multitier technique for bone augmentation using intraoral ...€¦ · multitier intraoral onlay...

Multitier Technique for Bone AugmentationUsing Intraoral Autogenous Bone Blocks

Devorah Schwartz-Arad, DMD, PhD,* and Liran Levin, DMD†

Brånemark et al1 originally de-scribed autologous bone graftsused with dental implants, and

they are now a well-accepted proce-dure in oral and maxillofacial rehabil-itation.2–5 Placement of an endosseousimplant requires sufficient bone volumefor complete bone coverage. Further-more, the pattern of ridge resorption,which contributes to an unfavorablemaxillomandibular relationship, re-quires angulation of the implant and/orangled abutment, and affects the prox-imity of adjacent facial concavities(maxillary sinus, nasal cavity) and vitalstructures (mandibular nerve).6

Possible origins for autogenousbone include the calvarium,7 tibia,8

and iliac crest.9–11 Although the iliaccrest is frequently used in major jawreconstruction, it is not always recom-mended because of its morbidity, al-tered ambulation, and the need forhospitalization. There is also signifi-cant resorption associated with corti-cocancellous block grafts.11–13 Thesedisadvantages, together with the factthat dental implants do not requirelarge amounts of bone, lead to thegrowing use of intraoral block bonegrafts from intraoral sources, espe-cially the mandibular symphysis3,6,14–17

and ramus.2,3

In the repair of alveolar defects,bone grafts from the symphysis and ra-mus offer several benefits (e.g., conven-tional surgical access),15–17 and the prox-

imity of donor and recipient sites reduceoperative and anesthesia time, making itideal for outpatient implant surgery.There is no cutaneous scarring, minimaldiscomfort, and less morbidity com-pared with extraoral locations.

The mandibular symphysis andramus are possible origins for intraoralblock bone grafts that have been de-scribed as effective.18 However, themandibular ramus area provides goodbone quality with fewer postoperativecomplications compared to the sym-physis area.3,11

The purpose of this article is to de-scribe a multitier technique for recon-struction of extensive bone deficiency,using only intraoral block bone graftsfor implant site augmentation.

SURGICAL TECHNIQUE

Preoperatively, panoramic andconventional or computerized tomog-raphy scans were evaluated for boneshape (mesiodistal width and vertical

distance from adjacent facial concavi-ties and vital structures) and bone an-gulation. In severe bone deficiency(greater than 5 mm), the option of amultitier bone graft technique wasconsidered.19

One hour before each bone graft sur-gery, 1 g amoxicillin and 8 mg dexameth-asone were administered. For thepenicillin-allergic patients, 0.6 mg clinda-mycin was the drug of choice. Amoxicil-lin (1.5 g/day) or clindamycin (0.9 g/day)was continued for 10 days postopera-tively, and 4 mg dexamethasone/day wasadministered for 2 additional days. Pa-tients were instructed to rinse their mouthwith chlorhexidine 0.5% for 2 minutesimmediately preoperatively and to con-tinue for 10 additional days, twice dailywith chlorhexidine 0.2% postoperatively.

First Tier Operation

A midcrest incision was madealong the recipient area. A mucoperi-osteal flap was reflected. The recipient

*Department of Oral and Maxillofacial Surgery, The Mauriceand Gabriela Goldschleger School of Dental Medicine, Tel AvivUniversity, Tel Aviv, Israel.†Department of Oral Rehabilitation, The Maurice and GabrielaGoldschleger School of Dental Medicine, Tel Aviv University,Tel Aviv, Israel; Unit of Periodontology, Dept. of Oral andDental Sciences, Rambam Health Care Campus, Haifa, Israel.

ISSN 1056-6163/07/01601-005Implant DentistryVolume 16 • Number 1Copyright © 2007 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3180327595

Purpose: Intraoral bone graftsare a convenient and acceptablesource of autogenous bone for alve-olar reconstruction due to bone ori-gin similarity and less morbidity. Inlarge bone defects, 1 tier might beinsufficient to achieve the desiredbone shape. The purpose of this ar-ticle was to describe a multitier tech-nique for reconstruction of extensivebone deficiency, using only intraoralblock bone grafts for implant siteaugmentation.

Materials: After clinical and ra-diographic evaluation of the recipientsite, measurements were taken to de-termine the size of the bone deficiency.The first tier of bone graft was harvest-

ed from the mandibular ramus. Afteradditional clinical and radiographicevaluation of the recipient site 5months later, bone graft blocks forthe second tier were harvested eitherfrom the second ramus or the man-dibular symphysis.

Conclusions: A new technique,the multitier intraoral bone blockgraft, for the future use of dental im-plants, is described. This techniquecan serve as an optional operationprocedure for extensively atrophic al-veolar bone augmentation. (ImplantDent 2007;16:5–12)Key Words: bone deficiency, onlaybone graft, vertical ridge augmenta-tion, donor site, recipient site

IMPLANT DENTISTRY / VOLUME 16, NUMBER 1 2007 5

site was decorticated and recontouredusing a round bone bur (Aesculap AG,Tuttlingen, Germany) for better adap-tation of the graft and to improvegraft-to-recipient bone contact. Thebone defect was evaluated to deter-mine the size and shape of the blockneeded.

Bone blocks for the first tier wereharvested from the mandibular ramus(Fig. 1).19–21 Access to the ramus areafor bone harvest was gained throughan extension of the commonly usedenvelope flap for third molar extrac-tion. The incision was made in thebuccal vestibule, medial to the exter-nal oblique ridge, and extended ante-riorly and laterally to the retromolarpad, continuing anteriorly into thebuccal sulcus of the molars. A muco-periosteal flap was reflected exposingthe lateral aspect of the ramus andthird molar area. To begin the ramusosteotomy, a reciprocating or oscillat-ing saw was used to cut through thecortex along the anterior border of theramus. An anterior vertical cut wasmade in the mandibular body (thelength depended on the size of thegraft needed), and a posterior verticalcut was made on the lateral aspect ofthe ramus. No inferior osteotomy wasneeded. The border cuts were madeonly to the depth where bleeding oc-curred from the underlying cancellousbone to prevent injury to the underly-ing neurovascular bundle. A thin

chisel was gently tapped along the en-tire length of the osteotomy, takingcare to avoid injury to the inferioralveolar nerve by preventing the can-cellous bone to penetrate beneath thecortical layer. Graft splitting from theramus was then completed.

The bone blocks were restored ina sterile cold sodium chloride 0.9%solution (TEVA Medical Ltd, Ashdod,Israel) for a minimal time beforeplacement in the recipient site. Theblock graft was positioned over therecipient site with the endosteal side ofthe graft facing the cortical bone. Theblock was adapted to fit close to thesite. To ensure immobility, the graftwas fixed to the recipient site usingtitanium self-tap screws, 1.6 mm indiameter (Osteomed Corp., Ltd, Addi-son, TX), to be removed during secondtier operation or implant placement (Fig.2). Any sharp angles in the block seg-ment that could perforate the overlyingflap were eliminated, leaving a smoothoutline. Corticocancellous particles andbovine material (Bio-Oss; GeistlichPharma AG, Wolhusen, Switzerland)filled the gap between the graft and re-cipient site to avoid interference of vas-cularization of the graft and creation offibrous tissue ingrowth between the bedand graft. Resorbable membrane (Bio-Gide; Geistlich Pharma AG) coveredthe bone particles, taking care not tocover the block. Platelet-rich andplatelet-poor plasma (Harvest Technol-ogy, Plymouth, MA) were used to coverthe entire augmented area.

The periosteum at the base of thefacial flap in the recipient site wascarefully incised to allow stretching ofthe mucosa and tension-free adaptationof the wound margins. The flap wassutured with 3-0 nonrapid polyglactin(Vicryl; Johnson & Johnson Int., Ethi-con, St. Stevens Woluwe, Belgium) su-ture and removed 2 weeks later.

Treatment of the donor site wascompleted after fixation of the bonegraft and closure of the recipient site,which was filled with bovine material(Bio-Oss), covered with resorbablemembrane (Bio-Gide), and closedwith the same sutures.

Second Tier Operation

The interval between the first andsecond tier operations was 5 months.Bone at the recipient area was reevalu-ated 3 weeks before the second tier bonegraft. Panoramic and conventional orcomputerized tomography scans wereevaluated for the new bone shape.

A mucoperiosteal flap was re-flected similar to the first operation.Decortication was not performed topreserve the bone grafted at the firsttier. The bone defect was reevaluatedto determine the size and shape of theblock needed. The titanium self-tapscrews were removed.

For the second tier, bone blockswere harvested either from the secondramus or the mandibular symphysis(Fig. 3). For the symphysis, an intra-sulcular incision and 2 vertical releas-ing incisions were made posterior tothe second premolar regions, reflectingthe mucoperiosteal flap at the facialside. After exposing the symphysis andlocating the mental foramina, a recipro-cating saw was used to outline a rectan-gle, the size of the exposed defect. Thesuperior aspect of the rectangle was atleast 3�5 mm below the tooth apices,and the integrity of the lower border of

Fig. 1. Bone block harvested from the man-dibular ramus before (A) and after (B) blockharvest.

Fig. 2. Clinical (A) and radiographic (B) viewsof the first tier of bone blocks following fixa-tion in the recipient site.

Fig. 3. Bone block harvesting from the man-dibular symphysis.

6 MULTITIER TECHNIQUE FOR BONE AUGMENTATION USING INTRAORAL AUTOGENOUS BONE BLOCKS

the mandible was maintained. Os-teotomes were used to free the blockgraft and harvest cancellous bone.

The block graft was positioned overthe previous tier, with the endosteal sideof the graft facing the cortical bone ofthe first tier. The block was adapted andfixed to the previous tier using titaniumself-tap screws, 1.6 mm in diameter (Os-teomed Corp., Ltd.), to be removed dur-ing implant placement. The gap wastreated and covered as described in thefirst tier operation. The periosteum atthe base of the facial flap in the recipientsite was, again, carefully incised to al-low stretching of the mucosa andtension-free adaptation of the woundmargins.

The flap was sutured with 3-0nonrapid polyglactin (Vicryl) sutureand removed 2 weeks later. The donorsite was filled and closed after fixationof the bone graft and closure of therecipient site as described in the firsttier (Fig. 4). Implants were placed 5months after the second tier surgery(Figs. 5 and 6).

DISCUSSION

Intraoral block bone graft surgeryis a relatively new technique for im-plant site preparation. The use of bonefrom the mandibular symphysis, retro-molar area, and mandibular ramus canserve as a good treatment alternativefor alveolar ridge augmentation.19,21

The present report describes amultitier intraoral onlay bone blockgraft that can serve as an alternative

operation for extensively absorbedridge augmentation. Other surgicalprocedures, such as distraction osteo-genesis or repositioning of mandibularnerve, are not always feasible in theextensively atrophic jaw due to insuf-ficient bone, nerve injuries, risk offractures of the basal mandibularbone, or the distracted segment andresorption of the distracted segment.Furthermore, in mandibular nerve re-positioning, the impaired intermaxil-lary relation remains uncorrected.

It is possible to combine severalaugmentation techniques, such as si-nus floor or subnasal elevation proce-dures, and onlay bone grafts.19,21,22 Themultitier procedure offers the surgeonan improved option for reconstructionof extensive bone deficiency and betterintermaxillary relation for dental im-plant treatment. The addition of boneimproves the crown-implant ratio by in-creasing the implant dimension and de-creasing the crown dimension. Thehigher amount of good quality bone af-ter augmentation allows the clinician toplace a longer implant in a better trajec-tory. The alveolar ridge should have ade-quate width to allow bone on both facialand lingual implant surfaces for circum-ferential osseointegration. Furthermore,

experimental evidence has shown thatgrafts from membranous bone have lessresorption than endochondral bone due toearly revascularization, better potential forincorporation in the maxillofacial regionbecause of a biochemical similarity in theprotocollagen, and greater inductive ca-pacity because of a higher concentrationof bone morphogenetic proteins andgrowth factors.2,3,14 Cortical bone graftsmaintain their volumes significantly bet-ter than cancellous bone grafts.23 Lessresorption of the graft harvested from theintraoral origin makes this bone more fa-vorable for implant placement. The maindisadvantage of the proposed technique isthe need for several operations, whichcould cause patient discomfort.

Today, fabricated bone blocks areavailable for alveolar reconstruction.However further research is warranted toinvestigate their long-term effectiveness.

CONCLUSIONS

A new technique, the multitier in-traoral bone block graft, for the futureuse of dental implants, was described.This technique can serve as an optionaloperation procedure for extensivelyatrophic alveolar bone augmentation.

Disclosure

The authors claim to have no finan-cial interest in any company or any ofthe products mentioned in this article

ACKNOWLEDGMENT

The authors thank Ms. Rita Lazarfor editorial assistance.

REFERENCES

1. Brånemark PI, Lindstrom J, HallenO, et al. Reconstruction of the defectivemandible. Scand J Plast Reconstr Surg.1975;9:116-128.

2. Misch CM. Comparison of intraoraldonor sites for onlay grafting prior to im-plant placement. Int J Oral Maxillofac Im-plants. 1997;12:767-776.

3. Misch CM. The harvest of ramusbone in conjunction with third molar re-moval for onlay grafting before placementof dental implants. J Oral Maxillofac Surg.1999;57:1376-1379.

4. Rissolo AR, Bennett J. Bone graftingand its essential role in implant dentistry.Dent Clin North Am. 1998;42:91-116.

5. Lynch SE, Genco RJ, Marx R. In:Tissue Engineering: Applications in Maxil-lofacial Surgery and Periodontics. 1st ed.

Fig. 4. Clinical (A) and radiographic (B) viewsof the second tier bone block placement fol-lowing fixation in the recipient site.

Fig. 5. Five months after second tier place-ment, a clinical view of the alveolar ridge justprior to dental implant placement.

Fig. 6. Follow-up radiograph 2 years afterrehabilitation.


Chicago, IL: Quintessence Publishing;1999:83-98.

6. Misch CM, Misch CE, Resnik RR, etal. Reconstruction of maxillary alveolar de-fects with mandibular symphysis grafts fordental implants: A preliminary proceduralreport. Int J Oral Maxillofac Implants. 1992;7:360-366.

7. Harsha BC, Turvey TA, Powers SK.Use of autogenous cranial bone grafts inmaxillofacial surgery: A preliminary report.J Oral Maxillofac Surg. 1986;44:11-15.

8. Breine U, Brånemark PI. Recon-struction of the alveolar jaw bone. Scand JPlast Reconstr Surg. 1980;14:23-48.

9. Keller EE, van Roekel NB, DesjardinsRP, et al. Prosthetic surgical reconstructionof the severely resorbed maxilla with iliacbone grafting and tissue-integrated prosthe-ses. Int J Oral Maxillofac Implants. 1987;2:155-165.

10. Listrom RD, Symington JM. Os-seointegrated dental implants in conjunc-tion with bone grafts. Int J Oral MaxillofacSurg. 1988;17:116-118.

11. Schwartz-Arad D, Dori S. Intraoralautogenous onlay block bone grafting forimplant dentistry [in Hebrew]. RefuatHapeh Vehashinayim. 2002;19:35-39.

12. Smith JD, Abramson M. Membra-nous vs endochondrial bone autografts.Arch Otolaryngol. 1974;99:203-205.

13. Zins JE, Whitaker LA. Membra-nous versus endochondral bone: Implica-tions for craniofacial reconstruction. PlastReconstr Surg. 1983;72:778-785.

14. Misch CM, Misch CE. The repair oflocalized severe ridge defects for implantplacement using mandibular bone grafts.Implant Dent. 1995;4:261-267.

15. Montazem A, Valauri DV, St-HilaireH, et al. The mandibular symphysis as adonor site in maxillofacial bone grafting: Aquantitative anatomic study. J Oral Maxil-lofac Surg. 2000;58:1368-1371.

16. Gungormus M, Yavuz MS. The as-cending ramus of the mandible as a donorsite in maxillofacial bone grafting. J OralMaxillofac Surg. 2002;60:1316-1318.

17. Proussaefs P, Lozada J, KleinmanA, et al. The use of ramus autogenousblock grafts for vertical alveolar ridge aug-mentation and implant placement: A pilotstudy. Int J Oral Maxillofac Implants. 2002;17:238-248.

18. Linkow LI. Bone transplants usingthe symphysis, the iliac crest and syntheticbone materials. J Oral Implantol. 1983;11:211-247.

19. Schwartz-Arad D, Levin L, Sigal L.Surgical success of intraoral autogenousblock onlay bone grafting for alveolar ridgeaugmentation. Implant Dent. 2005;14:131-138.

20. Misch CM. Ridge augmentationusing mandibular ramus bone grafts for theplacement of dental implants: Presentationof a technique. Pract Periodontics AesthetDent. 1996;8:127-135.

21. Schwartz-Arad D, Levin L. Intraoralautogenous block onlay bone grafting forextensive reconstruction of atrophic maxil-lary alveolar ridges. J Periodontol. 2005;76:636-641.

22. Levin L, Herzberg R, Dolev E, etal. Smoking and complications of onlaybone grafts and sinus lift operations. IntJ Oral Maxillofac Implants. 2004;19:369-373.

23. Ozaki W, Buchman SR. Volumemaintenance of onlay bone grafts in thecranio-facial skeleton: Micro-architectureversus embryologic origin. Plast ReconstrSurg. 1998;102:291-297.

Reprint requests and correspondence to:Devorah Schwartz-Arad, DMD, PhDDepartment of Oral and Maxillofacial SurgeryThe Maurice and Gabriela Goldschleger,School of Dental MedicineTel Aviv UniversityTel Aviv, IsraelFax: (972) 3-6409250E-mail: [email protected]

Abstract Translations

GERMAN / DEUTSCH

AUTOR(EN): Devorah Schwartz-Arad, DMD, PhD*, LiranLevin, DMD**. *Abteilung fur Gesichts- und Kieferchirurgie,und **Abteilung fur prothetische Zahnwiederherstellung, dasMaurice and Gabriela Goldschleger Institut fur Dentalmedizin,Universitat von Tel-Aviv, Tel Aviv, Israel; Fachbereich Parodon-tologie, Abteilung fur Oral und Dentalwissenschaften, RambamGesundheitsfursorge-Campus, Haifa, Israel. Schriftvehrkehr:Devorah Schwartz-Arad, DMD, PhD, Abteilung fur Gesichts-und Kieferchirurgie (Dept. of Oral and Maxillofacial Sur-gery), das Maurice und Gabriela Goldschleger Institut furDentalmedizin (The Maurice and Gabriela Goldschleger,School of Dental Medicine), Universitat von Tel Aviv (TelAviv University), Tel Aviv, Israel. Fax: �972-3-6409250,e-Mail: [email protected] zur Knochengewebsanreicherungmittels intraoralen autogenen Knochengewebsblocken

ZUSAMMENFASSUNG: Zielsetzung: Intraorale Knochen-transplantate stellen eine passende und akzeptable Quelle autogenen

Knochengewebes fur die alveolare Wiederherstellung dar, da einegroße Ahnlichkeit des Knochengewebsursprungs sowie eine gerin-gere Morbiditat bestehen. Bei großen Knochengewebsdefektenreicht eine Lage eventuell nicht aus, um die gewunschte Knochen-form zu erzielen. Der vorliegende Artikel zielte nun darauf ab,eine Vielschichtentechnik zur Wiederherstellung weitreichenderKnochengewebsdefekte durch Anwendung ausschließlich in-traoraler Blockknochentransplantate zum Aufbau der Implan-tierungsstelle zu beschreiben. Materialien und Methoden: Nacheiner klinischen und rontgenologischen Bewertung der Emp-fangerstelle wurden Messungen unternommen, um daruber dasAusmaß des Knochengewebsdefekts zu erfassen. Die erste Lagedes Knochentransplantats wurde aus dem Unterkieferast ent-nommen. Nach zusatzlichen klinischen und rontgenologischenBeurteilungen der Empfangerstelle 5 Monate spater wurden dieKnochentransplantatblocke fur die zweite Schicht entweder ausdem zweiten Ast oder aus der Unterkiefersymphyse entnom-men. Schlussfolgerungen: Es wird die intraorale Vielschicht-entransplantierung von Knochengewebsblocken als neuartigeMethodik zur zukunftigen Verwendung von Zahnimplantatenbeschrieben. Diese Technik kann bei weitreichender atrophis-cher Alveolarknochenanreicherung als Moglichkeit der opera-tiven Vorgehensweise dienen.


SCHLUSSELWORTER: Knochengewebsdefizienz, Spanan-lagerung, Anreicherung des vertikalen Kamms, Spenderstelle,Empfangerstelle

SPANISH / ESPAÑOLAUTOR(ES): Devorah Schwartz-Arad, DMD, PhD*, LiranLevin, DMD**. *Depto. de Cirugıa Oral y Maxilofacial y**Depto. de Rehabilitacion Oral, Escuela de Medicina Den-tal Maurice y Gabriela Goldschleger, Universidad de TelAviv, Tel Aviv, Israel; Unidad de Periodontologıa, Depto. deCiencias Orales y Dentales, Campo de Atencion MedicaRambam, Haifa, Israel. Correspondencia a: DevorahSchwartz-Arad, DMD, PhD, Dept. of Oral and MaxillofacialSurgery, The Maurice and Gabriela Goldschleger, School ofDental Medicine, Tel Aviv University, Tel Aviv, Israel. Fax:�972-3-6409250, Correo electronico: [email protected] de multiples niveles para el aumento del huesousando bloques intraorales de hueso autogeno

ABSTRACTO: Proposito: Los injertos intraorales de huesoson una fuente conveniente y aceptable de hueso autogeno parala reconstruccion alveolar debido a la similitud en el origen delhueso y menos morbosidad. En defectos grandes de hueso, unnivel podrıa ser insuficiente para lograr la forma deseada delhueso. El proposito de este artıculo fue describir una tecnica demultiples niveles para la reconstruccion de una deficiencia ex-tensa de hueso, usando solamente injertos de bloques intraoralesde hueso para el aumento de la cavidad del implante. Materialesy metodos: Luego de la evaluacion clınica y radiografica delsitio del beneficiario, se tomaron mediciones para determinar eltamano de la deficiencia de hueso. El primer nivel de injerto dehueso se logro del ramus mandibular. Luego de evaluacionesclınicas y radiograficas adicionales del sitio del beneficiariocinco meses despues, se sacaron los bloques del injerto de huesopara el segundo nivel del segundo ramus o de la sınfisis man-dibular. Conclusiones: Se describe una nueva tecnica, un injertode hueso intraoral de multiples niveles para uso futuro de im-plantes dentales. Esta tecnica puede servir como un procedi-miento quirurgico opcional para el aumento del hueso alveolarextensivamente atrofico.

PALABRAS CLAVES: deficiencia de hueso, injerto delhueso onlay, aumento de la cresta vertical, lugar de donacion,tamano del sitio del beneficiario

PORTUGUESE / PORTUGUÊSAUTOR(ES): Devorah Schwartz-Arad, Doutor em MedicinaDentaria, PhD*, Liran Levin, Doutor em MedicinaDentaria**. *Depto. de Cirurgia Oral e Maxilo-facia.**Depto. de Reabilitacao Oral, Faculdade de Medicina Den-taria Maurice and Gabriela Goldschleger, Universidade deTel Aviv, Tel Aviv, Israel; Unidade de Periodontologia,Depto. de Ciencias Orais e Dentarias, Campus de AssistenciaMedica Rambam, Haifa, Israel. Correspondencia para: De-

vorah Schwartz-Arad, DMD, PhD, Dept. of Oral and Max-illofacial Surgery, The Maurice and Gabriela Goldschleger,School of Dental Medicine, Tel Aviv University, Tel Aviv,Israel. Fax: �972-3-6409250, E-mail: [email protected] Multicamadas para Aumento do Osso Usando Blo-cos de Osso Intra-Orais Autogenos

RESUMO: Objetivo: Enxerto de osso intra-orais sao umafonte conveniente e aceitavel de osso autogeno para recon-strucao alveolar devido a semelhanca da origem do osso emenos morbidade. Em grandes defeitos do osso, uma fileirapoderia ser insuficiente para alcancar a forma desejada doosso. O objetivo deste artigo era descrever uma tecnica mul-ticamadas para reconstrucao de extensa deficiencia do osso,usando apenas enxertos de osso de bloco intra-oral paraaumento do local de implante. Materiais e metodos: Aposavaliacao clınica e radiografica da area receptora, foramtomadas medidas para determinar o tamanho da deficienciado osso. A primeira fileira de enxerto osseo foi colhida doramo mandibular. Apos avaliacao clınica e radiografica adi-cional da area receptora 5 meses mais tarde, os blocos deenxerto do osso para a segunda fileira foram colhidos dosegundo ramo ou da sınfise mandibular. Conclusoes: Umanova tecnica, o enxerto do bloco do osso intra-oral multicama-das, para uso futuro de implantes dentarios, e descrita. Estatecnica pode servir como procedimento de operacao opcionalpara aumento do osso alveolar extensivamente atrofico.

PALAVRAS-CHAVE: deficiencia do osso, enxerto do osso “on-lay”, aumento do rebordo vertical, local doador, area receptora

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