Techniques On Vertical Ridge Augmentation Indicati

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Received: 17 August 2022 Accepted: 21 August 2022
DOI: 10.1111/prd.12471
REVIEW ARTICLE
Techniques on vertical ridge augmentation: Indications and

effectiveness
Istvan A. Urban1 | Eduardo Montero2 | Ettore Amerio3 | David Palombo2 |

Alberto Monje1,3,4
1
Department of Periodontology and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
2
Department of Periodontics, Universidad Complutense de Madrid, Madrid, Spain
3
Department of Periodontology, Universitat Internacional de Catalunya, Barcelona, Spain
4
Department of Periodontology, University of Bern, Bern, Switzerland
Correspondence
Alberto Monje, Department of Periodontology, Universitat Internacional de Catalunya, Carrer de Josep Trueta s/n, 08195 Sant Cugat del Vallès, Barcelona,
Spain.
Email: [email protected]
1 | I NTRO D U C TI O N when titanium mesh is used.16 Furthermore, Ozaki and Buchman17

tested the resorptive pattern of block grafts for bone augmentation
An unavoidable series of events takes place after tooth extraction, and found out that, irrespective of the bone graft embryologic origin,
sometimes ending up with vertical and horizontal ridge deficien- there is an unavoidable graft resorption (15%-60%) that takes place im-
cies.1–5 Schropp et al3 reported that 50% of the horizontal ridge di- mediately after grafting and that this may affect graft dimension during
mension and approximately 0.7 mm of vertical volumetric changes, early and late healing.15,18–20 Recently, allogeneic bone blocks without a
respectively, occurred within the first 3 months after extraction. In a barrier membrane have been used for vertical ridge augmentation and
systematic review, Van der Weijden et al6 showed that, after all the shown some promising results in terms of bone gain and implant sur-
resorptive events are over, a mean buccal-lingual/palatal dimension vival; nevertheless, there is still a lack of long-term evidence supporting
of 3.87 mm and a vertical reduction of 1.7 mm might preclude oral its utilization.21 Therefore, clinicians examined other possibilities (ie,
rehabilitation due to a dearth of support to obtain implant stabil- materials and techniques). This led to guided bone regeneration utiliz-
ity in an adequate position. Recent systematic reviews have further ing anorganic bovine bone in combination with autologous bone, which
supported these findings.7,8 As such, it can be very challenging for has been shown to be effective in vertical augmentation of atrophied
clinicians to place implants in these areas. These clinical difficulties maxillary ridges.22–26 In order to predictably achieve successful bone
might be overcome by shorter implant placements9 or by performing augmentation, the principle of “primary wound closure, angiogenesis,
bone augmentation10,11 or tilted implants.12 clot stability, and space maintenance” should be followed.27 As such,
The aforementioned techniques, although more minimally invasive, when performing vertical bone augmentation, space creation and its
may carry some esthetic concerns that can be overcome with pink maintenance during healing are essential (as per guided bone regener-
acrylics (ie, “pink esthetics”). On the other hand, vertical ridge augmen- ation biologic principles).28 Nonresorbable titanium-reinforced barrier
tation still constitutes a challenge regardless of the approach/biomate- membrane fulfills the aforementioned criteria and has been suggested
rials and, along these lines, this will rely directly on the degree of vertical for large vertical bone augmentation. On the other hand, the use of
deficiency and the host's existing anatomy.13 Autogenous bone blocks blocks or distraction osteogenesis represent alternatives where the na-
(BBs) have been demonstrated to reconstruct large vertical defects and ture (or the use) of the barrier membrane may not be so pivotal, given
achieve successful vertical bone gain. In a recent systematic review, it that these strategies assist in creating and maintaining the space for
has been shown that a mean gain of 4.75 mm can be achieved.14 In ad- de novo bone formation.29 Therefore, the goal of this review is to de-
dition, early membrane exposure rate associated with block grafting scribe the different approaches advocated for vertical ridge augmen-
15
was 12.5%. The exposure rate of the membrane can increase to 33% tation along with the indications and the evidence that support its use.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.
Periodontology 2000. 2023;00:1–30. |

wileyonlinelibrary.com/journal/prd 1
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2 URBAN et al.
2 | TEC H N I Q U E S O N V E RTI C A L R I D G E bone. Indeed, de novo bone formation has been demonstrated
AU G M E NTATI O N to be linked with the formation of new vessels within the grafted
area. This is the reason why corticotomies are suggested (intra-
2.1 | Guided bone regeneration bony marrow penetration) to allow the migration of the cells with
angiogenic and osteogenic potential.
2.1.1 | Biological foundation 3. Space creation and maintenance, to guarantee the proliferation
of the bone-forming cells. This principle is key in supracrestal
Guided bone regeneration has been broadly documented for the re- bone defects, where vertical ridge augmentation is aimed at
construction of alveolar ridge defects simultaneously with or staged deficient ridges. This is supplied primarily by the nature of the
to implant placement. The term implies the use of barrier membranes barrier membrane. Resorbable membranes are prone to col-
with the goal of fulfilling the principle by “compartmentalization.”12 lapse, whereas nonresorbable membranes are more valid and
Initially, it was advocated for the repair of the periodontium,12 al- effective at providing volume, particularly titanium-reinforced
though it was later used for implant site development.30,31 In other membranes. Other strategies/devices have been proposed to
words, the function of the barrier membrane aims to promote bone supply more stability to resorbable membranes, such as the use
formation while acting as a passive barrier to preclude soft tissue in- of meshes or screws.
growth. Moreover, the effect of the barrier membrane has been fur- 4. Stability of the clot that provides cytokines, growth factors,
ther shown to promote bone formation, as it induces molecular and and signaling molecules. Micromotion may lead to fibrous en-
cellular events. Preclinical studies have demonstrated that the use capsulation of the graft resulting in a failure of the regenerative
of nonresorbable barrier membranes enhances the levels of Runx2- procedure.
positive osteoprogenitor cells, osteocalcin, alkaline phosphatase, os-
teopontin, and sialoprotein.32–34 In fact, early healing (day 7) displays
inflammatory response, immune response, and an overexpression of 2.1.2 | Technical note
Gene Ontology terms related to angiogenesis and cell cycle regula-
tion. At day 15, a more complex cellular activity and cell metabolism Vertical ridge augmentation by means of guided bone regeneration
is evident, where the bone formation processes were significantly is a very technique-sensitive procedure.36 For reliable performance,
overexpressed, with several genes encoding growth factors, enzyme space creation and maintenance are demanded through the use of a
activity, and extracellular matrix formation. At this stage, a negative moldable barrier membrane in combination with a bone substitute
regulation of the Wnt signaling pathway is noted.35 Furthermore, capable of safely building up a robust biological structure mimick-
this type of barrier membrane has been shown to promote the ex- ing native tissues and providing sufficient volume. Nonresorbable
pression of tissue via increasing matrix metallopeptidases 2 and 9 titanium-reinforced barrier membranes fulfill these criteria and have
along with interleukin-1 and -6.33 Similarly, studies assessing the ef- been suggested to achieve successful vertical ridge augmentation
fect of resorbable (collagen-based) membranes on bone expression in large defects.37,38 Consequently, in order to successfully achieve
have noted that there is an increase in osteocalcin, cathepsin K, and vertical ridge augmentation, flap design should account for the fact
34
receptor activator of nuclear factor kappa B. In fact, it was shown that primary tension-free closure will need to be reached over an
that this type of membrane hosts different cell phenotypes that pro- increased dimension after the bone graft has been placed into the
gressively secrete major bone-related growth factors, such as bone defect. 27 In this sense, previous surgical procedures, such as other
34
morphogenetic protein-2. These findings, therefore, indicate that regenerative attempts, might alter the integrity of the soft tissues.
the principle of guided bone regeneration by means of using a barrier For instance, scarring of the periosteum impacts upon flap elastic-
membrane does not only preclude the migration of fibroblasts from ity and can impair flap advancement to achieve tension-free primary
an area aimed at being populated by bone-forming cells but also that wound closure.39 Other anatomical factors that can influence the
the membranes promote and orchestrate the healing events. ability to advance the flap coronally are the depth of the vestibule
From a clinical perspective, the principles for guided bone regen- and the severity of the alveolar defect. Therefore, different strat-
eration can be described as follows:27 egies have been outlined to overcome these drawbacks. Based on
this, a few preoperative factors listed in Table 1 have to be identified
1. Primary wound closure, to promote aseptic healing. Passive and controlled.
closure leads the wound to heal with less re-
epithelization, Different therapeutic approaches have been proposed for ver-
collagen formation, wound contraction, and remodeling while tical ridge augmentation by means of guided bone regeneration ac-
limiting the post-operative discomfort. This principle has proved cording to the anatomical region and the presence of critical factors.
critical in vertical ridge augmentation. In fact, dehiscences are These are examined in the following.
the most common leading cause of postoperative infection.
2. Angiogenesis, to stimulate the formation of the blood clot and ini- Vertical ridge augmentation in anterior ridges
tial formation of the granulation tissue that will result in the for- The following steps have been recommended for vertical ridge aug-
mation of the mineralization of the woven bone and later lamellar mentation in anterior atrophic ridges (Figure 1):
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TA B L E 1 Critical factors to be assessed preoperatively to enhance the likelihood of success in vertical ridge augmentation
Critical factor Rationale Management
Systemic factors and deleterious habits Systemic factors such as hyperglycemia and Smoking should be restricted 3 mo before
smoking may impair wound healing and vertical ridge augmentation. Other
increase the likelihood to postoperative conditions must be further controlled
infection
Defect morphology Concave/contained defect configurations Assess defect characteristics to identify
are rather more favorable than convex/ feasibility
uncontained defects
Nature of the periosteum The periosteum might be scarred in the case of Applying periosteoplasty or eliminating the
previous regenerative attempts. This may damaged periosteum
alter flap elasticity and may impede the
adequate coronal advancement to secure
tension-free flap closure
Vestibular depth Shallow vestibular depth may challenge the Applying remote vertical releasing incisions and
coronal advancement of the flap the safety flap
Presence of distal tooth (applicable in This may interfere with flap closure Extraction of the distal molar and let the site
posterior ridges) heal spontaneously for ≥3 mo
1. Remote flap: This design consists of crestal and vertical releasing papilla mesially in order to overcome the shortcomings of the
incisions. A full-thickness, midcrestal incision is typically used shallow vestibule.
in the keratinized gingiva with a surgical scalpel (15C). For 7. Flap closure: The flap must be sutured in two layers. The first layer
surgical access, the two divergent vertical incisions are placed is closed with horizontal mattress sutures placed 5 mm from the
at least one tooth away from the surgical site. The maximum incision line, and then single interrupted sutures are used to close
distance of the vertical incisions is two teeth away from the the edges of the flap.
defect. A larger flap will be easier to close and will result
in less mucogingival distortion. A periosteal releasing incision Vertical ridge augmentation in posterior ridges
must be carefully performed. In scenarios that exhibit shallow The following steps have been recommended for vertical ridge aug-
vestibule, a “suborbicularis preparation” should be carried to gain mentation in the posterior atrophic ridges:
advancement from the coronal and lateral regions. Moreover,
the periosteal releasing incision is different in scenarios that 1. Safety flap: A full-thickness, midcrestal incision is used in the
have scarred periosteum. In this case, a periosteoplasty or a keratinized mucosa with a surgical scalpel (15C). The distal
partial excision of the periosteum should be performed. extension of the crestal incision ends within 2 mm of the
2. Recipient site preparation: The recipient bone bed is prepared retromolar pad. For surgical access, a distal oblique vertical
with multiple de-cortication screw holes using a small round bur incision is made toward the coronoid process of the mandi-
to promote angiogenesis. ble. A vertical incision is placed mesio-
buccally at least one
3. Membrane adaptation: A suitable-sized titanium-reinforced pol- tooth away (preferably two) from the surgical site. Periosteal
ytetrafluoroethylene membrane is selected and trimmed so that elevators are used to reflect a full-
thickness flap beyond the
it completely covers the volume of the graft and its edges are not mucogingival junction and at least 5 mm beyond the bone de-
in contact with the natural teeth. Otherwise, a resorbable mem- fect. A periosteal releasing incision must be performed at this
brane with tenting screws is also a choice. Nevertheless, this is stage. Periosteoplasty might be encouraged in the case that
not advised in severely atrophic ridges. the periosteum is scarred.
4. Membrane fixation: Immobilization/stabilization of the mem- 2. Recipient site preparation: The recipient bone bed is prepared
brane of the graft is the key to success. The membrane is stabi- with multiple de-cortication screw holes using a small round bur
lized first on the lingual/palatal sides using titanium pins. to promote angiogenesis.
5. Bone grafting: A mixture of autogenous graft and bone substitute 3. Membrane adaptation: A titanium-reinforced polytetrafluoroeth-
is recommended. It must be placed into the defect and then the ylene membrane is selected and trimmed so that it totally covers
membrane is folded over and stabilized with additional titanium the volume of the graft and the edges are not in contact with the
pins or screws. natural teeth. Otherwise, a resorbable membrane with tenting
6. The free curtain flap and papilla shift technique: Two vertical in- screws is also a choice. Nevertheless, this is not advised in se-
cisions are made two, three, or even four teeth away from the verely atrophic ridges.
defect, depending on the severity of the vertical defect. After 4. Membrane fixation: Immobilization/stabilization of the mem-
periosteal incisions and elastic fiber separation, the clinician brane and the graft is the key to success. The membrane is sta-
can laterally position the remote areas of the flap and shift each bilized first on the lingual/palatal sides using titanium pins. If the
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4 URBAN et al.
A B F I G U R E 1 Representative case of
an anterior maxillary vertical defect
treated with guided bone regeneration.
A, Labial view of an anterior maxillary
defect after trauma. B, C, Labial and
occlusal views of a severe vertical and
horizontal ridge defect in the anterior
maxilla after flap elevation. D, Labial view
of a perforated polytetrafluoroethylene
C D titanium-reinforced membrane fixated
on the palate. E, F, Labial and occlusal
views of a particulated bone graft
consisting of a 60:40 ratio of autogenous
particulated bone and anorganic bovine
bone mineral. G, Labial view of the
polytetrafluoroethylene membrane
after fixation. H, Occlusal view of the
site after 9 mo of uneventful healing. I, J,
E F
Labial views of the newly formed bone at
membrane removal. K, Occlusal view of
three implants placed into the regenerated
bone. L, M, Occlusal and buccal views of
a mini sausage, protecting layer of bone
graft placed on the regenerated bone
consisting of 70% anorganic bovine bone
mineral and 30% autogenous bone. N,
Panoramic radiograph demonstrating
G H the implants placed into the regenerated
bone.
I J
K L
M N
URBAN et al. |
5
placement of the first lingual pin is tricky, a “temporary pin” is 3. Since the utilization of bone replacement materials such as al-
placed on the crest just behind the last tooth. lografts or xenografts has limited success in the reconstruction
5. Bone grafting: A mixture of autogenous graft and bone substitute of vertical ridge defects, the utilization of at least 50% of autog-
is recommended to provide osteoinductive and osteoconductive enous bone chips is still indicated in most reconstructions. When
properties in a ratio equal to or favoring autogenous bone. It must guided bone regeneration is utilized, in most cases the source of
be placed into the defect and then the membrane is folded over bone is intra-oral. Therefore, the availability of autogenous intra-
and stabilized with additional titanium pins or screws. oral bone can be the main limitation of sites treated with guided
6. Lingual flap advancement: The reason behind this flap design is bone regeneration.
based on the location of the attachment of the mylohyoid muscle
and also on the protection of vital anatomical landmarks, such as
the lingual nerve and the sublingual artery. Three maneuvers are 2.1.3 | Effectiveness based on clinical studies
encouraged based on three different zones (Figure 2):
• The first zone is around the retromolar pad where the lingual Several studies report on the effectiveness of guided bone regener-
nerve is running in close proximity. Tunneling and lifting on the ation in achieving vertical bone regeneration either in the maxilla or
retromolar pad is indicated. mandible (Table 2). A wide variety of surgical procedures have been
• The second zone is located in the molar region where the my- reported in the literature, employing different barrier membranes,
lohyoid line is attached closer to the crest. Mylohyoid detach- bone grafts, and space maintenance strategies that potentially im-
ment by means of blunt dissection is indicated. pact on the outcome of the regenerative surgery. In addition, when
• The third zone is the premolar region where the muscle is at- interpreting the results from the literature, it is important to take
tached deep and there is a deep periosteal attachment of the into consideration not only the amount of regenerated bone but also
soft tissue to the lingual side of the mandible. A horizontal the depth/dimensions of the original defect.
hockey stick periosteal incision is indicated. Most studies employed titanium-
reinforced polytetrafluo-
7. Flap closure: The flap must be sutured in two layers. The first layer roethylene membranes, which are considered ideal for this type
is closed with horizontal mattress sutures placed 5 mm from the of surgical procedure as they can provide a secluded space for a
incision line, and then single interrupted sutures are used to close long time as well as prevent the collapse of the soft tissue inside
the edges of the flap. the defect. In an early study, Simion et al41 proved the efficacy of
the titanium-
reinforced expanded polytetrafluoroethylene mem-
Indications and limitations branes in a simultaneous approach, reporting mean vertical bone
The following indications can be advocated for guided bone gains of 3.38 ± 0.81 mm (demineralized freeze-dried bone allograft
regeneration: group) and 4.16 ± 2.05 mm (autologous group), with the percentage
regeneration being 132.6 ± 41.3% and 93.5 ± 21.9%, respectively.
1. Simultaneous grafting and implant placement. Simultaneous In another study by the same research group, expanded polytet-
implant placement is possible when there is up to 4 mm of rafluoroethylene membranes combined with simultaneous implant
vertical bone deficiency when adequate bone width of the placement were able to regenerate 2.94 ± 1.15 mm (89.3 ± 64.2%),
basal bone exists. Beyond 4 mm of vertical deficiency, a staged 3.27 ± 0.88 mm (130 ± 40.7%), and 3.95 ± 1.79 mm (116 ± 51%) of
approach is recommended.40 the defect when they were used without graft, in combination
2. Localized vertical deficiency of partially edentulous patients with demineralized freeze-dried bone allograft, or in combination
is the most frequent indication for guided bone regeneration. with autologous graft, respectively. 26 Furthermore, nonresorbable
Edentulous patients can also be treated successfully; however, membranes were used in combination with alloplastic materials,42
only a few articles addressed the details of this approach. xenografts,43,44 allografts, 26,41,45,46 autologous grafts, 23,26,41,45–48
and combinations thereof38,45,49–56 yielding similar results with per-
On the other hand, limitations for guided bone regeneration are centage bone gain ranging between 62% and 139%. Regarding the
as follows: time of implant placement, both simultaneous23,26,38,41,42,44,45,48,52
and staged approaches23,41,43,45–47,49–56 were shown to be effective
1. There is no defect height or length limitation of the utilization in yielding vertical regeneration. However, a recent study of Urban
of guided bone regeneration. However, guided bone regeneration et al54 demonstrated that when using polytetrafluoroethylene mem-
was originally utilized for defects involving one to three teeth branes there is an increased probability of incomplete bone regen-
defects. This has been evolved in the past decades; however, eration by 2.5 times for each millimeter of regeneration needed;
the extent of defect that can be regenerated is still a widely hence, a simultaneous approach in a deep defect might result in an
thought misconception. increased risk of implant dehiscence at the reentry.
2. Posterior mandibular vertical defects when the infra-
alveolar Resorbable collagen membranes have also been employed in
nerve is exposed should not be treated with bone grafts placed di- vertical regenerative procedures either alone57 or in combination
rectly on the exposed nerve, including guided bone regeneration. maintenance strategies, such as tenting screws, 58,59
with space-
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6 URBAN et al.
F I G U R E 2 Representative case of
A B
a bilateral vertical and horizontal ridge
defect in the posterior mandible. A,
Panoramic radiograph demonstrating the
posterior mandibular defects. B, E, Labial
views demonstrating the vertical defect
in addition to a knife-edge atrophy on the
right side. C, F, Labial views of particulated
bone graft consisting of a mixture of 1:1
ratio of autogenous bone and anorganic
C D bovine bone mineral. D, G, Labial views
of a perforated polytetrafluoroethylene
titanium-reinforced membrane fixated.
H-K , Labial and occlusal views of the
regenerated bone at implant placement
after 9 mo of uneventful healing. L,
Panoramic radiograph demonstrating
stable crestal bone after loading.
E F
G H
I J
K L
URBAN et al. |
7
titanium mesh,50,60–63 osteosynthesis plates,48 and simultaneous report a mean marginal bone loss up to approximately 1 mm during the
48,50,57,58,64,65
implant placement. In addition, they were used ei- first year of loading. 23,43,45,55,78,79 A preclinical trial suggested that,
57 57,64
ther in combination with alloplastic material or xenograft or after membrane removal, bone is subjected to resorption.80 These
58,59 50,58,60,62,63
allograft or autogenous bone or mixed grafts. Their results can be also partially explained by the type of implants em-
amount of regenerated bone ranges from 25% to 92.9% and from ployed (Brånemark implants) and the incomplete bone regeneration
48,57,61,63,64 50,57,58,60,62,65
35% to 102% for the native and cross-linked at certain implants that were placed simultaneously with the verti-
collagen membrane, respectively. Consistently, a recent systematic cal guided bone regeneration. 26,81 After the first year, studies con-
66
review found that the mean vertical bone gain for nonresorbable, sistently showed stability of the peri-implant bone. 23,26,37,42,44,45,78
resorbable cross-
linked, and native collagen membranes was on Merli et al,42 in a randomized controlled trial with follow-up up to
average 4.42 mm (95% confidence interval 3.97-4.87 mm), 4.19 mm 6 years, showed a bone loss of 0.59 mm, 0.53 mm, and 0.49 mm in
(95% confidence interval 3.18-5.21 mm), and 2.66 mm (95% confi- comparison with baseline values at 1 year, 3 years, and 6 years, re-
dence interval 1.49-3.82 mm), respectively. spectively. Another prospective case series found that the marginal
bone loss at 2 years (0.98 ± 0.42 mm) was comparable to 1-year re-
sults (0.90 ± 0.60 mm).
2.1.4 | Postoperative complications In relation to resorbable membranes, Llambes et al,65 in a
12-
month prospective study, reported a marginal bone loss of
Postoperative complications during the healing period, such as mem- 1.36 ± 0.77 mm around implants placed simultaneously with a ver-
brane exposure and abscess, are potentially able to significantly af- tical bone regeneration performed with cross-linked collagen mem-
fect the outcome in terms of bone regeneration. Nevertheless, even brane and xenograft. In addition, two randomized controlled trials
though the occurrence of membrane exposure is rather frequent failed to find statistically significant differences in terms of vertical
(approximately 12%), the percentages of failures reported in the lit- ridge augmentation between polytetrafluoroethylene membranes
26,41,43,45,46,48,50,54,55,58–6 0,63,65,66 26
erature are low. Simion et al, using and resorbable membranes supported by osteosynthesis plates78 and
expanded polytetrafluoroethylene membranes, achieved regenera- titanium meshes.79 Recently, a retrospective case series reported a
tions of roughly 57% and 128% of the original defect in exposed and marginal bone loss of roughly 0.5 mm after 12 months of implants
nonexposed sites, respectively. Similarly, Beitlitum et al,58 using a after (a staged approach) guided bone regeneration was conducted
cross-linked collagen membrane, found that membrane exposure led with native collagen membrane supported by a titanium mesh.63 The
to approximately 50% less bone regeneration. In a recent study, the randomized controlled trial of Merli et al,37,78 is the only study report-
exposure of the native collagen membrane supported by a custom- ing results beyond 12 months on the marginal bone level of implants
ized titanium mesh led to a resorption of approximately 1 mm more placed following vertical guided bone regeneration conducted with
63
in comparison with nonexposed sites. resorbable membranes. These findings showed a bone remodeling
of 0.55 mm and 0.58 mm after 3 years and 6 years, respectively, and
the results were comparable to those of nonresorbable membranes.
2.1.5 | Long-term predictability All in all, the current literature suggests that an average bone
loss of about 1 mm is expected after the first year of loading and
Long-term predictability of vertical ridge augmentation is monitored a substantial stability of the marginal bone level could be assumed
by measuring the marginal bone loss around dental implants. It is after this period. Nonetheless, it should be taken into account that
generally accepted that implants might experience an early mar- only low-quality data are available due to the extreme heterogeneity
ginal bone remodeling as a result of the formation of the biologic of the surgical techniques employed, the poor study design of most
width,67,68 and a large number of factors have been suggested to af- studies, and the high percentage of patient dropout in trials with fol-
fect bone remodeling at this stage, including implant‑ and prosthetic- low-up greater than 12 months.
related and patient-based factors.69–75 Apropos the stability of the
marginal bone level after the first year, Albrektsson et al76 proposed
that successful implants register an annual marginal bone loss of less 2.2 | Block grafting: Onlay, inlay, and cortical plates
than 0.2 mm; yet, in the modern implant dentistry, progressive mar-
ginal bone loss around dental implants is no longer acceptable as it 2.2.1 | Biological foundation
77
is considered a sign of peri-implantitis. Hence, it seems reasonable
to wonder whether implants placed in regenerated bone are more Grafting with a bone block is a versatile and well-documented pro-
prone to experience bone loss in comparison with those that are lo- cedure for the treatment of alveolar ridge defects in a broad range
cated in pristine bone structure. of clinical scenarios.82,83
Data regarding the long-term stability of the peri-implant bone Onlay grafting represents the most conventional approach in-
are rather scarce in literature and mainly coming from retrospective herited from reconstructive procedures in orthopedic and cranio-
case series23,26,37,42–45,48,50,55,63,65,78,79 (Table 2). Concerning non- maxillofacial surgery and consists of the rigid fixation of a bone block
resorbable membrane, most short-term studies (up to 12 months) directly over a recipient site.84
TA B L E 2 Studies reporting on the effectiveness and long-term stability of vertical ridge augmentation by means of guided bone regeneration
|
8
Vertical bone
gain at site
level, mean ±
SD (mm)
Follow-up after Mean bone gain/ Membrane Abscess/infection

Patients/sites/ functional loading Mean bone exposure rate, rate, patient/ Failure rate, Marginal bone loss
Authors (y) Study design implants (mo) Surgical technique Location defect (%) patients/sites (%) sites (%) patients/sitesa (%) (mm)
Chiapasco Randomized Test 1: 6/6/13 12-36 Test: Expanded Maxilla and Test 1: Not Test 1: 33.3/33.3 Test 1: 16.6/16.6 Test 1: 0/0 Baseline
et al (2004) 81 controlled trial Test 2: 5/5/12 polytetrafluoroethylene mandible reported Test 2: 20/20 Test 2: 0/0 Test 2: 0/0 Test 1: 1.27 ± 0.8
(parallel) titanium-reinforced Test 2: Not Test 2: 0.69 ± 0.3
membrane) + reported 1y
autologous (1: Test 1: 1.83 ± 1.0
simultaneous; 2: staged Test 2: 1.29 ± 0.4
Control: Intra-oral 3y
distractor Test 1: 2.06 ± 0.9
Test 2: 1.69 ± 0.3
Abrahamsson Randomized Test: 10/10/10 Only reentry Test: Soft tissue expander + Single or Test: 3.0 ± 1.4 Test: 20/20 Test:0/0 Test:0/0 Not reported
et al (2012)61 controlled trial autologous + titanium partial Test: 73.1 ± 34.1
(parallel) mesh + native collagen anterior
resorbable membrane maxilla
(staged)
Control: Autologous graft
(staged)
Beitlitum Controlled clinical 23/23/51 Only reentry Test: Autologous bone Single or Test: 3.5 ± 1.2 Test: 25/25 Test: 0 Test: 0 Not reported
et al (2010)58 trial + freeze-dried bone partial Control: 3.47 ± Control: Control: 0 Control: 0
allograft + cross-linked anterior 1.25 33.3/33.3
resorbable membrane or Test: 35.9
(staged or simultaneous) posterior Control: 63.4
Control: Freeze-dried bone maxilla or
allograft + cross-linked mandible
resorbable membrane
(staged or simultaneous)
Canullo and Case series 10/10/24 36 (24-5 4) Expanded Partial 5.4 ± 1.5 10/10 0/0 0/0 1.4 ± 0.4
Malagnino (retrospective) polytetrafluoroethylene anterior 106 ± 18
(2008) 44 titanium-reinforced or
membrane + xenograft posterior
(simultaneous) maxilla or
mandible
Canullo and Sisti Case series 20/20/42 24 Expanded Single or 5.85 ± 1.48 5/5 0/0 0/0 1 y: 0.90 ± 0.60
(2010) 42 (prospective) polytetrafluoroethylene partial 139.6 ± 23.5 2 y: 0.98 ± 0.42
titanium-reinforced anterior
membrane + or
magnesium-enriched posterior
hydroxyapatite maxilla or
(simultaneous) mandible
URBAN et al.
TA B L E 2 (Continued)
Vertical bone
gain at site
URBAN et al.
level, mean ±
SD (mm)

Cardaropoli Case series 20/20/35 Only reentry Xenograft + fibrin- Single or 3.95 ± 1.47 0/0 0/0 0/0 Not reported
et al (2013)64 (prospective) fibronectin sealing partial 92.9
+ native collagen anterior
resorbable membrane or
(simultaneous) posterior
maxilla or
mandible
Chiapasco Case series 41/53/106 12 Custom-made titanium Maxilla or 4.39 (patient Not reported/20.8 Not reported/1.9 Not reported/1.9 6 mo (24 patients):
et al (2021)63 (retrospective) mesh + autogenous + mandible level) 0.33 ± 0.34
xenograft 1:1 + native 8.09 ± 12.27 mesial; 0.37 ±
collagen membrane (vertical 0.41 distal
(staged) bone 12 mo (13
resorption at patients): 0.54
reentry) ± 0.34 mesial;
0.56 ± 0.42
distal
Cucchi et al (2017, Randomized 40/40/99 12 Test: Allograft + autologous Partial Test: 4.1 ± 1 Test: 15.7/15.7 Test: 10.5/10.5 Test: 5.2/5.2 Baseline
2021)50,79 controlled trial (1:1) + titanium posterior Control: 4.2 ± 1 Control: 10/10 Control: 10/10 Control: 10/10 Test: −0.01 ± 0.75
(parallel) mesh + cross-linked mandible Test: 102.5 Control: 0.27 ±
collagen membrane Control: 105 0.76
(simultaneous) 1y
Control: Allograft + Test: 0.66 ± 0.80
autologous (1:1) Control: 0.89 ±
+ high-density 0.75
polytetrafluoroethylene
titanium-reinforced
membrane
(simultaneous)
Cucchi Randomized Test: 15/30/34 Till implant Test: Custom-made titanium Maxilla or Test: 4.74 ± 2.56 Healing complications Test: 0/0 Not reported
et al (2021)62 controlled trial Control: osteointegration mesh + autogenous + mandible Control: 6.36 ± Test: 33.3/16.7 Control: 0/0
(parallel) 15/30/37 xenograft 1:1 (staged) 2.31 Control: 13.3/6.7
Control: Custom-made Test: 74.32 ±
titanium mesh + 22.10
autogenous + xenograft Control: 82.30 ±
1:1 + cross-linked 17.98
collagen membrane
(staged)
|
9
(Continues)
|
Vertical bone
10
gain at site
level, mean ±
SD (mm)

Fontana Randomized 5/10/25 24 (12-36) Test: Expanded Partial Test: 4.7 ± 0.48 Test: 0/0 Test: 0/0 Test: 0/0 Not reported
et al (2008) 46 controlled trial polytetrafluoroethylene posterior Control: 4.1 ± Control: 0/0 Control: 20/20 Control: 0/0
(parallel) titanium-reinforced mandible 0.88
membrane + allograft Test: 91.3 ± 7.5
(staged) Control: 85.8 ±
Control: Expanded 20.5
titanium-reinforced
membrane + autologous
(staged)
Fontana Case series 21/29/75 42 (12-72) Autologous only, allograft Partial 4.15 ± 1.34 14.3/10.3 9.5/6.9 0/0 1 y: 0.64 ± 0.72
et al (2015) 45 (retrospective) only or xenograft posterior 90.1 ± 11.8 3 y: 1.34 ± 1.26
+ autologous mandible 6 y: 0.91 ± 0.74
1:1 + expanded
titanium-reinforced
membrane (staged or
simultaneous)
Funato Case series 19/19/not Only reentry Autologous + xenograft Partial 8.6 ± 4 11.8/11.8 0/0 0/0 Not reported
et al (2013)60 (retrospective) reported + cross-linked anterior 85.8 ± 25.6
resorbable membrane or
+ recombinant human posterior
platelet–derived growth maxilla or
factor + titanium mesh mandible
(staged)
Ji et al (2021)55 Case series 14/26/24 12 Titanium-reinforced Posterior 5.9 ± 2.7 Not reported/23.1 0/0 Not reported/not Mesial: 0.16 ± 0.05
(prospective) microporous expanded maxilla or 63.4 reported Distal: 0.15 ± 0.04
polytetrafluoroethylene mandible
membrane + allograft
and xenograft 1:1 or 2:1
(staged)
Lee et al (2022)57 Case series 22/22/not 1-7 y (after Xenograft or alloplastic Maxilla or 5.78 ± 1.72 9.1/9.1 0/0 0/0 No marginal bone
(retrospective) reported guided bone material + native mandible 85.6 loss noted
regeneration collagen membrane during the
treatment) or cross-linked follow-up
collagen membrane period
(simultaneous or
staged)
URBAN et al.
Vertical bone
gain at site
URBAN et al.
level, mean ±
SD (mm)

Leong Randomized 16/19/not Only reentry Test: Allograft + native Partial Test: 1.78 ± 2.3 Test: Not Test: 0/0 Test: 0/0 Not reported
et al (2015)59 controlled trial reported collagen resorbable posterior Control: 1 ± 2.2 reported/77.8 Control: 0/0 Control: 0/0
(parallel) membrane (staged) mandible Test: 44 Control: Not
Control: Cancellous and Control: 25 reported/30
cortical allograft
+ native collagen
resorbable membrane
(staged)
Llambes Case series 11/13/32 12 Autologous + xenograft + Partial 2.95 ± 1.21 18.2/15.38 0/0 9.1/7.7 1.36 ± 0.77
et al (2007)65 (prospective) cross-linked collagen posterior 81.1 ± 29.0
resorbable membrane mandible
(simultaneous)
Maiorana Randomized Test: 5/5/11 Till implant Test: High-density Posterior Test: 4.2 ± 2.2 Test: 0/0 Test: 0/0 Test: 0/0 Not reported
et al (2021)56 controlled trial Control: 5/5/10 osteointegration polytetrafluoroethylene mandible Control: 1.5 ± Control: 0/0 Control: 0/0 Control: 0/0
(split-mouth) membrane + tenting 1.6
screws + autogenous + Test: 100
xenograft 1:1 (staged) Control: 44.1
Control: Titanium mesh
+ tenting screws +
autogenous + xenograft
1:1 (staged)
Mendoza-A zpur Case series 35/not Only reentry High-density Posterior 5.44 26/not reported 0/0 0/0 Not reported
et al (2018)51 (retrospective) reported/ polytetrafluoroethylene maxilla or Not reported
not titanium-reinforced mandible
reported membrane + autologous
+ xenograft 50:50 +
tenting screws (staged)
|
11
(Continues)
|
Vertical bone
12
gain at site
level, mean ±
SD (mm)

Merli Randomized 22/22/77 72 Test: Native collagen Single or Test: 2.16 ± 1.51 Test: 9.1/9.1 Test: 18.2/18.2 Test: 18.2/18.2 Baseline
etal(2014,2010, controlled trial resorbable membrane partial Control: 2.48 ± Control: 9.1/9.1 Control: 9.1/9.1 Control: 9.1/9.1 Test: 0.75 ± 1.07
2007)37,48,78 (parallel) supported by anterior 1.13 Control: 0.54 ±
osteosynthesis or Test: 73.7 0.67
plates + autologous posterior Control: 90.8 1y
(simultaneous) maxilla or Test: 0.93 ± 0.34
Control: Expanded mandible Control: 1.03 ±
polytetrafluoroethylene 1.16
titanium-reinforced 3y
membrane + autologous Test: 1.30 ± 0.82
(simultaneous) Control: 1.07 ±
0.90
6y
Test: 1.33 ± 0.83
Control: 1.00 ±
0.97 (10 sites)
Rocchietta Controlled clinical 10/12/not Only reentry Test: Autologous block Partial Test: 2.91 ± 0.92 Test: 0/0 Test: 0/0 Test: 0/0 Not reported
et al (2016) 47 trial reported graft + expanded posterior Control: 4.45 ± Control: 0/0 Control: 0/0 Control: 0/0
polytetrafluoroethylene mandible 0.85
titanium-reinforced Test: 98 ± 4.6
membrane (staged) Control: 92 ± 9.3
Control: Autologous
particulate graft
+ expanded
titanium-reinforced
membrane (staged)
Ronda Randomized 23/26/38 (15-37) from the Test: High-density Partial Test: 5.02 ± 0.87 Test: 0/0 Test: 0/0 Test: 0/0 Not reported
et al (2014)38 controlled trial membrane polytetrafluoroethylene posterior Control: 4.49 ± Control: 0/0 Control: 0/0 Control: 0/0
(parallel) removal titanium-reinforced mandible 0.68
membrane + autologous Test: 120% ±
+ allograft 50:50 25%
(simultaneous) Control: 136% ±
Control: Expanded 46.5%
titanium-reinforced
+ allograft 50:50
(simultaneous)
URBAN et al.
Vertical bone
gain at site
URBAN et al.
level, mean ±
SD (mm)

Simion Controlled clinical 20/22/26 Only reentry Test: Expanded Partial Test: 3.38 ± 0.81 Test: 20/20 Test: 0/0 Test: 0/0 Not reported
et al (1998) 41 trial polytetrafluoroethylene anterior Control: 4.16 ± Control: 10/8.3 Control: 10/8.3 Control: 0/0
titanium-reinforced or 2.05
membrane + posterior Test: 132.6 ±
demineralized freeze- maxilla or 41.3
dried bone allograft mandible Control: 93.5 ±
(simultaneous) 21.9
Control: Expanded
titanium-reinforced
membrane +
Autologous + (staged
and simultaneous)
Simion Case series 49/54/123 (16-69) Expanded Partial Test 1: 2.94 ± Test 1: 0/0 Test 1: 14.3/16.6 Test 1: 0 Baseline
et al (2001)26 (retrospective) Test 1: 6/7/17 polytetrafluoroethylene anterior 1.15 Test 2: 18.2/18.2 Test 2: 0/0 Test 2: 0 Test 1: 1.29 ± 2.14
3 arms Test 2: titanium-reinforced or Test 2: 3.27 ± Test 3: 12.5/11.1 Test 3: 3.1/2.9 Test 3: 0 Test 2: −0.41 ±
11/11/24 membrane + Test 1 posterior 0.88 0.95
Test 3: (blood clot), or Test 2 maxilla or Test 3: 3.95 ± Test 3: −0.36 ±
32/36/82 (demineralized freeze- mandible 1.79 1.41
dried bone allograft), Test 1: 89.3 ± 1y
or Test 3 (autologous) 64.2 Test 1: 2.64 ± 1.99
(simultaneous) Test 2: 130 ± Test 2: 1.45 ± 0.56
40.7 Test 3: 1.34 ± 0.95
Test 3: 116 ± 51 3y
Test 1: 2.64 ± 1.99
Test 2: 1.40 ± 0.57
Test 3: 1.27 ± 0.82
Todisco (2010) 43 Case series 20/25/64 12 Expanded Single or 5.24 ± 1.5 10/8 0/0 10/8 0.95 ± 0.21
(prospective) polytetrafluoroethylene partial 96.8 ± 17.7 Intervention was
titanium-reinforced anterior repeated after
membrane + xenograft or 2 mo without
(staged) posterior complications
maxilla or
mandible
|
13
(Continues)
|
Vertical bone
14
gain at site
level, mean ±
SD (mm)

Urban Case series 35/36/82 40.3 (12-72) Expanded Full, single or 5.5 ± 2.29 0/0 2.9/2.7 0/0 1y
et al (2009)23 (retrospective) polytetrafluoroethylene partial Not reported 1.01 ± 0.57
titanium-reinforced anterior No further bone
membrane + autologous or loss during
bone (staged or posterior study period
simultaneous) maxilla or
mandible
Urban Case series 19/20/not Only reentry High-density Partial 5.45 ± 1.93 0/0 0/0 0/0 Not reported
et al (2014) 49 (prospective) reported polytetrafluoroethylene anterior Not reported
titanium-reinforced or
membrane + autologous posterior
bone chips + xenograft maxilla or
(1:1) (staged) mandible
Urban Case series 57/65/not Only re-entry Titanium-reinforced Maxilla or 5.2 ± 2.4 1.75/1.5 1.75/1.5 1.75/1.5 Not reported
et al (2021)54 (retrospective) reported polytetrafluoroethylene mandible 96.5 ± 13.9
mesh + autologous +
xenograft 1:1 + native
resorbable collagen
membrane (staged)
Amaral Valladão Case series 8/23/not 1-7 y (after High-density Maxilla or 5.6 ± 2.6 0/0 0/0 0/0 Not reported
et al (2020)53 (retrospective) reported guided bone polytetrafluoroethylene mandible 62.2
regeneration titanium-reinforced
treatment) membrane +
autologous + xenograft
1:1 + injectable
platelet-rich fibrin to
agglutinate the graft +
leukocyte and platelet-
rich fibrin covering
the high-density
membrane (staged)
URBAN et al.
URBAN et al. |
15
Marginal bone loss

These grafts heal through an orchestration of cellular, vascu-
prospective; PTFE-d, expanded polytetrafluoroethylene; PTFE-e, dense polytetrafluoroethylene; RCT, randomized clinical trial; Ret, retrospective; rhPDGF, recombinant human platelet-derived growth
lar, and architectural events, which have been described in differ-
Abbreviations: C, control; CCT, controlled clinical trial; DFDBA, demineralized freeze-dried bone allograft; FDBA, freeze dried bone allograft; GBR, guided bone regeneration; NR, not reported; Prosp,
Not reported
ent preclinical models.85–87 In the early stages of healing (3-5 days),
nutrients are provided to the bone block exclusively by plasmatic
patients/sitesa (%) (mm)

circulation. Subsequently, micro-angiogenesis begins through the
sprouting of capillaries from the surrounding soft tissues and the
recipient site edges, which start to penetrate the graft. At 2 weeks,
Failure rate,
a strong inflammatory and vascular response is present with bone

remodeling, micro-
angiogenesis, and hypervascularization of the
0/0
surrounding tissues; at 4 weeks, considerable remodeling is present,

Abscess/infection
with formation of osteoid and an increase in the size and dimensions

rate, patient/
of the micro vessels penetrating the graft. Finally, complete graft

sites (%)
revascularization is achieved at 8 weeks; and at 16 weeks, demarca-

0/0
tion from the recipient site disappears and newly formed, relatively
mature bone is present with no residual inflammatory cells.85–88
patients/sites (%)
exposure rate,
Similar to what has been described for guided bone regenera-

Mean bone gain/ Membrane
tion, 27 the healing process of bone block grafts is based upon the
5.2/3.8
following principles:
Not reported
1. Primary wound closure, to promote aseptic healing without

level, mean ±
Vertical bone
group: Not
group: 3.2
Staged group:
Staged group:
Simultaneous
Simultaneous
4.5 ± 2.2
reported
gain at site
graft contamination.
Mean bone
defect (%)
SD (mm)
± 1.9
2. Angiogenesis, to allow the graft revascularization by sprouting

capillaries projecting toward the medullar aspect of the graft.
3. Space creation and maintenance from the bone block, which al-
mandible
lows the proliferation of bone-forming cells during healing. Owing

Maxilla or
Location
to the solid nature of bone block, space is created by the graft and
no further device for space creation is required.
4. Stability of the blood clot provided by the structural integrity of

titanium-reinforced
the bone block and its rigid fixation to the recipient bed.
+ xenograft 50:50
(simultaneous and
Surgical technique
Furthermore, bone block grafting relies on the direct provision

High-density
staged)
of bone-forming cells into the defect, when the bone graft has an
autogenous origin, which represents the gold standard in vertical
Complete graft removal/no implant could be placed in the regeneration site.
bone augmentations for its osteogenic, osteo-inductive, and osteo-

conductive properties.82,89 In such a case, the osteogenic capacity
functional loading
Follow-up after
of the graft is dependent upon the number of living bone cells that
Only reentry
survive the early phases of healing, when nourishment is provided

to the graft through plasmatic circulation from the surrounding
(mo)
tissues.86
It must be noted that bone block grafting does not rely on the
Patients/sites/
principles of compartmentalization and cell exclusion as, in the

19/24/45
implants
majority of cases, no barrier membranes are required to avoid soft

tissue infiltration or to provide further mechanical stability to the
grafted area.90 Indeed, some researchers advocate the direct con-
(prospective)
tact of the bone block with the surrounding soft tissues as a means
Study design
to promote graft nourishment and micro-angiogenesis during the

Case series
early stages of healing, especially when using bone block grafts with
a high cortical composition.91,92
In fact, bone blocks with intramembranous origin (skull and
et al (2021)52
mandible), presenting a predominant cortical composition, were

factor; T, test.
Authors (y)
reported to have greater volumetric stability and scaffolding ef-

Windisch
fect but poorer osteogenic and angiogenetic capacities than bone

blocks with endochondral origin (rib, iliac crest), presenting a higher
a
|
16 URBAN et al.
A B F I G U R E 3 Representative case of an anterior maxillary vertical

defect treated with the bone shell technique. A, Labial preoperative
view of the defect and its relationship with the prosthetic
rehabilitation. B, Vestibular shifted flap design. C-E, Labial, occlusal,
and lateral views of the bone defect. F-H, Stabilization of the
occlusal and buccal bone shells and filling of the regenerative space
C D
with bone chips. Both the shells and bone chips were obtained
from the extraoral splitting and scraping of an autogenous bone
block harvested from the linea obliqua externa of the mandible.
I, J, Labial and occlusal views of the bone reconstruction after the
removal of sharp edges. K, L, Labial and occlusal views of the first
E F intention wound closure. M, N, Labial and occlusal views of the
reconstructed bone at surgical reentry, 4 mo after surgery. O-R ,
Labial and occlusal views of the prosthetically guided implant
placement. S-U, Contour augmentation with demineralized bovine
bone matrix and a collagen membrane after implant placement. V,
First intention wound closure
G H
content of cancellous bone.84,93,94 Such a difference is based upon

the capacity of endosteal osteoblasts and sprouting capillaries to
form osteoid and new vessels directly on the surface of cancellous
I J bone trabeculae, whereas revascularization and bone formation in
the presence of cortical grafts occur following the path of the pre-
existing Haversian system, through a process called creeping substi-
tution. Such a process occurs at a much slower pace and can result
in the persistence of islands of necrotic bone enclosed within the
K L newly formed vital bone.95,96 Donos et al80 showed in a preclinical
study that barrier membranes combined with a bone block, irrespec-
tive of their embryologic origin, exert a beneficial role in stabilizing
initial bone gain after the reconstructive procedure when compared
M N with bone block with no barrier membrane covering the grafts.
Based on those premises, further strategies have been devel-
oped aiming at promoting the revascularization of the grafted area:
1. The plates technique (“shell technique”).91 Thin bone laminae

O P are utilized as space-making devices to delimit a regenerative
space that is filled with particulated autogenous bone, in order
to minimize the cortical component of the graft and thus fa-
cilitate the ingrowth of sprouting capillaries during healing.
2. The inlay bone block technique.97 Here, a bone block graft is in-
Q R
terposed within a segmental osteotomy of the vertically atrophic
bone crest in order to sustain the displacement of the segmented
bone in a coronal direction, without detaching the supracrestal
soft tissues and related vascular network from the occlusal aspect
of the mobilized fragment.
S T
2.2.2 | Technical note
U V Similar to guided bone regeneration, vertical ridge augmentation

through a bone block is a complex, technique-sensitive intervention
where optimal soft and hard tissue management is indispensable to
avoid short‑ and long-term complications.66 In this context, the man-
agement of the soft tissues follows the same principles and technical
TA B L E 3 Studies reporting on the effectiveness and long-term stability of vertical ridge augmentation by means of bone block
Vertical
Follow-up bone gain
URBAN et al.
Number of of implants, at site level,

implants, mean (range) mean ± SD Marginal bone
Authors (y) Study design Patients/sites baseline (final) (mo) Surgical technique Graft origin Location (mm) Complication rate loss (mm)
De Stavola and Case series 10 10/10 10 18 (18) 12 Autologous bone Autologous Single or partial 6 ± 1.29 No exposure of the Not reported
Tunkel (2013)101 (prospective) using the shell anterior or graft and no
technique posterior complications
(staged) maxilla or with the donor
mandible site (0%)
Mangano Case series 10 10/10 10 10 (10) 12 Custom-made Synthetic Single anterior 3.7 ± 0.82 One graft was Not reported
et al (2014)159 (prospective) hydroxyapatite graft or posterior exposed 2 mo
(milling from a maxilla or after the
block) (staged) mandible procedure
and the most
coronal portion
of the graft had
to be removed
(10%)
Nissan et al (2011)160 Case series 20 20/not 31 (30) 42 (12-65) Freeze-dried Allograft Single or partial 2 ± 0.5 Not reported Not reported
(prospective) reported cancellous anterior
allograft maxilla
(staged)
Nissan et al (2011)21 Case series 34 31/not 63 (62) 34 (6-59) Freeze-dried Allograft Single or partial 2 ± 0.5 Not reported Not reported
(prospective) reported cancellous anterior
allograft maxilla
(staged)
Peleg et al (2010)122 Case series 13 13/16 16 26 (26) 26 Allogenic cortico- Allograft Single or partial 2.4 ± 1.09 No cases with Not reported
(prospective) cancellous iliac anterior or exposure of the
graft (staged) posterior graft material
maxilla or (0%)
mandible
Roccuzzo Case series 18 18/18 18 37 (37) Only reentry Autologous block Autologous Single or partial 4.8 ± 1 Temporary Not reported
et al (2004)123 (prospective) from ramus/ anterior or paresthesia
symphysis ± posterior observed in five
titanium mesh maxilla or cases (27.8%).
(staged) mandible Exposure of the
titanium mesh
in four patients
(22.2%)
|
17
(Continues)
|
Vertical
18
Follow-up bone gain

137
Yu et al (2016) Case series 21 21/21 21 21 (21) 73 (48-96) Autologous bone Autologous Single or partial 5.12 ± 1.05 Six patients 6 y: 0.77 ± 0.5
(prospective) using the shell anterior required
technique maxilla additional
(staged) grafting
(28.6%).
One patient
presented a
membrane
exposure
(4.76%)
Jensen et al (2006)97 Case series 10 10/10 10 15 (15) 60 Interpositional graft Autologous Partial anterior 4.2 ± 0.92 Not reported Not reported
(retrospective) using a cortical maxilla
wedge obtained
from the ramus
(staged)
Roccuzzo Controlled clinical trial 23 23/24 24 Not reported Only reentry Autologous Autologous Single or partial Test: 4.8±1.5 Test: Four patients Not reported
et al (2007)16 from ramus/ (test and anterior or Control: presented
symphysis ± control) posterior 3.6±1.4 mesh exposure
titanium mesh maxilla or (33.3%)
(staged) mandible Control: One graft
mobilization
at implant
placement
(8.3%). Three
incomplete
integration of
the graft (25%).
One temporary
paresthesia
(8.3%). Two
significant graft
resorption
(16.7%)
Tunkel et al (2021)124 Case series 5 5/10 10 Not reported 12 Autologous/ Autologous Single or partial Test: 3.2 ± 0.3 Temporary Test: 0.2 ± 0.4
(retrospective) allogenic bone (control) posterior Control: sensitivity Control:
plates using the Allograft (test) mandible or 3.9 ± 1.3 disturbance on 0.0 ± 0.2
shell technique maxillae the donor side
(staged) (20%)
URBAN et al.
Vertical
Follow-up bone gain
URBAN et al.

Chaushu Case series 16 16/16 16 73 (69) 48 (12-92) Allogenic bone Allograft Anterior 10.7 ± 3.2 Sensory/motor Not reported
et al (2021)126 (retrospective) block (staged) mandible in impairment
edentulous (5.5%)
Early implant failure
(5.5%)
Late implant failure
(2.2%)
Pfaffeneder-Mantai Case report 1 1/2 2 6 (6) 19 Custom-made Allograft Maxillary Not reported No complications Not reported
et al (2022)127 allograft block full-arch
(staged)
Khoury and Hanser Case series 117 88/128 97 287 (223) 120 (120-204) Autologous bone Autologous Single or partial 7.4 ± 2.6 Delayed wound 1 y: 0.66 ± 0.38
(2022)103 (retrospective) using the shell posterior (reentry) healing (1.6%) 3 y: 0.69 ± 0.32
technique mandible 6.7 ± 2.6 (10 y) Late bone exposure 5 y: 0.72 ± 0.31
(staged) (1.6%) 10 y: 0.75 ± 0.43
Infection (0.8%)
Gingival recession
on neighboring
teeth (2.3%)
Early screw
exposure
(24.2%)
Implants lost (1.7%)
Nilius et al (2022)125 Case report 30 not Not reported 36 (6-36) Custom-made Allograft Maxillary 5.73 ± 3.5 Block/plate Blocks
reported/75 allograft block/ full-arch exposure (not 1 y: 1.03 ± 1.54
not reported shell technique reported) 2 y: 2.14 ± 2.20
with allograft 3 y: 3.83 ± 1.98
plate (staged) Shell technique
1 y: 1.71 ± 1.6
2 y: 2.42 ± 2.83
3 y: 5.51 ± 3.8
Schlee and Rothamel Case series 3 3/3 3 9 (9) 12 Custom-made Allograft Posterior Not reported Partial exposure of 6 mo:
(2013)119 allograft block mandible a block (33.3%) 1.69 ± 3.31
12 mo:
1.64 ± 1.22
Blume et al (2019)133 Case report 1 1/2 2 4 (4) 10 Custom-made Allograft Premolar area in 3.5 ± 1.1 None (0%) Not reported
allograft block the maxilla
Abbreviations: BOP, bleeding on probing; C, control; CBG, clinical bone gain; CCT, controlled clinica trial; COM, complication; IS, implant survival; ISUC, implant success; NC, no control; NR, not reported;
PPD, peri-implant probing depth; PRGF, platelet rich growth factors; prosp, prospective; ret, retrospective; T, test.
|
19
TA B L E 4 Studies reporting on the effectiveness and long-term stability of vertical ridge augmentation by means of distraction osteogenesis
|
Vertical bone
20
gain at site level

mean ± SD (range)
Follow-up (mm)
after
functional Mean bone gain/
loading Mean bone defect Marginal bone
Authors (y) Study design Patients/sites (mo) Surgical technique Location (%) Healing complications loss (mm)
Chiapasco Case series 37/37 12-42 Intra-oral distractor Full or partial anterior 9.9 (4-15) 21.6% 1.4 ± 0.4
et al (2004)152 (prospective) or posterior maxilla Not reported
or mandible
Chiapasco Randomized Control: 10/10 12-36 Test: Expanded Maxilla and mandible Control: Not Lingual inclination bone fragment Baseline
et al (2004) 81 controlled trial polytetrafluoroethylene reported Control: 20%/20% Control:
(parallel) titanium-reinforced 0.50 ± 0.4
membrane + autologous 1 y
(1: simultaneous; 2: Control: 1.13 ± 0.3
staged) 3 y
Control: Intra-oral distractor Control: 1.41 ± 0.3
Jensen Case series 28/30 60 Transcortical distractor Partial anterior maxilla 6.5 ± 1.4 (3-15) Relapse of the segment: 50%/46.6% 1 ± 1.3
et al (2002)143 (prospective) 100 (mean: 1.6 ± 1.5 mm)
Device failure: 17.9%; 20%
Froum et al (2008)148 Case series 30/30 34-6 0 Endo-osseous distractor and Partial anterior or 7.8 ± 4.9 (3.5-13) Need for additional soft tissue surgery: Not reported
extraosseous distractor posterior maxilla or 100%/100%
mandible Need for additional hard tissue surgery:
60%/60%
Lingual inclination bone fragment:
73.3%/73.3%
Failure to achieve buccal augmentation:
73.3%/73.3%
Diminished vestibule (extraosseus
distractors only): 43.3%/43.3%
Flap dehiscence (extraosseus
distractors only): 13.3%/13.3%
Compromised esthetic result:
40%/40%
Temporization difficulties: 10%/10%
Distractor instability: 6.6%/6.6%
Infection: 6.6%/6.6%
Resorption of the transport segment
(intraosseus distraction only):
3.3%/3.3% (full), 26.6%/26.6%
(partial)
Klug et al (2001)153 Case series 10/13 2-19 Distractor and titanium Mandible 7.5 ± 1.27 (6-9) Dehiscence: 20%/15.4% Not reported
membrane in 4/13 sites Not reported Device failure: 10%/7.7%
McAllister (2001)154 Case series 7/10 12-3 0 Endosseous distractor Maxilla and mandible 7 (5-9) Slight setting: 14.3%/10% Not reported
(prospective) Not reported Incomplete bone consolidation:
28.6%/20%
URBAN et al.
Vertical bone
gain at site level
mean ± SD (range)
URBAN et al.
Follow-up (mm)
after
functional Mean bone gain/
loading Mean bone defect Marginal bone
Authors (y) Study design Patients/sites (mo) Surgical technique Location (%) Healing complications loss (mm)
Rachmiel Case series 14/14 6-20 Endosseous distractor Maxilla and mandible 10.3 ± 1.3 (8-13) Device failure: 7.1%/7.1% Not reported
et al (2001)149 Not reported Neurological alterations: 7.1%/7.1%
Raghoebar Case series 10/10 6-20 Distractor Mandible 6.8 ± 0.8 (6-8) Dehiscence: 10%/10% Not reported
et al (2002)150 96.1 ± 8.7
Kunkel Case series 10/10 48 Intraosseous implant–shaped Mandible 7.3 ± 1.6 Infection: 20%/20% Not reported
et al (2005)155 distractor Not reported Loosening of the distractor: 10%/10%
Iizuka et al (2005)156 Case series 7/7 12 Bidirectional distractor Anterior mandible and 11.9 ± 2.6 (10-15) Insufficient anterior inclination: Not reported
maxilla Not reported 28.6%/28.7%
Enislidis Case series 37/45 36 Intraosseous distractor: (14) Mandible 8.2 (5-15) Major complications Not reported
et al (2005)157 (retrospective) Subperiosteal distractor: (31) Not reported Fracture of basal bone or transport
segment: Not reported/8.9%
Device failure: Not reported/2.2%
Mechanical problems: Not
reported/6.7%
Minor complications
Dehiscence: Not reported/26.7%
Infection: Not reported/4.4%
Tilting of segment or wrong direction:
Not reported/13.3%
Neurological alterations: Not
reported/4.4%
Pain: Not reported/11.1%
Swelling: Not reported/8.9%
Türker et al (2007)151 Case series 10/10 12 Intraosseous distractor Mandible 9.6 ± 1.8 (6-12) Resorption of the segment: 10%/10% Not reported
Not reported Lingual inclination bone fragment:
10%/10%
Schleier Cohort 21/21 30 Unidirectional: (10) Maxilla and mandible Unidirectional: Crestal bone dislocation and infection Not reported
et al (2007)158 (retrospective) Bidirectional: (11) 5.3 ± 1.8 Unidirectional: 60%/60%
Not reported Bidirectional: 27.3%/27.3%
Bidirectional:
6.1 ± 2.3
Not reported
Chiapasco Randomized Control: 9/9 42 Test: Autologous block graft Mandible Control: 5.3 ± 1.6 Lingual inclination bone fragment: Baseline
et al (2007)15 controlled trial Control: Intra-oral (2-8) 22.2%/22.2% Control: 0.2 ± 0.3
extraosseous distractor Not reported Incomplete distraction: 11.1%/11.1% 1y
Control: 0.9 ± 0.4
3 y
Control: 1.0 ± 0.4
Abbreviations: C, control; CCT, controlled clinica trial; NC, no control; NR, not reported; prosp, prospective; ret, retrospective; T, test.
|
21
|
22 URBAN et al.
steps described for guided bone regeneration, which include the buccal and lingual one. Fixation is performed with titanium micro-
elevation of a full-
thickness mucoperiosteal flap, its passivation screws (1-1.2 mm diameter).
through periosteal fenestration/periosteoplasty, and the closure 4. Particulated autogenous bone collected from scraping the split
over the regenerated site with a multilayer suturing approach, to bone block is placed within the regenerative space delimited by
achieve a watertight first intention wound healing. the two shells.
5. Sharp edges from the shells are carefully removed with a dia-
Soft tissue management mond bur or piezoelectric insert, in order to avoid any risk of flap
In order to facilitate the achievement of primary closure, multiple perforation.
technical approaches implying soft tissue management and sutur- 6. After the completion of the reconstructive phase, periosteal re-
ing techniques have been described: (a) the free curtain flap and leasing is performed and first intention closure is achieved.
papilla shift technique for anterior regions;39 (b) the zone-specific 7. Surgical reentry is performed 4 months after surgery, to allow the
lingual flap advancement technique;98 (c) the vestibular shifted flap placement of dental implants.91 At this time point, horizontal re-
99 100
design; (d) the suspended external-internal suture; and (e) the lining of the vertically augmented bone can be performed with
101–103
tunnel approach. See “Technical note” for a description of a layer of slowly resorbable bovine bone matrix stabilized by a
these techniques. resorbable collagen membrane, in order to reduce the risk of bone
resorption over time.92
Hard tissue management
With regard to hard tissue management, the following steps have
been recommended based on the adopted technique: 2.2.3 | Inlay bone block
1. After flap elevation, the bone defect is thoroughly degranulated 1. A modified flap design is adopted, to preserve the periosteal
to remove any soft tissues remnants, and decortication holes attachment and related vascularization on the occlusal aspect
are then made with a round bur to promote angiogenesis. of the vertically atrophic crest. Thus, a para-crestal horizontal
2. Bone block harvested from the mandibular ramus,104 chin,105 iliac full-
thickness incision is performed in the alveolar mucosa to
crest,106 or parietal calvarium107 are modeled to obtain adapta- expose the alveolar process apical to the defect.
tion to the recipient site and then rigidly fixed with titanium mini- 2. A segmental osteotomy is performed with a horizontal apical cut
screws (1.5-2 mm diameter). and a mesial and distal vertical cut to separate the coronal portion
3. Sharp edges from the bone block are carefully removed with a of the bone crest presenting the defect from the basal bone.97
diamond bur or piezoelectric insert, in order to avoid any risk of 3. The osteotomized segment is then elevated coronally.
flap perforation. 4. The bone block is shaped and inserted within the horizontal os-
4. Remaining gaps between the bone block and recipient site are teotomy, in order to support the coronal advancement of the
filled with autogenous bone chips collected during the harvest of osteotomized segment. This can be stabilized with either osteo-
the bone block. synthesis plates97 or by simple mechanical friction with the ad-
5. A layer of slowly resorbable bovine bone matrix mixed with au- ditional protection of a collagen membrane.112
togenous bone chips can be placed over the grafts and stabilized 5. After completion of the reconstructive phase, periosteal releasing
with collagen membranes, in order to reduce the risk of bone is performed and first intention closure is achieved.
resorption.108,109 6. Surgical reentry is performed 2 months112 to 4 months later113 to
6. After the completion of the reconstructive phase, periosteal re- allow the placement of dental implants.
leasing is performed and first intention closure is achieved.
7. Surgical reentry is performed between 4 and 12 months after sur-
gery, to allow the placement of dental implants.104 2.2.4 | Indications and limitations
Shell technique Autogenous bone block grafts have been extensively used for verti-
See Figure 3 for a representative case of the shell technique. cal ridge augmentation for more than 35 years, with their main ad-
vantage (compared with the use of particulate bone grafts) of being
1. After flap elevation, the bone defect is thoroughly degranulated easily fixed with osteosynthesis screws.114 Several donor sites have
to remove any soft tissues remnants. been investigated, including extraoral sources, such as the iliac
2. The bone block harvested from the mandibular ramus is split in crest,115 or intra-oral sources, such as the symphysis or the ramus.116
two parts and then scraped in order to create two 1 mm thin bone Among the different techniques used to increase the vertical ridge
110,111
shells. dimension with the aid of autogenous bone block, the so-called shell
3. Based on the defect configuration, the two bone shells can be technique, using a thin cortical bone block to restore the contours
fixed at the buccal and occlusal aspect of the defect, or at the of the alveolar ridge, is nowadays the standard-of-care technique,
URBAN et al. |
23
as long as it reduces bone resorption to below 10%.101 These low to be used in the shell technique has also become a reality, solving
resorption rates could be reduced even further by combining the the problem of insufficient intra-oral bone quantity and reducing
implant placement after ridge augmentation with relining with a par- the morbidity of these procedures. Furthermore, a recent publica-
ticulated xenograft and a resorbable membrane.92 tion comparing both horizontal and vertical ridge augmentation with
The following indications can be advocated for bone block allogeneic and autogenous bone plates using the shell technique did
grafting: not find any difference among them, at least as long as augmenta-
tive relining at implant placement with a xenogeneic bone substitute
1. Simultaneous grafting and implant placement.117 and a collagen membrane are used in order to reduce the resorption
2. Extensive vertical defects in partially or totally edentulous pa- processes.124
tients, especially in the mandible. The feasibility and security of allogeneic bone block manually
milled before surgery has been confirmed in several clinical stud-
In contrast, limitations for autogenous bone block grafting are ies.131,132 The main advantages of this technique are the time re-
as follows: duction and ease of graft adaptation. For example, Chaushu et al126
recently published a retrospective case series showing impressive
1. Limited amount of intra-
orally available bone. clinical results after the use of an allograft bone block (vertical
2. Higher morbidity than with the use of particulated bone bone gain approximately 10 ± 3 mm); however, it should be ac-
substitutes. knowledged that all the cases included in the study were edentu-
lous subjects in the mandible in which vertical ridge augmentation
Somehow, these limitations could be overcome with the use an was performed in the anterior region, which may be a completely
allogeneic bone block, which could be milled to suit the defect ge- different scenario to the posterior mandible in terms of healing
ometry following preoperative diagnosis with cone beam computed pattern.
118,119
tomography in order to lessen the morbidity of the procedure. Also, allogeneic bone blocks specially designed and manufac-
tured using computer-
aided design/computer-
aided manufactur-
ing have been used for horizontal and vertical ridge augmentation,
2.2.5 | Effectiveness based on clinical studies thus allowing the preshaping of bone block grafts and to plan the
position of the fixation screws. One of the first reports was pub-
The effectiveness of vertical ridge augmentation with bone block lished by Schlee and Rothamel,119 who showed that this strategy
grafts has been evaluated in several investigations (Table 3) was efficient in terms of new bone formation with reduced patient
.16,21,97,101,103,120–127 Depending on the nature of the graft, the re- morbidity, decreased surgery time, and high patient acceptance.
sults provided have been heterogeneous, with the vertical bone gain Another case report, by Blume et al,133 demonstrated the regenera-
ranging from 4.12 mm (95% confidence interval 3.11-5.13 mm) for tion of two large osseous defects with customized computer-aided
autogenous bone block to 2.03 mm (95% confidence interval 1.88- design/computer-aided manufacturing allogeneic bone blocks that
2.18 mm) for allograft bone block according to a recent systematic perfectly matched the defect geometry and enabled implant place-
66
review. Also, when using autogenous bone, the choice of the tech- ment according to the initial treatment plan. However, even if both
nique seems to influence the results heavily, with worse results for bone blocks were covered by a porcine pericardium membrane, the
onlay bone block (3.5 mm, 95% confidence interval 2.2-4.9 mm) than rate of resorption of both was heterogeneous. Finally, a retrospec-
for the three-dimensional “shell technique” (2.0 mm, 95% confidence tive case series with 30 patients (15 of them treated by allogeneic
interval 1.9-2.2 mm). Anyway, it must be acknowledged that the bone block) showed a 5.73 ± 3.5 mm vertical bone gain in maxillary
amount of vertical ridge augmentation obtained always depends on full-arch restorations following an “advanced backward planning”
the baseline dimension of the defect, so these numbers should be procedure (ie, based on a digital prosthetic mock-up, the correct
interpreted with care (Table 3). implant positions and the bone block size needed to overcome the
More recent data seem to support better results for the shell bone loss were anticipated).
technique versus classical onlays for vertical ridge augmentation.
Specifically, a recently published retrospective study by Khoury and
Hanser103 reported the results of 117 consecutively treated patients 2.2.6 | Postoperative complications
with 128 grafted sites followed for up to 17 years, with 88 patients
and 97 augmented sites followed up for at least 10 years. In this Since vertical ridge augmentation procedures are technically de-
study, the mean vertical bone gain was 7.4 ± 2.6 mm at the reentry, manding, it is compulsory to assess the rate of complications to
whereas the results after 10 years of follow-up remain pretty stable, properly evaluate their effectiveness, as it is insufficient just to con-
103
accounting for a mean vertical ridge augmentation of 6.7 ± 2.6 mm. sider the vertical gain obtained. The most common complication in
However, the limited amount of intra-orally available bone has led to vertical ridge augmentation procedures with a bone block is the ex-
an increasingly important role for both allogeneic and xenogeneic posure of the graft, with or without infection. A recent systematic
graft materials.128–130 Thus, the use of allogeneic cortical bone plates review prepared for the XV European Workshop in Periodontology
|
24 URBAN et al.
reported an overall risk for vertical ridge augmentation procedures

of 16.9% (95% confidence interval 12.5%-21.2%), whereas it was 2.3 | Distraction osteogenesis
23.9% with the use of a bone block (95% confidence interval 11.3%-
36.6%).66 In the particular case of a bone block, apart from wound 2.3.1 | Biological foundation
dehiscence/graft exposure, other complications may arise as a con-
sequence of the need for a second surgical site (donor site) in the Distraction osteogenesis is an advanced hard and soft tissue engi-
case of autogenous grafts; namely, temporary paresthesia, pulp ne- neering protocol for the treatment of anatomical deformities. It was
crosis of lower incisors, and so on. Furthermore, incomplete integra- originally applied on long bones in orthopedic surgery138,139 and
tion of the bone block may lead to its mobilization at the time of then later found extensive application on membranous bones, in the
134
implant placement. correction of cranio-maxillofacial malformations,140 in orthognathic
Even though no randomized controlled trials are available surgery,141 and in the correction of severe atrophies of the alveolar
comparing the incidence of complications between autogenous processes to allow the placement of dental implants.15,142,143
or allogeneic bone blocks, it seems that bone block allografts are Its biological rationale is based on the segmentation of the atro-
more technique sensitive, and so clinical training is strongly recom- phic bone and on the progressive displacement of the bone segment
mended for clinicians unfamiliar with the use of this type of bone and the attached soft tissues in a coronal direction to create a se-
graft. Complications include opening of the incision line (possibly cluded regenerative chamber where new bone and soft tissues are
due to inadequate suturing technique), perforations of the mucosa, formed throughout the distraction process.138 Such displacement is
and infections leading to partial or total bone block loss being more achieved through a segmental osteotomy that separates the atro-
common than for autogenous bone block.135 For example, the pre- phic crest from its basal bone; the subsequent application of a dis-
viously mentioned publication by Khoury and Hanser103 reported traction device then progressively opens the osteotomy line with
that for 117 patients (128 sites) there were just 1.6% cases of bone slow and calibrated tension forces.15,138,144
exposure (although 24.2% of early screw exposure), 0.8% infections, Evidence from preclinical studies, showed that the regeneration
and just four implants lost (1.74%) over a 10-year period; and data chamber progressively undergoes an intramembranous ossification
from another retrospective case series including 101 consecutive process in a centripetal direction.145–147 During the first days after
patients (137 sites) treated with cancellous bone block allografts surgery, the regeneration chamber is initially filled with a blood clot
showed a 30.7% incidence of membrane exposure, a 13% incidence and fibrous tissue; then, after 10 days of distraction, a fibrous matrix
of infected bone block, and an implant failure rate of 4.4% with a fol- is present, with fibers oriented in the direction of elongation. New
low-up that ended at the time of placement of the implant-supported bone formation starts at the periphery of the regeneration cham-
restorations.136 ber with the formation of slender calcified spicules, oriented in the
direction of distraction, that become covered by osteoblasts. At
2 weeks, osteoclastic activity is present behind the extending front
2.2.7 | Long-term predictability of bone formation and the slender spiculae undergo a structural re-
modeling, becoming thicker trabeculae separated by wider spaces.
Long-term results of vertical ridge augmentation procedures per- At 4 weeks, the bone trabeculae have progressively extended to the
formed by means of bone blocks are seldomly reported, and the central zone of the regeneration chamber, re-establishing bone con-
same could be said for the incidence of biological complications tinuity. At 12 weeks, the completion of distraction, the regeneration
(ie, peri-
implant mucositis and peri-
implantitis) on the implants chamber is completely filled by new bone.145–147
placed in the augmented bone. However, if the radiographic mar-
ginal bone levels are evaluated once the implants are restored in a
series of studies on vertical ridge augmentation by means of bone 2.3.2 | Technical note
block grafting (Table 3), it can be observed that marginal bone loss
is below 1 mm in periods up to 10 years when autogenous bone fol- Regardless of the site of application, the following basic principles
lowing the “shell technique” have been used.101,103,124,137 In contrast, have been described:138
marginal bone loss reported in studies using “conventional” bone
blocks (specifically those of allogeneic origin) is significantly higher, 1. Osteotomy of the bone site with minimal periosteal stripping.
ranging between 1 mm at 1-year follow-up and up to 3 mm at 3 years 2. Latency period of 3, 5, or 7 days, depending on the surgical site.
after implant placement.119,125 This may be related to the poor re- 3. Distraction rate of 1.0 mm per day (0.5-2.0 mm).
vascularization leading to increased resorption of the grafted area, 4. Distraction through continuous force application is best, albeit a
which may be related more to the different methods for shaping and device activation twice a day is more practical and allows for bet-
processing bone block grafts than with their origin. Nevertheless, ter patient compliance.
the allogeneic/xenogeneic three-dimensional printed bone block re- 5. Consolidation should be extended until a cortical outline can be
quire long-term results from comparative studies to determine the seen radiographically across the distraction gap, which usually re-
predictability of their outcomes. quires 6 weeks.
URBAN et al. |
25
Currently, the majority of those principles is still applied for dis- 1. When the residual bone volume required for the fixation of the
15,142,148
traction osteogenesis of the atrophic edentulous ridges. distractor and also the transported bone fragment dimensions
Specifically, the following steps are followed: are insufficient, it should be taken into account that a residual
vertical bone height of at least 6-8 mm is usually required
1. A modified flap design, similar to the one described for and that small transported fragments (eg, single-tooth defect)
inlay bone blocks, is adopted that preserves the supracr- may potentially lead to more complications due to vascular
estal soft tissue attachment and related vascularization on impairment.81,143,149–151
the occlusal aspect of the vertically atrophic crest. Thus, a 2. Whenever it is desired to augment the ridge in both the vertical
para-crestal horizontal full-t hickness incision is performed on and horizontal directions.
the alveolar mucosa to expose the alveolar process apical 3. Posterior ridges are often more complicated due to access and the
to the defect. morphology of the ridges.
2. A segmental osteotomy is performed with a horizontal apical cut,
combined with a mesial and distal vertical osteotomy, to separate
the coronal portion of the bone crest presenting the defect from 2.3.4 | Effectiveness for vertical ridge augmentation
the basal bone. based on clinical studies
3. The intra-oral distractor is fixated to the basal bone and the oste-
otomized bone segment with titanium mini-screws. The effectiveness of distraction osteogenesis has been evaluated
4. Once fixated, the distractor is immediately activated to check the in different case series (Table 4),143,148–158 and it was demonstrated
vector of distraction and the undisturbed mobility of the bone that this surgical technique is able to vertically regenerate a consid-
segment. erable amount of bone, ranging between 5 and 12 mm depending on
5. The segment is repositioned at its initial position and the surgical the original extent of the defect. Chiapasco et al,15 in a randomized
access is sutured by first intention, leaving access exclusively to controlled trial study design on nine patients, reported a mean verti-
the most coronal part of the distractor to allow its progressive cal regeneration of 5.3 ± 1.6 mm using both intra-oral and extraoral
activation from the patient. distractors. In agreement with these results, a recent systematic
6. Seven days after surgery, distraction is started with either a fixed review and meta-analysis calculated a mean vertical bone gain of
15
rate (eg, 0.5 mm every 12 h since the first day of distraction) or 8.04 mm (95% confidence interval 5.68-10.41 mm).66 Hence, the pre-
an increasing rate over time (eg, 0.4 to 0.6 mm/day for the first dictability of the results obtained with this approach is high even in
3 days, followed by 1.2 mm a day for the following days148). cases of severe vertical discrepancies. Nonetheless, a high percent-
7. Distraction osteogenesis is carried out until the desired bone aug- age of complications is associated with this procedure, and some of
mentation is achieved. them may lead to the failure of the vertical regeneration, such as
8. The distractor is maintained in place for 2-3 months after com- device failure/mechanical problems,143,155,157 fracture of the basal
pleting the distraction osteogenesis phase to allow bone matura- bone/transport segment,157 and bone resorption.148,151 In compari-
tion in the distracted segment (consolidation phase). son with other techniques, it is rather difficult to draw conclusions
9. Surgical reentry is performed to remove the distractor device and as the comparative studies available did not analyze the difference
place the dental implants in the augmented bone. in terms of vertical bone gain.15,81 Nonetheless, the mean vertical
bone gain values reported in studies adopting distraction osteogen-
esis are higher than with other techniques (eg, guided bone regen-
2.3.3 | Indications and limitations eration, bone block).36,66
The following indications are advocated for distraction osteogenesis:

2.3.5 | Long-term predictability
1. Distraction osteogenesis is indicated prior to the implant place-
ment in the case of severe vertical discrepancies in order to Data on the stability of the marginal bone loss around implants in
regenerate the bone. regenerated bone after distraction osteogenesis are scarce in lit-
2. Whenever it is desired to reduce the intermaxillary distance for erature. In fact, most studies did not report information regarding
better esthetics and function. the implant stability of the peri-implant bone over time. A 5-year
3. In scenarios where it is desired to augment the hard and the soft prospective case series on 48 implants showed a marginal bone loss
tissues simultaneously. of 1 ± 1.3 mm,143 and another longitudinal study from the same re-
4. In highly damaged soft tissues where flap advancement is not search group showed a marginal bone resorption of 1.4 ± 0.4 mm in a
feasible. 1‑ to 3.5-year study on 138 implants.152 Two randomized controlled
trials showed that, during the first year, marginal bone remodeling
The following limitations are disclosed for distraction was roughly 0.6-0.7 mm on average and that bone levels were quite
osteogenesis: stable up to 3 years.15,81 In addition, based on these two latter
|
26 URBAN et al.
7. Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge

studies, the amount of bone resorption following autologous block preservation interventions following tooth extraction: a system-
graft and guided bone regeneration by means of polytetrafluoro- atic review and meta-analysis. J Clin Periodontol. 2019;46(Suppl
ethylene membranes before the implant placement was higher than 21):195-223.
8. Avila-O rtiz G, Elangovan S, Kramer KW, Blanchette D, Dawson
with distraction osteogenesis15,81 and the number of successful im-
DV. Effect of alveolar ridge preservation after tooth ex-
plants was higher in distraction osteogenesis than with guided bone
traction: a systematic review and meta- a nalysis. J Dent Res.
regeneration.81 2014;93:950-958.
9. Garaicoa-Pazmiño C, Suárez-López del Amo F, Monje A, et al.
Influence of crown/implant ratio on marginal bone loss: a system-
atic review. J Periodontol. 2014;85:1214-1221.
3 | CO N C LU S I O N 10. Tonetti MS, Hämmerle CHF. Advances in bone augmentation
to enable dental implant placement: consensus report of the
Vertical ridge augmentation is feasible and effective to restore Sixth European Workshop on Periodontology. J Clin Periodontol.
esthetics and function in atrophic ridges. Different therapeutic 2008;35:168-172.
11. Hämmerle CHF, Jung RE. Bone augmentation by means of barrier
modalities have been advocated to achieve vertical bone gain. All
membranes. Periodontol 2000. 2003;33:36-53.
these techniques require an orchestrated sequence of maneuvers, 12. Melcher AH. On the repair potential of periodontal tissues. J
implying soft and hard tissue management to minimize the risk of Periodontol. 1976;47:256-260.
complications. In particular, guided bone regeneration combined 13. Bernstein S, Cooke J, Fotek P, Wang HL. Vertical bone augmenta-
tion: where are we now? Implant Dent. 2006;15:219-228.
with bone block is a technically demanding surgical procedure in
14. Milinkovic I, Cordaro L. Are there specific indications for the
regard to soft tissue management and longer healing periods. On different alveolar bone augmentation procedures for implant
the other hand, distraction osteogenesis is faster, with less morbid- placement? A systematic review. Int J Oral Maxillofac Surg.
ity, and may not demand high skills for soft tissue management; 2014;43:606-625.
15. Chiapasco M, Zaniboni M, Rimondini L. Autogenous onlay bone
nevertheless, its application is limited to scenarios that do not
grafts vs. alveolar distraction osteogenesis for the correction
demand lateral ridge augmentation simultaneous to vertical ridge of vertically deficient edentulous ridges: a 2-4-year prospective
augmentation. study on humans. Clin Oral Implants Res. 2007;18:432-4 40.
16. Roccuzzo M, Ramieri G, Bunino M, Berrone S. Autogenous bone
graft alone or associated with titanium mesh for vertical alveolar
C O N FL I C T O F I N T E R E S T
ridge augmentation: a controlled clinical trial. Clin Oral Implants
The authors have no direct financial interests with the products and
Res. 2007;18:286-294.
instruments listed in the paper. 17. Ozaki W, Buchman SR. Volume maintenance of onlay bone grafts
in the craniofacial skeleton: micro-architecture versus embryo-
DATA AVA I L A B I L I T Y S TAT E M E N T logic origin. Plast Reconstr Surg. 1998;102:291-299.
18. Widmark G, Andersson B, Ivanoff CJ. Mandibular bone graft in the
The data that support the findings of this study are available on re-
anterior maxilla for single-tooth implants. Presentation of surgical
quest from the corresponding author. The data are not publicly avail- method. Int J Oral Maxillofac Surg. 1997;26:106-109.
able due to privacy or ethical restrictions. 19. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures
for the rehabilitation of deficient edentulous ridges with oral im-
plants. Clin Oral Implants Res. 2006;17(Suppl 2):136-159.
ORCID
20. Monje A, Monje F, Hernández- Alfaro F, et al. Horizontal bone
Eduardo Montero https://orcid.org/0000-0001-9948-3767 augmentation using autogenous block grafts and particulate xe-
Alberto Monje https://orcid.org/0000-0001-8292-1927 nograft in the severe atrophic maxillary anterior ridges: a cone-
beam computerized tomography case series. J Oral Implantol.
2015;41(S1 ):366-371.
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Received: 17 August 2022 Accepted: 21 August 2022

Techniques on vertical ridge augmentation: Indications and

Istvan A. Urban1 | Eduardo Montero2 | Ettore Amerio3 | David Palombo2 |

1 | I NTRO D U C TI O N when titanium mesh is used.16 Furthermore, Ozaki and Buchman17

Periodontology 2000. 2023;00:1–30. ﻿ |

Critical factor Rationale Management

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Follow-­up after Mean bone gain/ Membrane Abscess/infection

Marginal bone loss

patients/sitesa (%) (mm)

a strong inflammatory and vascular response is present with bone

surrounding tissues; at 4 weeks, considerable remodeling is present,

with formation of osteoid and an increase in the size and dimensions

of the micro vessels penetrating the graft. Finally, complete graft

revascularization is achieved at 8 weeks; and at 16 weeks, demarca-

Similar to what has been described for guided bone regenera-

1. Primary wound closure, to promote aseptic healing without

2. Angiogenesis, to allow the graft revascularization by sprouting

lows the proliferation of bone-­forming cells during healing. Owing

4. Stability of the blood clot provided by the structural integrity of

Furthermore, bone block grafting relies on the direct provision

bone augmentations for its osteogenic, osteo-­inductive, and osteo-

survive the early phases of healing, when nourishment is provided

principles of compartmentalization and cell exclusion as, in the

majority of cases, no barrier membranes are required to avoid soft

to promote graft nourishment and micro-­angiogenesis during the

mandible), presenting a predominant cortical composition, were

reported to have greater volumetric stability and scaffolding ef-

fect but poorer osteogenic and angiogenetic capacities than bone

A B F I G U R E 3 Representative case of an anterior maxillary vertical

content of cancellous bone.84,93,94 Such a difference is based upon

1. The plates technique (“shell technique”).91 Thin bone laminae

2.2.2 | Technical note

U V Similar to guided bone regeneration, vertical ridge augmentation

Number of of implants, at site level,

Follow-­up bone gain

Number of of implants, at site level,

gain at site level

reported an overall risk for vertical ridge augmentation procedures

The following indications are advocated for distraction osteogenesis:

7. Avila-­Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge

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Periodontology 2000. 2023;00:1–30. |

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

Follow-up after Mean bone gain/ Membrane Abscess/infection

lows the proliferation of bone-forming cells during healing. Owing

bone augmentations for its osteogenic, osteo-inductive, and osteo-

to promote graft nourishment and micro-angiogenesis during the

Follow-up bone gain

7. Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge