft tissue opening, perfect
seating of the implant in the subperiosteal space. It is fixed by numerous screws in bone
areas that are not subject to alveolar process atrophy. The metal construction bridges all
bone defects of the maxilla. The maxillary sinus is not opened. e. The lateral view shows
how far the prosthetic abutments project in relation to the framework. This is possible to
achieve without any problems because the metal structure is enormously rigid. f. Soft tissue
adaptation to the prosthetic abutments.

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Fig 14-11 Augmentation-free restoration with digitally fabricated subperiosteal
implant. g. The prefabricated provisional prosthesis is inserted intraoperatively. The
excellent stability of the implant is striking and far exceeds the usual level achieved in
conventional implantology. h. The implant is fully loaded immediately. Full immediate
loading of the implant as well as immediate restoration of esthetics are permitted. i. The
definitive prosthesis is fabricated by dental technology a few weeks later. j. The prosthesis
is screw-retained and is conditionally removable. k. Detail of the soft tissue emergence
region, which has been free of irritation and very accessible to oral hygiene for an
observation period of 2 years. This is a new augmentation-free procedure that has only
been in trial since 2017. Long-term data are not available. l. Panoramic image after implant
placement.

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Augmentation of a Cawood class IV atrophied maxilla for placement
of four to six implants and a removable restoration
In preparation for augmentation surgery under local anesthesia, a CBCT is
helpful to measure the residual bone on the maxillary sinus floor and the
residual width in the anterior maxilla. Cawood class IV means that there is a
pointed ridge with sufficient height and insufficient width in the anterior
region. If a removable restoration is to be made, the narrow ridge can be
treated by bone splitting in the region anterior to the canines bilaterally,
provided that 4 mm of residual bone and two splittable cortical walls are
present in the CBCT. Then, as a rule, the restoration can be carried out
together with bilateral sinus elevations in one stage. If this condition does
not exist, two-stage bone block grafting can be performed in the anterior
canine region, in combination with guided bone regeneration (GBR) and
bilateral sinus elevation, followed by implant restoration 4 months later. A
large GBR across the entire ridge has also been described.37 The ideal
implant distribution in the maxilla is first molar for occlusal height, canine
for guidance, and central incisor for arch support during mastication. If the
patient can only afford four implants, the anterior implants can be omitted
and a fixed bar used instead to absorb the occlusal force. It is important to
use the surgical guide to achieve accurate prosthetic positioning of the
anterior implants so that they do not interfere with esthetics later.

Augmentation of a Cawood class V atrophied maxilla for placement

of four to six implants and a removable restoration
The combined vertical and horizontal atrophy is best addressed by a Le Fort
I interpositional bone graft. The alternative overlay bone graft through iliac
or cranial blocks has several disadvantages. First, much more bone graft
volume is required than with interposition, which increases postoperative
discomfort and removal trauma. Furthermore, onlay blocks are at high risk
of dehiscence and especially resorption. Third, in contrast to the Le Fort I
interposition, an additional vestibuloplasty is required (see chapter 8).
Although restoration with particulate grafts in the sense of a large GBR has
been described,38 it is still at the experimental stage and probably does not
lead to load-bearing bone as quickly as the other techniques, which require
only 4 months if autologous iliac bone is used.

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Augmentation of a Cawood class IV or V atrophied maxilla for
placement of four to six implants and a fixed restoration
Even a severely atrophied jaw can be regenerated in favorable cases in
young patients to the extent that a fixed restoration with crown-and-bridge
prosthetics becomes possible. However, this approach is more common in
Cawood class IV in patients in the fourth to sixth decade of life. These
augmented arches can then be restored very attractively with fixed crown-
and-bridge prosthetics. The method of choice is the Le Fort I interpositional
bone graft. In the case of a low degree of horizontal atrophy, this can also
be performed with blocks from the external oblique ridge of the mandible
instead of iliac bone in order to completely avoid postoperative gait
restrictions.

Augmentation of a Cawood class IV atrophied mandible for

placement of four implants
The Cawood class IV atrophied mandible rarely requires augmentation
because a pointed ridge can usually be converted to a wide ridge by
modelling osteotomy (height reduction). However, there are exceptions
here, which can be identified by palpation or by taking a CBCT, which is
recommended. Some alveolar ridges are very narrow to the basal arch;
some even become narrower toward the base. The latter are to be widened
by block grafting in the interforaminal region.
If a CBCT of the anterior mandible is made, then one is sometimes
surprised in this radiographic representation how prominently and widely
the incisive canal extends as an extension of the inferior alveolar nerve to
about the lateral incisor site. The incisive nerve may initially be 4 mm in
diameter.39 Cases of chronic pain after implant placement have been
reported and may be related to injury to the ramus incisivus.40 If possible,
the incisive nerve should not be injured by implant drilling; shorter implants
should be chosen instead, and augmentation should be performed laterally
by GBR, splitting, or block grafts in case of pointed ridges.

Augmentation of a Cawood class V atrophied mandible for

placement of four implants

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Augmentation is best accomplished by interforaminal sandwich bone
grafting with interposition of a mixed bone graft. The anterior plateau of the
interposition can then be continued to the retromolar region by
monocortical blocks from the iliac crest. This technique succeeds down to
an 8-mm symphysis height by separating the mandible at a slight angle (see
chapter 8), but increased caution is required in patients with osteoporosis.
For even more atrophied cases, onlay grafting of iliac or cranial bone blocks
and extraoral techniques such as lower border augmentation and the tent-
pole technique can be considered.

14.16 References
1. Fontijn-Tekamp FA, Slagter AP, Van Der Bilt A, et al. Biting and chewing in overdentures, full
dentures, and natural dentitions. J Dent Res 2000;79:1519–1524.
2. Nam DH, Lee DW, Chung CJ, Kim KH, Park KH, Moon IS. Change in masticatory ability with
the implant restoration of second molars. J Prosthet Dent 2014;111:286–292.
3. Fontijn-Tekamp FA, Slagter AP, van’t Hof MA, Geertman ME, Kalk W. Bite forces with
mandibular implant-retained overdentures. J Dent Res 1998;77:1832–1839.
4. Fonteyne E, Van Doorne L, Becue L, Matthys C, Bronckhorst E, De Bruyn H. Speech evaluation
during maxillary mini-dental implant overdenture treatment: A prospective study. J Oral Rehabil
2019;46:1151–1160.
5. Bradbury J, Thomason JM, Jepson NJA, et al. Perceived chewing ability and intake of fruit and
vegetables. J Dent Res 2008;87:720–725.
6. van der Bilt A. Assessment of mastication with implications for oral rehabilitation: A review. J
Oral Rehabil 2011;38:754–780.
7. Cousson PY, Bessadet M, Nicolas E, Veyrune JL, Lesourd B, Lassauzay C. Nutritional status,
dietary intake and oral quality of life in elderly complete denture wearers. Gerodontology
2012;29:e685–e692.
8. Feldman RS, Kapur KK, Alman JE, Chauncey HH. Aging and mastication: Changes in
performance and in the swallowing threshold with natural dentition. J Am Geriatr Soc
1980;28:97–103.
9. Shin HE, Cho MJ, Amano A, Song KB, Choi YH. Association between mastication-related
factors and the prevalence of dementia in Korean elderly women visiting senior centres.
Gerodontology 2020;37:177–184.
10. Weijenberg RAF, Scherder EJA, Lobbezoo F. Mastication for the mind—The relationship
between mastication and cognition in ageing and dementia. Neurosci Biobehav Rev
2011;35:483–497.
11. Nickenig HJ, Wichmann M, Terheyden H, Kreppel M. Oral health-related quality of life and
implant therapy: A prospective multicenter study of preoperative, intermediate, and posttreatment
assessment. J Craniomaxillofac Surg 2016;44:753–757.
12. Farzadmoghadam M, Mohammadi TM, Goudarzi R, Mohammadi M, Hasheminejad N. Is there a
relationship between general and oral health-related quality of life in partially edentulous patients

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 before and after implant treatment? A quasi-experimental study. Clin Oral Implants Res
2020;31:557–564.
13. Gjerde CG, Shanbhag S, Neppelberg E, Mustafa K, Gjengedal H. Patient experience following
iliac crest-derived alveolar bone grafting and implant placement. Int J Implant Dent 2020;6:4.
14. Chrcanovic BR, Custódio AL. Mandibular fractures associated with endosteal implants. Oral
Maxillofac Surg 2009; 13:231–238.
15. Enkling N, Saftig M, Worni A, Mericske-Stern R, Schimmel M. Chewing efficiency, bite force
and oral health-related quality of life with narrow diameter implants—A prospective clinical
study: Results after one year. Clin Oral Implants Res 2017;28:476–482.
16. Stellingsma C, Meijer HJ, Raghoebar GM. Use of short endosseous implants and an overdenture
in the extremely resorbed mandible: A five-year retrospective study. J Oral Maxillofac Surg
2000;58(4):382–387.
17. Raghoebar GM, Stellingsma K, Batenburg RH, Vissink A. Etiology and management of
mandibular fractures associated with endosteal implants in the atrophic mandible. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2000;89:553–559.
18. Testori T, Mandelli F, Mantovani M, Taschieri S, Weinstein RL, Del Fabbro M. Tilted trans-sinus
implants for the treatment of maxillary atrophy: Case series of 35 consecutive patients. J Oral
Maxillofac Surg 2013;71:1187–1194.
19. Erkapers M, Segerström S, Ekstrand K, Baer RA, Toljanic JA, Thor A. The influence of
immediately loaded implant treatment in the atrophic edentulous maxilla on oral health related
quality of life of edentulous patients: 3-year results of a prospective study. Head Face Med
2017;13:21.
20. Schwarz F, Giannobile WV, Jung RE. Groups of the 2nd Osteology Foundation Consensus
Meeting. Evidence-based knowledge on the aesthetics and maintenance of periimplant soft
tissues: Osteology Foundation Consensus Report Part 2-Effects of hard tissue augmentation
procedures on the maintenance of peri-implant tissues. Clin Oral Implants Res 2018;29(Suppl
15):11–13.
21. Del Fabbro M, Ceresoli V. The fate of marginal bone around axial vs. tilted implants: A
systematic review. Eur J Oral Implantol 2014;7(Suppl 2):S171–S189.
22. Lin WS, Eckert SE. Clinical performance of intentionally tilted implants versus axially
positioned implants: A systematic review. Clin Oral Implants Res 2018;29(Suppl 16): 78–105.
23. Omori Y, Lang NP, Botticelli D, Papageorgiou SN, Baba S. Biological and mechanical
complications of angulated abutments connected to fixed dental prostheses: A systematic review
with meta-analysis. J Oral Rehabil 2020;47:101–111.
24. Jensen OT, Adams M, Cottam JR, Ringeman J. Occult peri-implant oroantral fistulae: Posterior
maxillary periimplantitis/sinusitis of zygomatic or dental implant origin. Treatment and
prevention with bone morphogenetic protein-2/absorbable collagen sponge sinus grafting. Int J
Oral Maxillofac Implants 2013;28:e512–e520.
25. Davó R, Bankauskas S, Laurincikas R, Koçyigit ID, Mate Sanchez de Val JE. Clinical
performance of zygomatic implants-retrospective multicenter study. J Clin Med 2020;9:480.
26. Aleksandrowicz P, Kusa-Podkańska M, Grabowska K, Kotuła L, Szkatuła-Łupina A,
Wysokińska-Miszczuk J. Extra-sinus zygomatic implants to avoid chronic sinusitis and
prosthetic arch malposition: 12 years of experience. J Oral Implantol 2019;45:73–78.
27. Sato FR, Sawazaki R, Berretta D, Moreira RW, Vargas PA, de Almeida OP. Aspergillosis of the
maxillary sinus associated with a zygomatic implant. J Am Dent Assoc 2010; 141:1231–1235.
28. Davó R, Felice P, Pistilli R, et al. Immediately loaded zygomatic implants vs conventional dental
implants in augmented atrophic maxillae: 1-year post-loading results from a multicentre
randomised controlled trial. Eur J Oral Implantol 2018; 11:145–161.

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29. Chrcanovic BR, Albrektsson T, Wennerberg A. Survival and complications of zygomatic
implants: An updated systematic review. J Oral Maxillofac Surg 2016;74:1949–1964.
30. Haßfeld S, Scheerer F, Abel D, Linardi G, Böker T, Bonitz L. Periorbital abscess after
explantation of a zygoma implant. Dental Communications 2019;17.
31. Van Camp P, Vrielinck L, Gemels B, Politis C. Intraorbital hemorrhage following a secondary
intervention at integrated zygomatic implants: A case report. Int J Surg Case Rep 2018; 43:21–
24.
32. Reychler H, Olszewski R. Intracerebral penetration of a zygomatic dental implant and
consequent therapeutic dilemmas: Case report. Int J Oral Maxillofac Implants 2010;25:416–418.
33. Stellingsma K, Raghoebar GM, Visser A, Vissink A, Meijer HJ. The extremely resorbed
mandible, 10-year results of a randomized controlled trial on 3 treatment strategies. Clin Oral
Implants Res 2014;25:926–932.
34. Mommaerts MY. Evolutionary steps in the design and biofunctionalization of the additively
manufactured subperiosteal jaw implant ‘AMSJI’ for the maxilla. Int J Oral Maxillofac Surg
2019;48:108–114.
35. Jehn P, Spalthoff S, Korn P, et al. Oral health-related quality of life in tumour patients treated
with patient-specific dental implants. Int J Oral Maxillofac Surg 2020;49:1067–1072.
36. Schou S, Pallesen L, Hjørting-Hansen E, Pedersen CS, Fibaek B. A 41-year history of a
mandibular subperiosteal implant. Clin Oral Implants Res 2000;11:171–178.
37. Mordenfeld A, Aludden H, Starch-Jensen T. Lateral ridge augmentation with two different ratios
of deproteinized bovine bone and autogenous bone: A 2-year follow-up of a randomized and
controlled trial. Clin Implant Dent Relat Res 2017;19:884–894.
38. Gultekin BA, Cansiz E, Borahan MO. Clinical and 3-dimensional radiographic evaluation of
autogenous iliac block bone grafting and guided bone regeneration in patients with atrophic
maxilla. J Oral Maxillofac Surg 2017;75:709–722.
39. Ferreira Barbosa DA, Barros ID, Teixeira RC, et al. Imaging aspects of the mandibular incisive
canal: A PROSPEROregistered systematic review and meta-analysis of cone beam computed
tomography studies. Int J Oral Maxillofac Implants 2019;34:423–433.
40. Politis C, Agbaje J, Van Hevele J, et al. Report of neuropathic pain after dental implant
placement: A case series. Int J Oral Maxillofac Implants 2017;32:439–444.

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 15
Reparative Surgery and Complication
Management

When surgery is performed, complications are always imminent:

Those who operate little have many complications.
Those who operate a lot have few complications.
Only those who do not operate at all have no complications.
— F. Härle

15.1 Reparative Surgery and Implant Replacement

The number of patients is increasing who already had their teeth replaced
with implants (ie, third teeth) and have acquired ridge defects after implant
loss and present for restoration with fourth teeth (Fig 15-1). One cannot
repair defects after implant loss with the same success rate as with initial
surgery.1 There are visible reasons for this, such as soft tissue scarring after
the initial surgery with consequent deterioration of the blood supply.
However, there are also non-visible reasons, eg, the long half-life of
proteins such as the proinflammatory cytokines in the tissue. Even long
periods of time after inflammation subsides, residues of the
proinflammatory cytokine environment are present in the tissue.
In a recently published study of second- and third-time removals of
failed implant restorations, the following revealing statistics emerged. The
first-implant group of a cohort of more than 5,000 patients had 95.4%
implant survival. Second implant placements had 77.4% implant survival,
third implant placements had 72.7% implant survival, and fourth implant
placements had 50% implant survival.2 Another study of more than 10,000
patients came to a similar conclusion, with 94% survival of first implants
and 73% survival of second implants.3 It can be seen that the chances of

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success of the repeat procedure are lower than for the initial procedure, and
these continue to decrease with further repeat procedures. This is different
from the technology and consumer world, where a like-new condition can
be achieved through repair and replacement parts. Clinicians must
disengage patients and payers from the idea of technical repair of a
consumer good in the case of implant loss; otherwise, expectations will be
too high (Fig 15-2).
Three main conclusions can be drawn from these results. Firstly,
defensive incision patterns (midcrestal and sulcus incision), full-layer
subperiosteal flap formation, and generally a conservative as opposed to a
more invasive therapeutic approach should be used during the initial
implant placement. The goal is to not complicate a potential second
procedure with significant scarring. Some humility on the part of the
surgeon is required here, to recognize that he or she may not be the last to
perform surgery at this site in the patient’s life.

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Fig 15-1 Fourth teeth: repair after implant loss. a. Panoramic radiograph of 76-year-old
patient with complete loss of the maxillary alveolar process after 26 years of wearing an
implant-supported maxillary total denture. After implant removal, remnants of former IMZ
implants (Friatec) are still visible apically in the maxillary left central incisor and canine sites;
see also the mandibular left lateral incisor site. b. The lateral cephalometric radiograph
shows that only the palatal plate remains of the maxilla; during inspection, a spatula can be
placed flat on the palatal plate from anterior. c. Intraoperative image of a LeFort
interpositional bone graft. After sinus elevation and downfracture, a frame of strip-shaped
autogenous iliac crest grafts has already been built up here. Osteosynthesis plates support
the interposition gap. d. The voids between the bone strips are filled with a 25%/75%
mixture of autogenous chips and bone substitute (Bio-Oss, Geistlich). This material makes
up the main volume of the grafts. e. The bone grafts are covered by collagen membranes in
the suture area (Bio-Gide, Geistlich). f. Because the maxilla was physically displaced
inferiorly by downfracture and because the mucosa on the maxilla was not detached, there

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is relatively little need for mobilization of the soft tissue. This aspect also makes the surgery
more tolerable than an onlay bone graft.

Fig 15-1 Fourth teeth: repair after implant loss. g. Panoramic radiograph after
augmentation. h. The lateral cephalometric image shows significant vertical and volume
gain compared to Fig 15-1b. i. Four months after augmentation, the osteosynthesis material
is removed. Here, the position screws have already been loosened. The retaining screws of
the osteosynthesis plates show that no major surface resorption has occurred except for a
slight rounding of the bone edges. j. The already vascularized bone of the iliac crest grafts
allows correct implant osteotomies. However, the bone is still quite soft at this stage (like
type IV bone, according to Lekholm and Zarb classification). k. Inserted dental implants.
The implant in the maxillary left first premolar site was lost subsequently as an early loss,
confirming that second implants placed in the same site have a worse prognosis than the

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initial implants. l. Prosthetic restoration by bar-supported overdenture (Dr J. Tetsch,
Münster).

Fig 15-1 Fourth teeth: repair after implant loss. m. The overdenture allowed chewing
function for another 10 years, at which time the patient suffered a severe stroke from which
he did not recover. n. Good esthetics of the fourth teeth.

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Fig 15-2 Reparative surgery after implant removal. a. Clinical view of a 27-year-old
female patient 5 years after immediate implants were placed at a different dental practice
for severe tooth trauma. There has been extensive bone and soft tissue loss in the esthetic
area labial to the maxillary central incisors. b. Removal of the old implants, which were too
large and malpositioned in relation to the ridge width. c. Pronounced soft tissue defect after
implant removal. d. The vascularized palatal connective tissue flap (axial pattern flap) with
contained central vessel from the nasopalatine artery in the incisive foramen (adapted from
Sclar4). e. Soft tissue coverage by vascularized connective tissue flaps on both sides. f. A
removable pontic-type provisional is placed in the soft tissues to form the subsequent
emergence profile. g. A few days later, the connective tissue of the vascularized flaps
already shows a fibrin coating and granulation tissue, both of which are an activity of the
flap and require substance and cell transport that would not be present in a free transplant.
h. Panoramic view after implant placement with bone grafting (autogenous external oblique
ridge block graft). i. Placement of the new prosthetic restoration (Dr H. Schröder, Kassel);

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some soft tissue deficits still exist. j. The maxillary mirror image shows that thanks to the
augmentation, the implants could be placed vertically despite the anatomical obliquity of the
maxillary alveolar process, allowing the screw channels to emerge palatally and enabling a
screw-retained restoration. Scars from removal of the connective tissue flaps are visible on
both sides of the palate.

Fig 15-2 Reparative surgery after implant removal. k. Panoramic radiograph after
prosthetic restoration. l. Follow-up examination 5 years later with spontaneous improvement
of the soft tissue deficit, see Fig 15-2i. As a consequence of implant removal and second
implant placement, a visible soft tissue scar will remain for life. m. The panoramic
radiograph after 5 years shows no marginal bone resorption on the new implants, and
therefore stable conditions can be expected for the further life of the young patient.

Second, if a biologic implant complication such as peri-implantitis has

occurred, then it follows from the above figures to prioritize retention of the
initial implant over removal and replacement.
Third, reparative surgery can no longer be mapped with the SAC
(straightforward, advanced, complex) classification due to the reduced
chances of success. Here, in many cases, a degree of difficulty beyond C is
present, and these problems require experienced teams.

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15.2 Augmentative Treatment of Peri-implantitis
From the worsened prognosis of secondary implant placement, it follows
that surgical therapy of periimplantitis is usually justified while the implant
is still stable. Another prerequisite for surgical periimplantitis therapy is that
a conservative therapy attempt was not sufficient to eliminate bleeding on
probing and suppuration of the pockets.5 Therapyresistant peri-implantitis
requires relatively rapid surgical intervention in about a month’s time,
because peri-implant infections can progress rapidly and lead to implant
loss.
Attempting to maintain infected implants, as opposed to removal or
waiting inactively until they are lost, is supported by the relatively good
success rates of peri-implantitis treatment. A meta-analysis yielded implant
survival rates of 81.73% to 100% at 3 years, 74.09% to 100% after 4 years,
76.03% to 100% after 5 years, and 69.63% to 98.72% after 7 years.6
Surgical peri-implantitis treatment aims to permanently remove the
biofilm on the implant surface.7 Pocket elimination is necessary for this,
because the gingival pocket protects the biofilm and allows it to escape the
patient’s oral hygiene. The patient cannot get into the pocket with normal
oral hygiene measures. Therapy of peri-implantitis starts with nonsurgical
pretreatment a few weeks before the surgical procedure, eg, supragingival
professional cleaning, glycine powder air abrasion (Air-Flow Perio, EMS)
and pocket rinsing with chlorhexidine solution. This is firstly to test a
nonsurgical pretreatment and secondly to reduce the inflammation to create
better conditions for surgical treatment.
The surgical intervention has the purpose of exposing the biofilm and
making it accessible (Fig 15-3). The surgical difficulty of peri-implantitis
therapy is to clean and clearly expose all implant surfaces so that the
blasting devices and brushes can engage the implant threads at a 90-degree
angle, even from the lingual direction in the floor of the mouth. This
requires a great deal of surgical skill and patient cooperation. The surgical
procedure consists of the steps of degranulation, decontamination, and
regeneration. Degranulation is important to remove titanium particles8 and
toxic granulocytes from the wound and to resect the pocket epithelium.
Decontamination ensures the macroscopic removal of concretions (with an
air scaler), the microscopic cleaning of the metal implant threads (with a
titanium brush), and complete removal of the toxin molecules by glycine

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powder air abrasion and chemical rinsing, for example, with chlorhexidine
solution. The goal of the treatment of peri-implantitis is the permanent
elimination of the biofilm. For the prevention of re-infection, pocket
elimination or reduction is the goal. This goal could be achieved after
completion of the first therapeutic steps by apical displacement of the
mucoperiosteal flap, but this then leads to recession with exposed titanium
and is at best suitable in non-visible areas. The more tissue-sparing
approach is to raise the pocket floor by filling the bone defect with a bone
substitute filler. Here no clear material recommendation can be given. Bone
substitute material with and without membranes, with the aim of fibrous
regeneration, is recommended. Even if only integrated in scars, it limits the
apical growth of the junctional epithelium. A metaanalysis yielded an
average of 3.5-mm reduction in probing depth by these measures.9 An
implantoplasty did not yield any advantage over glycine powder
irradiation.10 The goal of the subsequent maintenance phase is to prevent re-
infection through patient cooperation and periodontal supportive treatment.

Fig 15-3 Peri-implantitis treatment: degranulation, decontamination, and

regeneration. a. Severe peri-implantitis at the maxillary first premolar and right lateral
incisor sites almost without externally visible symptoms, but with probing depths >10 mm. b.
Panoramic image shows severe osteolysis at the maxillary right lateral incisor and first

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premolar sites near the apex and at the left first premolar periapically. c. After conservative
anti-infective pretreatment for 4 weeks, the flap was opened via a sulcus incision with
visualization of the granulation tissue. The left first premolar implant was removed. d. The
granulation tissue was carefully excised from the palatal and buccal aspects with a scalpel
and sent for pathohistologic evaluation.

Fig 15-3 Peri-implantitis treatment: degranulation, decontamination, and

regeneration. e. Careful exposure of all contaminated metal surfaces under good visibility.
f. Removal of visible concretions by ultrasonic scaler and hand instruments. g. Visualization
of palatal implant surfaces via palatal flaps. h. Cleaning of the titanium surfaces with
rotating titanium brushes (HANS Korea). i. Fine decontamination by glycine powder blasting
(Air-Flow). j. Deposition of bone substitute material (BoneCeramic, Straumann).

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Fig 15-3 Peri-implantitis treatment: degranulation, decontamination, and
regeneration. k. The material has a certain stability and shapeability in the defect due to
adhesion and sharpness. l. The material is introduced in excess, although a bone
regeneration can only be expected in the vertical defect components. m. Wound closure by
interdental sutures according to Lindhe. n. Panoramic radiograph postoperatively with
defect filling in excess. o. The follow-up photograph 2 months postoperatively shows
recession compared to Fig 15-3a of about 3 mm at the right second premolar to lateral
incisor sites. The probing depth at the right lateral incisor and first premolar sites is 8 mm
without bleeding on probing.

15.3 Infectious Complications of Augmentations

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Complications of augmentation procedures are mostly infectious in nature
(Fig 15-4). The most obvious factor for early dental implant11 and
augmentation loss is infection due to primary and secondary wound
contamination by endogenous bacteria. The patient must be informed
preoperatively about the possibility of infection and its possible subsequent
treatments; otherwise the patient will have unrealistic expectations that
must be corrected. Impaired wound healing can cause considerable
economic and psychologic damage due to exposure of implants and
augmentation materials with consecutive loss, which is often accompanied
by a loss of confidence in the physician:
Wound dehiscence with exposed augmentation material
Membrane exposure
Purulent or fistulous lesion
Osteosynthesis material loosening
Implant loss
Graft loss
Sinusitis after sinus floor augmentations
Abscesses with and without tendency to spread
Osteomyelitis

Intraoral surgery belongs to the class of cleancontaminated procedures,

because it always takes place in a non-sterile environment. In this infectious
class, according to general experience, wound infections can statistically be
expected to be about 5% in minor procedures and 20% to 50% in major
procedures with transplants.12 Infections occurred in 1% to 30% of oral
surgical procedures such as third molar removal, depending on the study
and counting method.13 Implantology procedures are no exception to this
rule. Most infectious complications of augmentation operations in healthy
patients remain localized because drainage is ensured quite quickly via the
wound dehiscence. Such local infections should also only be treated with
local disinfection. It is important to recognize deep cervical abscesses and
infections with a tendency to spread and to treat them surgically in a
maxillofacial surgery clinic within a short time frame.

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Fig 15-4 Late extrusion of a sequestrum after block grafting. a. A 31-year-old patient
had a jaw fracture in the mandibular left canine site 14 years previously with tooth loss and
subsequent implant restoration, which was later removed. As a consequence, there is a

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bone defect in the canine region. b. Two-stage augmentation with autogenous bone block
graft from the external oblique ridge. c. Use of Bio-Gide collagen membrane. d. Autogenous
chips for contour filling. e. Use of membrane sections and more bone chips for recession
coverage on the neighboring lateral incisor. f. Staged implant placement was performed 4
months later. Panoramic radiograph taken another 3 months later, after crown restoration of
the new implant. g. Six years postoperatively, the patient presented again because of
complaints in the area of the implant; the findings were a slight bleeding on probing at a
probing depth of 5 mm. Initially, conservative treatment was attempted. h. After surgical
opening for exploration of the canine region, a small loose bone sequestrum was found to
be the cause of infection, originating from a bone block that was not completely
vascularized. i. After debridement and decontamination of the implant surface, marginal
bone loss was found on the implant. This was treated with bone substitute material. j.
Result after treatment of the complication.

15.4 Preoperative Measures to Prevent Wound Dehiscence

in Augmentation Sites
Primary and secondary wound contamination
Contamination of a wound in the mouth can occur primarily due to bacterial
presence (see chapters 2 and 5). Such primary infections occur quite
quickly postoperatively, after 1 to 4 days, and are very acutely accompanied
by pain and swelling. However, contamination of the wound may also occur
secondarily by ingrowth of a biofilm on the augmentation materials. Such
infections announce themselves slowly only about a week postoperatively
by wound dehiscence and are not so foudroyant in course.

Intraoral infection prophylaxis

The aim of intraoral infection prophylaxis and antisepsis is to reduce the
infection dose of the wound. The goal of oral antisepsis is not a sterile
surgical field, but to reduce the bacterial load of the surgical wound as
much as possible. Bactericidal antibiotics should directly inactivate
invading bacteria before they can establish and multiply. The step-by-step
concept of general infection prophylaxis is listed in chapter 5 (section 5.6
Anti-infective Patient Preparation).

Antibiotic administration against primary wound contamination

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Extensive and prolonged or even preoperative antibiotics with reserve
antibiotics are not the right way to control surgical wound infections14,15
because they promote the selection of resistant germs. Single-shot
antibiotics should be administered no earlier than 60 minutes before surgery
and repeated if surgery lasts longer than 4 hours.16 The dose of penicillins
must be sufficiently high to be bactericidal. Intravenous administration of 3
g ampicillin-sulbactam achieved infection prevention rates equal to long-
term antibiotics for 5 days in a prospective oral surgery study.17 When
administered orally during implant surgery, 3 g of amoxicillin 1 hour
preoperatively was most effective, according to a network meta-analysis.18
In a retrospective study of third molar extraction, oral and intravenous drug
applications had equivalent effects.19 This may be explained by the fact that
bactericidal antibiotics such as penicillin, once sufficiently effective, kill all
bacteria inside the tissue and inside the autogenous grafts. Then the tightly
sutured wound is initially sterile inside. New bacterial colonization takes
place only secondarily through the suture gaps and stitch channels, and this
takes several days. In many cases, antibiotics in the first days after a tightly
sutured wound are therefore overtreatment that only promotes side effects
(dysbiosis in the intestine) and selection of resistant germs.

Perioral skin antisepsis and intraoperative wound irrigation with

chlorhexidine
There is no reason why preoperative perioral disinfection with
chlorhexidine should not be performed prior to augmentation surgery, since
the patient also rinses intraorally with it anyway. In skin antisepsis,
chlorhexidine was superior to povidone-iodine.20

15.5 Intraoperative Measures to Prevent Wound

Dehiscence in Augmentation Sites

Ten-point plan for the prevention of wound dehiscence

The main complication and imponderability of alveolar ridge augmentation

is wound dehiscence with exposure of the inserted materials to the
bacterially contaminated oral cavity. Here are 10 intraoperative measures

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that can be taken to make this event less likely or to mitigate the
consequences. The preoperative and postoperative measures as well as
general antisepsis must of course also be observed.
Make the incision in the midline of the attached gingiva. The rigid
attached gingiva can be adapted more tightly and sutured more easily
than the alveolar mucosa.
Tension-free flap mobilization. Flap traction leads to reduced blood
flow. The flap is mobilized by periosteal incisions, and by spreading
with the dissecting scissors, and lifting the flap with the elevator.
Coverage with a native collagen membrane and/or platelet-rich
fibrin (PRF) membranes. A native PRF or collagen membrane, due to
its gel state in aqueous solution, does not form interfaces on which
bacteria can attach and migrate to depth. Membranes block the path of
bacteria from the intraoral environment to the bone graft.
Do not squeeze flap edges with tweezers, use a single hook
retractor. Wound margin necrosis jeopardizes wound closure.
Round off or cushion sharp edges. Point pressure from the underside
of the flap may exceed arterial perfusion pressure and cause ischemic
necrosis of the soft tissue.
Use pseudomonofilament suture material. One of the entry routes for
bacteria to the biomaterial are the threads of the sutures, which
therefore should be as smooth as possible with little retention for
biofilm and no wicking effect.
Interrupted sutures with spacing or continuous suture. The fewer
the stitch channels, the fewer the entry ports for bacteria. Any loop or
suture pattern (eg, backstitch suture) leads to reduced blood flow or
necrosis in the tissue. If the sutures are too tight, the ischemic zones
confluence to form wound margin necrosis. The interrupted suture 4-0
to 5-0 has the best holding power compared to tissue strangulation. The
continuous suture additionally has only half the stitch channels of the
single button suture.
Particulate materials allow partial loss. With block grafts, it is often
all or nothing. With particulate materials, the part in the area of
influence of the biofilm can be rejected without consequences. The
disadvantages of particulate materials include lower precision and loss
of height due to resorption and sintering.

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 Use intrabony defects, reduce material load, avoid interfaces.
Foreign and autologous materials that are not initially perfused increase
the likelihood of biofilm formation and should be used sparingly. It is
most beneficial if these materials are located far from the bacterial
entry point of the suture. Therefore, intrabony placement of grafts is
safer than onlay techniques.
Tunneling preparation. Tunneling preparation is not always possible,
but when it is used, dehiscence is very unlikely.

In a meta-analysis on third molar extraction, irrigation of the extraction

socket with chlorhexidine resulted in a reduction in infection rates. The
number needed to treat was eight.21 Whether this procedure of wound
irrigation can be transferred to augmentation wounds in implantology is
very questionable, because disinfectants also have a toxic effect on body
cells in antibacterial concentrations.22
The sequence above is also a prioritization from the author’s
experience. Other measures are often discussed, but from a wound
physiologic point of view they are unnecessary or counterproductive. These
include recommendations such as performing very fine suturing under a
microscope, because even this cannot seal wounds on a bacterial scale, and
the number of stitches increases. In fact, the probability of infection
increases with the duration of a surgical procedure. The duration of surgery
is an independent risk factor for wound infections.23 It is much more
effective to extend and impede the path of bacteria so that the organism can
win the race between biofilm formation and angiogenesis. Furthermore,
there are questionable measures that work against dehiscence but cause
great harm, such as vestibular incisions, which cause irreparable destruction
of flap anatomy and damage flap perfusion.

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Fig 15-5 a. Local disinfection of a slightly dehiscent wound after augmentation surgery with
polyvidone-iodine solution (Braunol, B. Braun). The bone augmentation materials are not
yet exposed. The plaque is removed from the adjacent tooth roots in particular to prevent
biofilm formation per continuitatem. b. Daily self-treatment of the wound is performed by the
patient with 1% chlorhexidine digluconate gel (Chlorhexamed DIREKT Gel,
GlaxoSmithKline).

15.6 Postoperative Measures to Prevent Wound

Dehiscence in Augmentation Sites

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Postoperative local disinfection treatment against secondary
wound contamination

Dehiscences in augmentation sites usually occur 1 to 2 weeks

postoperatively. They tend not to be primary wound infections caused by
wound contamination but are triggered by secondary biofilm ingrowth and,
in the author’s experience, require a different strategy than perioperative
antibiosis. Bacterial biofilm formation on foreign materials and grafts in the
wound occurs through the entry port of the suture gaps and exploits the
bridge of the puncture channels and suture materials. Biofilm formation
takes several days, as we know from dental plaque. Taking this into
consideration, regular local care of the wound by the physician from the
third day onwards is advisable. For this purpose, one takes a blunt cannula
on a small syringe and inserts it first into the sulcus of the adjacent teeth in
order to detach the biofilm from the tooth here, which would otherwise
allow growth per continuitatem into the wound. Next, one carefully
explores the suture gaps with the cannula and tries to insert it, checking for
resistance. Usually, after a few days, it is possible to feel the augmentation
material in depth with the tip of the cannula (Fig 15-5a). Now the suture
gap is gently irrigated to remove or kill the already established biofilms.
This is done for the next 14 days because this is how long the
vascularization needs to open up the augmentation material from below.
In addition, the patient should perform careful dental hygiene and,
where it is not possible to brush due to the wounds, minimize plaque
formation by rinsing three times a day with 0.2% chlorhexidine solution
and chlorhexidine gel (Fig 15-5b). The goal is for angiogenesis to win the
race against biofilm (chapter 2, Fig 2-26) to biomaterials and graft surfaces.

Secondary suture (Salvage surgery)

Wound dehiscence is a precursor to a bacterial infection process and graft
loss. Dehiscence indicates a proinflammatory to toxic wound environment
in which proteases are released from granulocytes, leading to degradation of
collagen in the wound margin. This causes the tissue to become loose and
the sutures to mechanically tear. At this point, there is usually a
proinflammatory wound environment present, but no pus formation yet. In

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this stage, in the author’s experience, an attempt at soft tissue flap coverage
is worthwhile in order to save the inserted hardware and grafts.
In the event of soft tissue dehiscence over the augmentation, it is
important to react quickly (Fig 15-6). As long as there is no suppuration,
debridement with curettage of loose augmentation particles, irrigation
treatment with povidone-iodine solution, and, if necessary, cleaning of bone
grafts by grinding are indicated. Biofilm must be removed from the
materials. After local debridement, an attempt at secondary suturing with
renewed soft tissue coverage of the grafts and implants is warranted. For
this purpose, the sutures grasp the wound margin further than before, and
the wound is re-adapted with a few sutures. In most cases, the flap is
already sufficiently mobilized by the initial operation. If this is not the case,
the flap should be loosened by submucosal spreading with the dissecting
scissors so that it can cover the area without tension.
In orthopedic implants, secondary soft tissue coverage of exposed
hardware such as knee prostheses has a longer tradition than in
augmentation surgery. Here, according to meta-analyses, about 88% success
is achieved by secondary soft tissue coverage.24 The recommendation to
intercept the tissue proteases by offering substrate through collagen-
containing products (eg, collagen fleece, membranes) also originates from
the general wound healing theory, so that the body’s own collagen can
recover somewhat in the equilibrium state of buildup and degradation.

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Fig 15-6 Secondary soft tissue coverage in case of dehiscence (salvage surgery). a.
Autogenous bone block transplantation for augmentation of the maxillary right lateral incisor
region. b. Coverage with a collagen membrane. c. Onset of wound dehiscence on
postoperative day 13 with membrane exposure. d. Immediate debridement with biofilm
removal and secondary soft tissue coverage of the bone block.

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Fig 15-6 Secondary soft tissue coverage in case of dehiscence (salvage surgery). e.
Complete healing of the soft tissue after renewed coverage. f. Panoramic radiograph
postoperatively. g. Minimally invasive removal of the osteosynthesis screw 4 months after
grafting. h. Periapical radiograph following Implant placement. i. Case completion with
prosthetic restoration. j. Panoramic radiograph.

Strategy of debridement followed by open postoperative treatment

If secondary soft tissue coverage was too late or is unsuccessful, open
retreatment can be attempted (Fig 15-7). This has the advantage that
infectious material does not lie deep down but can drain off openly. This

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prevents the spread of infection from the starting point of the biofilm on the
augmentation material.

Fig 15-7 Open postoperative treatment with debridement and partial loss. a. Single-
stage autogenous bone block augmentation in the maxillary left central incisor to canine
region. b. Periapical radiograph of implants and osteosynthesis screws. c. Development of
dehiscence with exposure of the bone blocks and implant at the maxillary left central incisor
3 weeks postoperatively. The foreign material (implant and osteosynthesis screws) was
removed, the bone refreshed, and the dehiscence of the soft tissue was treated with local
disinfection for several weeks. Overall, the procedure went smoothly, with secondary
healing and no major discomfort for the patient. d. Periapical radiograph after debridement.
e. After 4 months, the implant was uncovered, and prosthetic restoration with a cantilevered
fixed prosthesis was performed at the maxillary left central incisor site. f. Panoramic
radiograph at implant exposure showing no significant bone loss.

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Fig 15-8 Possible anatomical risk factors in sinus floor augmentation. a. The situation of
narrow sinuses occurs especially after trauma or previous surgery. b. Pathological
conditions to be clarified prior to sinus floor augmentation. Mucosal adherence to the floor
often occurs at the site of former tooth roots if one does not wait at least 3 months after
tooth extraction.

In most cases, secondary healing is then observed over a period of

months. This almost always occurs with particulate material after partial
loss and rejection. In the case of block grafts, complete rejection of the
block usually occurs, but sometimes the necrotic part is separated as a bone
sequestrum by the osteoclasts, and the deeper part of the block can survive.
It is also frequently observed that the particulate portion of the graft under
the bone block survives, eg, in the shell technique, and partial augmentation
success occurs despite open healing. Often, in such situations of exposed
augmentation material, it is sufficient to perform thorough debridement and
early removal of the osteosynthesis material about 4 weeks before further
restoration with dental implants. Then, in most cases, irritation-free bone
surface and healed soft tissue are present until implant placement.

15.7 Complications and Their Avoidance During Sinus

Elevation
In order to avoid complications during sinus elevation, a prior health history
and diagnostics are required (Fig 15-8). In case of anamnestic or anatomical
abnormalities, three-dimensional radiography is indicated.

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Inflammatory complications
Bacterial maxillary sinusitis occurs in approximately 5% of cases,25 with
conventional radiographs overestimating the incidence due to non-
infectious polypoid swelling.26 It is now known that the ciliated epithelium
of the paranasal sinuses often responds to nonspecific stimuli with severe
edema formation, which was most severe on CBCT images 1 week after
sinus floor augmentation and had resolved 3 weeks later without pathologic
significance.27 One study showed an increased rate of sinusitis in patients
treated with the fallback antibiotic clindamycin.28 The sinusitis risk of
zygoma implants was discussed in chapter 14 (Fig 15-9). Gas-forming
infections caused by anaerobic clostridia have also been reported after sinus
elevation with allografts.29

Fig 15-9 a. Severe inflammation-related osteolyses on zygoma implants in the right maxilla.
The implants were removed from the zygoma. b. Panoramic image showing pronounced
maxillary alveolar process atrophy (Cawood class V). c. CBCT showing severe maxillary
sinusitis on the right with complete obstruction of the air space (opacity of the right sinus).

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 If a sinus elevation site is infected, the intraoral sutures should first be
removed to create drainage. Loose bone substitute material can be removed
by curettage, followed by local disinfecting irrigation. The accompanying
sinusitis is initially treated conservatively with decongestant nasal drops
and, if necessary, inhalations with chamomile vapor to reduce the swelling
in the ethmoidal infundibulum so that the maxillary sinus is ventilated and
receives drainage. If possible, these nasal drops should be instilled while the
patient is lying supine so that they reach the middle nasal passages, which
are at the level of the eyes. If conservative therapy is not effective, surgical
remediation with removal of the augmentation is indicated. This is best
done by a maxillofacial surgeon or in maxillofacial surgical clinics. Fistulas
from the mouth to the maxillary sinus usually disappear on their own after
removal of the origin of infection. If this does not occur, the maxillary sinus
should be surgically drained by fenestration to the nose so that the fistula
can then be covered with soft tissue.
Preexisting sinusitis is a risk factor.30 When there is a history of
sinusitis, it is important to rule it out using tomography; if it is present, it
must be resolved before augmentation. In the case of maxillary sinuses with
previous surgical procedures (eg, Caldwell-Luc technique), special caution
is required, and sinus floor augmentation is contraindicated in some cases.
Apical inflammation at the teeth adjacent to a sinus elevation must
absolutely be remediated preoperatively or eliminated intraoperatively at
the latest by apicectomy or extraction.

Pseudocysts
Similarly, larger basal pseudocysts and polyps of the maxillary sinus should
be removed prior to sinus elevation, although there are increasing reports in
the literature that sinus elevations have been successful even in the presence
of pseudocysts or that these can be endoscopically aspirated at the same
time as the sinus elevation.31 But the general duty of care recommends the
elimination of unnecessary risks before elective surgery. Removal is best
performed by referral to the maxillofacial surgeon, who usually removes the
pseudocyst endoscopically via a minimally invasive approach. Six weeks
later, the augmentation procedure can be performed with peace of mind.

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Septa and perforations of the sinus membrane
Vertical bone walls in the maxillary sinus (Underwood septa, described in
1910 by Arthur S. Underwood, anatomist at King’s College in London) in
the transverse, longitudinal, and horizontal directions complicate the
procedure and predispose to membrane perforation (Fig 15-10). Membrane
tears should be avoided because they are a risk factor for sinus graft
infections. Septa are naturally present in 57% of human maxillary sinuses
and are therefore a common finding.32 Their location should be identified by
3D diagnostics if suspected, because two-dimensional diagnostics are often
inadequate in view of longitudinally oriented septa. If a septum is present,
two sinus elevations should be performed if possible, one anterior and one
posterior to the septum. Dissection of the sinus membrane over the edge of
a septum is extremely prone to perforation. A better method is to carefully
separate the septum from the maxillary sinus floor anterior to one side with
a small diamond bur or chisel until it is completely loose and can be lifted
along with the remaining sinus membrane.33
Sinus membrane perforation is an undesirable yet common condition,
occurring in 20% to 40% of cases, and usually heals without
complications.34 In a study, membrane tears had been consistently managed
surgically according to the regimen below and showed no negative impact
on graft success.35 The participants of this prospective study were also re-
examined 10 years later, with no recorded implant losses.36 However,
another study showed a correlation between perforations and an increased
infection and implant loss rate.37 If a membrane tear has occurred during
sinus floor augmentation, reliable surgical treatment is indicated based on
the size:
Small perforations (<5 mm): Cover with collagen fleece or collagen
membrane
Medium perforations (0.5 to 1 cm): Suture with 6-0 absorbable sutures,
cover with collagen fleece or collagen membrane
Subtotal perforations: Abort surgery and repeat 6 weeks later.

Aspergillosis due to protrusion of implants or bone augmentation

materials into the free maxillary sinus

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Inflammatory complications of the maxillary sinus are not always bacterial
(Fig 15-11). If a foreign body interface is created in the human maxillary
sinus, which is not lined with ciliated epithelium, then fungi, mostly
Aspergillus fumigatus, the mold, can also take advantage of this to form a
biofilm. Such nesting sites result, for example, when an internal sinus
elevation fails and an implant protrudes bare into the air space of the
maxillary sinus. As long as implants protrude into the maxillary sinus
covered by mucosa, even if this is more than 4 mm, the risk is not
increased.38 Metal that protrudes bare into the air space of the maxillary
sinus39 or is located in a sinus as an accidentally displaced implant40 may be
a colonization site for molds. One should also avoid inadvertently
dislocating augmentation material into the free maxillary sinus through
membrane tears. Bone grafting materials are a growth site for Aspergillus
fumigatus, which has been observed experimentally41 and clinically.42
Aspergillosis can also be induced by allogeneic graft materials.43

Dislocation of dental implants into the sinus and neighboring cavities

Sinus floor augmentation is placed in the C level of the SAC classification
in part because severe complications can occur. In connection with implant
placement in the posterior maxilla, dislocations of dental implants into the
sinus (Fig 15-12) and all neighboring cavities have been reported in the
literature, including the main and paranasal sinuses, orbit,44 sphenoid
sinus,45 anterior cranial fossa,46 and even temporal brain lobe.47 When
something like this occurs intraoperatively, immediate referral of the patient
to the maxillofacial surgeon or to a maxillofacial surgery clinic is indicated.
Here, the implant body is usually removed from the facial maxillary sinus
wall endoscopically or via an osteoplastic approach before it can cause
damage.48

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Fig 15-10 a. Preoperative panoramic radiograph clearly showing an Underwood septum. In
cases of doubt, 3D preoperative radiography is indicated. b. To properly perform sinus floor
augmentation in the presence of septa, first perform two separate sinus elevation
preparations anterior and posterior to the septum. c. Then the septum is milled off at the
base and mobilized. It can now be lifted cranially along with the adherent sinus mucosa. In
contrast, if one attempts to dissect over the edge of a septum, membrane perforation almost
always occurs. d. Radiograph after augmentation. e. Radiograph after implant placement.

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Fig 15-11 a. Panoramic radiograph showing non-functional dental implants in the maxillary
right second molar and left second premolar sites, which probably protruded bare into the
air space of the maxillary sinus after insertion. b. The patient complained of discomfort,
discharge, and odor from both sides of the nose for several years, but no swelling, fever, or
pain. Brown crumbly material oozed out when the maxillary sinuses were opened. c.
Material curetted out of the maxillary sinus under careful mucosal protection,
histopathologically confirmed as fungal hyphae. d. The left second premolar dental implant
protruding bare into the maxillary sinus air space was the cause of the fungal colonization
on the left side, with an analogous situation at the second molar implant on the right side.

In addition to acute intraoperative displacement, chronic migration of

poorly osseointegrated dental implants into neighboring cavities has also
been described.49

Bleeding after sinus elevation

Bleeding after sinus elevation can be life threatening50 and should not be
underestimated, especially when the patient is discharged to go home. On
the other hand, the patient should be informed before discharge that slight
nose bleeding after sinus elevation is common and merely indicates that the
maxillary sinus has drainage to the nose.

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 Bleeding from the maxillary sinus should be avoided preoperatively if
possible and stopped intraoperatively. The most common source of bleeding
is the intraosseous portion of the infraorbital artery or the superior posterior
alveolar artery in the lateral wall of the maxillary sinus51 (Fig 15-13). The
preparation of the access window for the external sinus elevation should not
be performed so superiorly as to be in reach of this artery in the first place,
but rather as close to the floor as possible. However, if only the floor of the
maxillary sinus is used as an orientation, the window may still be too high,
because it may be that the jaw is atrophied from the crestal side and the
floor of the maxillary sinus is in fact already high. In this case, the entire
indication for sinus elevation would have to be reconsidered and, if
necessary, this would have to be replaced by a Le Fort interposition or an
onlay graft.

Fig 15-12 A dental implant accidentally dislocated into the maxillary sinus is transported in
the direction of the natural ostium by the activity of the ciliated epithelium if left unattended.
Here, the implant has become wedged in the ethmoidal infundibulum due to its size and led
to inflammation of the surrounding mucosa. This in turn led to blockage of the ostium with
secondary severe maxillary, ethmoidal, and frontal sinusitis.

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 If there is intraoperative bleeding, bipolar coagulation should be used. If
this does not help, try closing the bone canal with a plunger or by pressing
bone wax into it. In case of heavy bleeding from the maxillary sinus, blood
pressure should be checked and normalized.

Ciliated epithelial cysts after sinus elevation

This rare complication occurs a few years after sinus elevation52,53 (Fig 15-
14). Starting from remnants of the sinus membrane remaining at the bottom
of the maxillary sinus under an augmentation, occlusal cysts are formed.
These sometimes nestle around the dental implants placed there and are
noticeable by a crackling sound on palpation. Because of the tendency to
enlarge, a cystostomy to the residual maxillary sinus, analogous to
treatment of occlusal cysts, is the method of choice.

Fig 15-13 Intraoperative view of the intraosseous portion of the infraorbital artery in the right
facial maxillary sinus wall. This artery is not always as large in diameter as in this case.
However, it can still cause significant bleeding if the maxillary sinus window is placed too

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superiorly, which can easily happen with increasing atrophy of the height of the alveolar
process.

Fig 15-14 Example of a ciliated epithelial cyst 1 year after sinus floor augmentation in the
area of a dental implant in the right maxillary sinus floor. The cyst appeared clinically as a
painless nodular distension with parchment crackling sounds. The cyst was filled with
mucus and could be removed by curettage. This type of cyst originates from leftover shreds
of sinus mucosa during incomplete sinus floor augmentation and is also referred to as an
occlusal cyst.

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Fig 15-15 a. After the occurrence of a sensory disturbance, detailed findings are recorded,
including photographic documentation of the area of anesthesia. In the photographic
comparison, tendency toward a reduction of this area can be recognized during follow-up
examinations. b. Operative decompression of an inferior alveolar nerve after iatrogenic
injury.

15.8 General Complications of Augmentation Surgery

Mandibular fractures

Fractures of the basal mandible may occur during bone block removal at the
external oblique ridge, but also during implant placement in the atrophied
jaw, nerve lateralization (see chapter 13), or sandwich interpositional bone
grafts. Therapy depends on the situation and may consist of soft diet,
maxillomandibular fixation, or most commonly osteosynthesis. Treatment is
performed in a maxillofacial surgery clinic.

Aspiration of implants or materials

If material falls into the pharynx while the patient is supine, one should
remain calm.54 Ideally, an anatomical forceps is in the surgeon’s non-
dominant hand, with which the material can usually be removed quickly
before the patient swallows and gags. If the tool, dental implant, or dental
crown has come off into the pharynx, then it must be diagnostically
clarified whether it has been aspirated. This is done by chest radiography. If
the foreign body shows up in the lungs, it must be removed
bronchoscopically. If it does not show up here, it must be assumed to have
passed into the digestive tract, from which it can be retrieved via stool
sample after natural discharge. If the foreign body is sharp or pointed,
endoscopic removal from the stomach should be performed. For this, an
abdominal radiograph is indicated first. This is all done by referral to a
maxillofacial surgical department, which will arrange for further action.

Nerve injuries
If the peripheral branches of the trigeminal nerve show sensory disturbance
postoperatively, the cause must be clarified (Fig 15-15). If this is known,

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eg, because a dental implant has been placed in the vascular-nerve bundle
of the mandible or is compressing the nerve, then the implant must be
removed immediately or replaced with a shorter one.55 A case series from
England showed that only patients with decompression within the first 48
hours experienced recovery of the nerve.56 For this purpose, the patient
should be admitted in questionable cases after the local anesthesia has worn
off, at the latest on the following day. The clarification of nerve
compression by implants is done by 3D imaging by CBCT, but MRI can
also help to clarify in questionable cases.57 If there is complete loss of
sensation due to the position of an implant or if an intraoperative
transection is known, then referral to a maxillofacial surgical clinic for
microsurgical nerve reconstruction is made immediately, which in one study
resulted in 100% at least partial improvement if performed within the first
90 days after injury.58 If no cause for the nerve injury is known, one must
assume damage from local anesthesia. The decision to wait and see and, if
necessary, perform cortisone therapy is difficult. In principle, referral to a
specialist clinic for maxillofacial surgery is recommended, among other
things because the damage to sensation is then objectively documented for
the benefit of both parties.
Experimental nerve regeneration creates 3.7 mm of new axon growth
per day in myelinated and unmyelinated fibers.59 This means that if starting
from the site of damage, for example, at the position of the first molar in the
mandible, there is 100 mm of distance to the lip, incipient signs of return of
sensitivity can be expected after about 27 days (100/3.7) at the earliest. This
can be objectified by various tests, including two-point discrimination of lip
touch over the various time points. Tingling (paresthesia) is a good sign of
regeneration.

15.9 References
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3. Chrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. Survival of dental implants placed in
sites of previously failed implants. Clin Oral Implants Res 2017;28:1348–1353.
4. Sclar A. Soft Tissue and Esthetic Considerations in Implant Therapy. Chicago: Quintessence,
2003.

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5. Khoury F, Keeve PL, Ramanauskaite A, et al. Surgical treatment of peri-implantitis—Consensus
report of working group 4. Int Dent J 2019;69(Suppl 2):18–22.
6. Roccuzzo M, Layton DM, Roccuzzo A, Heitz-Mayfield LJ. Clinical outcomes of peri-implantitis
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14. Blatt S, Al-Nawas B. A systematic review of latest evidence for antibiotic prophylaxis and
therapy in oral and maxillofacial surgery. Infection 2019;47:519–555.
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diacetate and povidone-iodine cytotoxicity to canine embryonic fibroblasts and Staphylococcus
aureus. Vet Surg 1988;17:182–185.

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23. Leong G, Wilson J, Charlett A. Duration of operation as a risk factor for surgical site infection:
Comparison of English and US data. J Hosp Infect 2006;63:255–262.
24. Economides JM, DeFazio MV, Golshani K, et al. Systematic review and comparative meta-
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26. Wiltfang J, Schultze-Mosgau S, Merten HA, Kessler P, Ludwig A, Engelke W. Endoscopic and
ultrasonographic evaluation of the maxillary sinus after combined sinus floor augmentation and
implant insertion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:288–291.
27. Quirynen M, Lefever D, Hellings P, Jacobs R. Transient swelling of the schneiderian membrane
after transversal sinus augmentation: A pilot study. Clin Oral Implants Res 2014;25:36–41.
28. Khoury F, Javed F, Romanos GE. Sinus augmentation failure and postoperative infections
associated with prophylactic clindamycin therapy: An observational case series. Int J Oral
Maxillofac Implants 2018;33:1136–1139.
29. Choukroun J, Simonpieri A, Del Corso M, Mazor Z, Sammartino G, Dohan Ehrenfest DM.
Controlling systematic perioperative anaerobic contamination during sinus-lift procedures by
using metronidazole: An innovative approach. Implant Dent 2008;17:257–270.
30. Kozuma A, Sasaki M, Seki K, Toyoshima T, Nakano H, Mori Y. Preoperative chronic sinusitis as
significant cause of postoperative infection and implant loss after sinus augmentation from a
lateral approach. Oral Maxillofac Surg 2017;21:193–200.
31. Chiapasco M, Palombo D. Sinus grafting and simultaneous removal of large antral pseudocysts
of the maxillary sinus with a micro-invasive intraoral access. Int J Oral Maxillofac Surg
2015;44:1499–1505.
32. Bornstein MM, Seiffert C, Maestre-Ferrín L, et al. An analysis of frequency, morphology, and
locations of maxillary sinus septa using cone beam computed tomography. Int J Oral Maxillofac
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33. Jung J, Hwang BY, Kim BS, Lee JW. Floating septum technique: Easy and safe method
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34. Becker ST, Terheyden H, Steinriede A, Behrens E, Springer I, Wiltfang J. Prospective
observation of 41 perforations of the Schneiderian membrane during sinus floor elevation. Clin
Oral Implants Res 2008;19:1285–1289.
35. Beck-Broichsitter BE, Westhoff D, Behrens E, Wiltfang J, Becker ST. Impact of surgical
management in cases of intraoperative membrane perforation during a sinus lift procedure: A
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36. Beck-Broichsitter BE, Gerle M, Wiltfang J, Becker ST. Perforation of the schneiderian
membrane during sinus floor elevation: A risk factor for long-term success of dental implants?
Oral Maxillofac Surg 2020;24:151–156.
37. Nolan PJ, Freeman K, Kraut RA. Correlation between schneiderian membrane perforation and
sinus lift graft outcome: A retrospective evaluation of 359 augmented sinus. J Oral Maxillofac
Surg 2014;72:47–52.
38. Ragucci GM, Elnayef B, Suárez-López Del Amo F, et al. Influence of exposing dental implants
into the sinus cavity on survival and complications rate: A systematic review. Int J Implant Dent
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39. Sato FR, Sawazaki R, Berretta D, Moreira RW, Vargas PA, de Almeida OP. Aspergillosis of the
maxillary sinus associated with a zygomatic implant. J Am Dent Assoc 2010;141: 1231–1235.

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40. Lee DH, Yoon TM, Lee JK, Lim SC. Dental implant and fungus ball in the ethmoid sinus. Int J
Oral Maxillofac Surg 2019;48:1594–1596.
41. Stacchi C, Del Lupo V, Berton F, et al. Aspergillus fumigatus biofilm formation on different bone
substitutes used in maxillary sinus augmentation: An in vitro analysis. Int J Implant Dent
2019;5:22.
42. Scolozzi P, Perez A, Verdeja R, Courvoisier DS, Lombardi T. Association between maxillary
sinus fungus ball and sinus bone grafting with deproteinized bovine bone substitutes: A case-
control study. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;121:e143–e147.
43. Sohn DS, Lee JK, Shin HI, Choi BJ, An KM. Fungal infection as a complication of sinus bone
grafting and implants: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;107:375–380.
44. Griffa A, Viterbo S, Boffano P. Endoscopic-assisted removal of an intraorbital dislocated dental
implant. Clin Oral Implants Res 2010;21:778–780.
45. Felisati G, Lozza P, Chiapasco M, Borloni R. Endoscopic removal of an unusual foreign body in
the sphenoid sinus: An oral implant. Clin Oral Implants Res 2007;18:776–780.
46. Cascone P, Ungari C, Filiaci F, Gabriele G, Ramieri V. A dental implant in the anterior cranial
fossae. Int J Oral Maxillofac Surg 2010;39:92–93.
47. Reychler H, Olszewski R. Intracerebral penetration of a zygomatic dental implant and
consequent therapeutic dilemmas: Case report. Int J Oral Maxillofac Implants 2010;25: 416–418.
48. Biglioli F, Chiapasco M. An easy access to retrieve dental implants displaced into the maxillary
sinus: The bony window technique. Clin Oral Implants Res 2014;25:1344–1351.
49. Yamashita Y, Iwai T, Hirota M, Omura S, Aoki N, Tohnai I. Removal of migrated dental implants
from maxillary sinus 4 years 10 months after implant placement. Oral Maxillofac Surg
2015;19:315–319.
50. Hong YH, Mun SK. A case of massive maxillary sinus bleeding after dental implant. Int J Oral
Maxillofac Surg 2011; 40:758–760.
51. Basma HS, Abou-Arraj RV. Management of a large artery during maxillary sinus bone grafting:
A case report. Clin Adv Periodontics 2021;11:22–26.
52. Yamamoto S, Maeda K, Kouchi I, et al. surgical ciliated cyst following maxillary sinus floor
augmentation: A case report. J Oral Implantol 2017;43:360–364.
53. Han YS. Postoperative maxillary cyst developing after sinus augmentation for dental implants: A
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54. Zitzmann NU, Fried R, Elsasser S, Marinello CP. Aspiration and ingestion of foreign bodies.
Schweiz Monatsschr Zahnmed 2000;110:619–632.
55. Shavit I, Juodzbalys G. Inferior alveolar nerve injuries following implant placement importance
of early diagnosis and treatment: A systematic review. J Oral Maxillofac Res 2014;5:e2.
56. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Postimplant neuropathy of the trigeminal
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57. Dessouky R, Xi Y, Zuniga J, Chhabra A. Role of MR neurography for the diagnosis of peripheral
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58. Zuniga JR. Sensory outcomes after reconstruction of lingual and inferior alveolar nerve
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59. Lozeron P, Krarup C, Schmalbruch H. Regeneration of unmyelinated and myelinated sensory
nerve fibres studied by a retrograde tracer method. J Neurosci Methods 2004;138: 225–232.

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