clinical horizontal ridge augmentation utilizing · horizontal ridge augmentation utilizing a...

Horizontal Ridge Augmentation Utilizinga Composite Graft of DemineralizedFreeze-Dried Allograft, MineralizedCortical Cancellous Chips, and aBiologically Degradable ThermoplasticCarrier Combined With a ResorbableMembrane: A Retrospective Evaluation of73 Consecutively Treated Cases FromPrivate PracticesNicholas Toscano, DDS, MS1*Danny Holtzclaw, DDS, MS2

Ziv Mazor, DMD3

Paul Rosen, DMD, MS4

Robert Horowitz, DDS5

Michael Toffler, DDS6

Ridge deficiency is an unfortunate obstacle in the field of implant dentistry. Many techniques

are available to rebuild the deficient ridge. Some of these techniques are associated with

significant morbidity and often require a second surgical site. With the advent of guided

bone regeneration (GBR), one may now graft the deficient ridge with decreased morbidity

and without a second surgical site. The purpose of this retrospective consecutive case series

from 5 private practices is to report on the outcomes of a composite material of

demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically

degradable thermoplastic carrier (Regenaform RT) when combined with a resorbable

1 Private practice, periodontics, New York, NY.2 Private practice, periodontics, Austin, Tex.3 Private practice, periodontics, Raanana, Israel.4 Private practice, periodontics, Yardley, Pa.5 Private practice, periodontics, Scarsdale, NY.6 Private practice, periodontics, New York, NY.* Corresponding author, e-mail: [email protected]: 10.1563/AAID-JOI-D-09-00100

CLINICAL

Journal of Oral Implantology 467

membrane for GBR of lateral ridge defects in human patients. The specific aim was to quantify

clinical results through direct measurement. Data were obtained from 73 consecutively treated

lateral ridge augmentations performed on 67 partial and/or completely edentate patients.

Clinical data (presurgical ridge width, ridge width at implant placement, and bone density at

implant placement) were obtained retrospectively from 5 private practices via an exhaustive

retrospective chart review, which was pooled and averaged for analysis. The average gain in

horizontal ridge width was 3.5 mm (range, 3–6 mm). The density of the bone was noted to be

type 2 to 3, with type 3 being the predominant finding. This retrospective case series from 5

clinical private practices suggests that the use of a composite material of demineralized freeze-

dried allograft, mineralized cortical cancellous chips, and a biologically degradable

thermoplastic carrier, when covered by a resorbable collagen membrane for GBR, is an

effective means of horizontal ridge augmentation.

Key Words: ridge augmentation, bone graft, particulate graft, dental implant

INTRODUCTION

Advances in surgical and im-

plant technology have enabled

dentists to meet the treatment

needs of an esthetically de-

manding patient population.

Historically,1 Albrektsson’s criteria have

served as the benchmark by which dental

implant success has been measured.2 Al-

though these criteria have remained the

gold standard, with a strict focus on

osseointegration and function, they do not

address contemporary concerns such as

esthetics or restorability secondary to im-

plant positioning. For example, implants may

be suboptimally placed because of anatomic

limitations, developmental defects, pathol-

ogy, bone resorption, and long-standing

ridge deficiencies, which when restored

may satisfy all of Albrektsson’s criteria for

success. Yet the implant may be a failure, as

seen in an undesirable esthetic outcome.

Implant malpositioning has been an

unfortunate complication of our profession.

The consequence of this can be off-axial

loading, which may result in biomechanical

problems, loosening, and/or fracturing of the

cover screw, implant, or implant collar.3,4

Implant malpositioning can adversely affect

clinical and prosthetic outcomes by creating

a suboptimal emergence profile, fracture of

the restoration, poor screw-hole positioning,

occlusal discrepancies, and compromised

esthetics and phonetics.

An ideal volume of bone is essential for

proper implant placement in the buccal/

palatal, apical/coronal, or mesial/distal di-

mension. Studies have demonstrated that

bone resorption will occur secondary to

tooth extraction5–12 (Figure 1). This tends

to occur over a 12 month period, most

notably in the first 4 months following

extraction5–11 and, depending upon location,

may range up to 5–7 mm buccolingually.8–12

In addition, 2–4 mm of vertical height loss

frequently accompanies the horizontal loss

and usually is seen when multiple adjacent

extraction sites are combined.8–12 To combat

this dimensional loss of bone volume, ridge

preservation techniques have been used to

maintain the alveolar ridge secondary to

tooth extraction.5,12–15 However, even with

current techniques, postextraction resorp-

tion may occur, mandating surgical manage-

ment of the ridge deficiency.12

Ridge splitting and expansion tech-

niques concurrent with bone grafting have

been well documented for treating hori-

zontal deficiencies. Included in these cate-

gories are ridge splitting and expansion,16,17

guided bone regeneration (GBR),18–21 dis-

traction osteogenesis,22 and block graft-

Horizontal Ridge Augmentation Utilizing a Composite Graft

468 Vol. XXXVI/No. Six/2010

ing.23–28 The purpose of this retrospective

consecutive case series from 5 private

practices is to report on the outcomes of

a composite material of demineralized

freeze-dried allograft, mineralized cortical

cancellous chips, and a biologically degrad-

able thermoplastic carrier (Regenaform RT,

Exactech Dental Biologics, Gainesville, Fla)

when combined with a resorbable mem-

brane for GBR of lateral ridge defects in

human patients. The specific aim was to

quantify the clinical results through direct

measurement.

MATERIALS AND METHODS

Clinical data (presurgical ridge width, ridge

width at implant placement, and bone

density at implant placement) were obtained

retrospectively from 5 private practices via

an exhaustive retrospective chart review,

which was pooled and averaged for analysis.

A total of 73 consecutively treated lateral

ridge augmentations were performed on 67

partial and/or completely edentate patients

with a composite material of demineralized

freeze-dried allograft, mineralized cortical

cancellous chips, and a biologically degrad-

able thermoplastic carrier (Regenaform RT)

that was covered by a resorbable collagen

membrane (Ossix, Oropharma Inc, Langhorne,

Pa). All patients were free of systemic disease

that might compromise the results, such as

uncontrolled diabetes or thyroid disease,

osteopenia or osteoporosis, and blood dys-

crasias such as anemia, and all were smokers

of less than 1 pack of cigarettes per day. A

total of 43 augmentations were performed in

the maxilla and 40 in the mandible. Three

patients underwent bilateral grafts of the

mandible. Patients were treated under local

anesthesia using 2% lidocaine with 1:100 000

epinephrine or articaine 4% with 1:100 000

epinephrine. A beveled crestal incision was

made slightly to the palate or lingual of the

treatment site and was extended at least 1

tooth beyond in both mesial and distal

directions. After elevation of full-thickness

flaps, measurements were made near the

crest of the ridge using a UNC-15 probe to

record the preaugmentation ridge width.

Measurements were rounded up to the

nearest millimeter at pretreatment and at

posttreatment. The bone defect was decorti-

cated using a #4 round bur through the

cortical plate to enhance revascularization of

the site. The membrane (Ossix, Orapharma,

Inc, Warminster, Pa) was soaked in sterile

water or sterile saline, according to the

manufacturer’s instructions, and was trimmed

to fit the site. Further periosteal release was

performed to allow for tension-free closure of

the flap over the membrane and graft. The

thermoplastic composite graft was mixed

according to the manufacturer’s instructions

and was molded to fit the ridge defect. The

graft was covered with the pretrimmed

resorbable collagen membrane, and tension-

free closure was provided utilizing a combi-

nation of horizontal and vertical mattress

sutures (Figures 2 through 6). Patients were

placed on postoperative Motrin 800 mg 3 to 4

times daily for up to 10 days to provide both

anti-inflammatory and analgesic benefits, as

well as amoxicillin 500 mg 3 times a day or

875 mg 2 times daily for 10 days. Patients

were also instructed to use 0.12% chlorhex-

idine rinse, starting on the day after surgery,

twice daily for the first 2 weeks when the

sutures were removed, and for up to 4 weeks

if the membrane became exposed. Pa-

tients were subsequently seen at 1 month,

3 months, and 6 months after the implants

had been placed.

All cases were allowed to heal for a

minimum of 6 months before implants were

placed. At this time, a second measurement

was made following the elevation of a full-

thickness flap. Again, a UNC-15 probe was

used to record ridge width postaugmenta-

tion. This was done close to where the first

measurement was made. All clinicians noted

Toscano et al


bone density according to the Lekholm

and Zarb scale at the time of implant

placement.

RESULTS

Average presurgical ridge width was 4 mm,

and it was noted that maxillary sites tended

to have more advanced ridge defects then

mandibular sites. At stage I implant place-

ment, ridge width postaugmentation was

recorded at an average of 7.5 mm. The

average gain in horizontal ridge width was

3.5 mm (range, 3–6 mm). The density of the

bone was noted to be type 2 to 3, with type

3 being the predominant finding. All im-

plants were successfully placed and ulti-

mately restored after an average 4 months of

healing (Figures 7 through 12).

DISCUSSION

The use of autogenous iliac crest block grafts

has been associated with higher rates of

FIGURES 1–6. FIGURE 1. A horizontal defect as a result of bone loss from tooth extraction. FIGURE 2. Flap isreflected, revealing a horizontal defect impeding implant placement. FIGURE 3. The graft is prepared viathe manufacturer’s instructions to form a block before placement within the defect. FIGURE 4. Defectgrafted. FIGURE 5. Flap released and sutured over the membrane and graft. FIGURE 6. Six monthspostgrafting with implant placed in adequate ridge of bone postaugmentation.



FIGURES 7–12. FIGURE 7. Nonrestorable tooth #7 with endodontic lesion noted. FIGURE 8. A large defect isseen postremoval of tooth and lesion. FIGURE 9. Defect is grafted before membrane placement. FIGURE 10.Six months postgraft with implant placed. FIGURE 11. #7 showing nonrestorable of implant placed ingrafted bone. FIGURE 12. Implant restored 8 months postgrafting.

Toscano et al


postoperative sequelae and morbidity,29

often requiring patient hospitalization. Al-

though iliac crest bone may present certain

advantages, such as the ability to obtain a

larger volume of graft material that would

include osteogenic material, its value has to

be questioned in light of excellent results

obtained with other graft materials and

techniques, and the significant costs and

morbidities associated with its procure-

ment.30 Autogenous block grafts from the

mandibular symphysis or ramus may be more

advantageous in that they can be procured

through an in-office, outpatient procedure.

Furthermore, intraoral autogenous grafts

have a lower rate of resorption and better

revascularization vs iliac crest grafts.31,32

Ramus and symphysial grafts have their own

sets of reported postoperative complications

such as pain, infection, edema, chin ptosis,

incision dehiscence, paresthesia, anesthesia,

and neurosensory changes.25,27,28,33,34

When GBR is compared with block grafting

techniques for ridge augmentation, little

difference is seen in the horizontal bone gain

that can be achieved. Studies by Buser have

demonstrated that using ramus and symphy-

sis blocks yielded an average ridge width gain

of 3.53 mm (range, 1–7.5 mm).35–38 More

recently, Schwartz-Arad demonstrated that

the mean ridge width increase in more than

60 onlay grafts from the symphysis and ramus

was 3.8 mm, and a mean success rate of 87.5%

was defined as sufficient bone for implant

placement.30 Additionally, Triplett (1993) re-

ported success rates for onlay grafts at 93%.36

When this is compared with the GBR literature,

bone volume gains between techniques

appear similar. Buser showed that GBR

procedures produced a horizontal ridge width

gain of 1.5–5.5 mm.18 Studies by Feulle using

GBR techniques demonstrated a mean ridge

width gain of 3.2 mm (range, 2.2–4.2 mm).43

Success rates for GBR techniques have been

similar to those of block grafts, with studies by

Tolman, Zitmann, and Nevins reporting in-

creases of 81% to 97%.39–41 A meta-analysis by

Tolman concluded that in most areas, the

success of GBR was similar to that of block

grafts, with only a slight advantage favoring

block grafting in the mandibular arch.39 A

systematic review by Aghaloo and Moy

reported findings of statistically significant

reduced implant survival rates at sites grafted

with autogenous bone block, compared with

other regenerative techniques.35 Their meta-

analysis found an implant survival rate of

74.4% for iliac crest grafts, as compared with

95.5% for GBR.

Block grafts from intraoral or extraoral

sources have the advantage of allowing

reentry slightly sooner for implant place-

ment. Pikos suggested that block grafts can

be reentered at 3–4 months in the mandible

and at 4–5 months in the maxilla.42 However,

the disadvantages of utilizing a second

surgical site, along with the increased

morbidity associated with the graft harvest,

make GBR an attractive technique for aug-

mentation of alveolar defects in preparation

for dental implant placement.

In the current study, grafting with com-

posite material of demineralized freeze-dried

allograft, mineralized cortical cancellous chips,

and a biologically degradable thermoplastic

carrier (Regenaform RT), when combined with

a resorbable membrane for GBR, resulted in

average horizontal ridge augmentation of

3.5 mm. This compares favorably with Buser’s

study of ramus and symphysial block grafts,

resulting in an average of 3.53 mm of ridge

width.37 The handling characteristic of the

composite graft, its combined osteoinductive

and osteoconductive nature, and the benefits

of avoiding a second surgical site make it

preferable over autogenous grafting tech-

niques.

CONCLUSION

This retrospective case series from 5 clinical

private practices suggests that the use of



composite material of demineralized freeze-

dried allograft, mineralized cortical cancel-

lous chips, and a biologically degradable

thermoplastic carrier, when covered by a

resorbable collagen membrane for GBR, is

an effective means of achieving horizontal

ridge augmentation (Figures 13 through

15). An average of 3.5 mm of horizontal

ridge width was achieved via this technique.

Additional prospective and randomized

controlled clinical trials are needed to

determine the efficacy of this technique

and to compare it with others currently

used.

ABBREVIATION

GBR: guided bone regeneration

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FIGURES 13–15. FIGURE 13. Deficient mandibular ridge with temporary implants placed. FIGURE 14. Ridgegrafted with tenting screws before membrane placement. FIGURE 15. Implants placed 6 monthspostgrafting.

Toscano et al


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