Are There Specific Indications For

Int. J. Oral Maxillofac. Surg.
2014; 43: 606–625

http://dx.doi.org/10.1016/j.ijom.2013.12.004, available online at http://www.sciencedirect.com
Systematic Review Paper

Dental Implants
Are there specific indications for I. Milinkovic, L. Cordaro

Department of Periodontology and
Prosthodontics, Eastman Dental Hospital,
Rome, Italy
the different alveolar bone

augmentation procedures for
implant placement? A
systematic review
I. Milinkovic, L. Cordaro: Are there specific indications for the different alveolar bone
augmentation procedures for implant placement? A systematic review. Int. J. Oral
Maxillofac. Surg. 2014; 43: 606–625. # 2014 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Bone resorption following tooth loss often interferes with dental implant
placement in a desired position, and requires additional bone augmentation
procedures. Many techniques have been described to augment and reconstruct
alveolar ridge width and height. The aim of this study was to systemically review
whether there is evidence to provide indications for the various bone
augmentation procedures based on defect dimension and type. An electronic
search of the Medline database and Cochrane library, complemented by a manual
search, was performed. Inclusion criteria for partial edentulism were: clinical trials
on bone augmentation procedures in preparation or at the time of implant
placement, reporting preoperative and postoperative dimensions of the ridge. For
edentulous patients, studies were included when providing the data on ridge and
defect description, or the amount of augmentation achieved. The search yielded 53
publications for partially edentulous patients and 15 publications for edentulous
patients. The literature provides evidence that dehiscence and fenestrations can be
treated successfully with guided bone regeneration (GBR) at the time of implant
placement (mean implant survival rate (MISR) 92.2%, mean complication rate
(MCR) 4.99%). In partially edentulous ridges, when a horizontal defect is present,
procedures such as staged GBR (MISR 100%, MCR 11.9%), bone block grafts
(MISR 98.4%, MCR 6.3%), and ridge expansion/splitting (MISR 97.4%, MCR
6.8%) have proved to be effective. Vertical defects can be treated with
simultaneous and staged GBR (MISR 98.9%, MCR 13.1% and MISR 100%, MCR
6.95%, respectively), bone block grafts (MISR 96.3%, MCR 8.1%), and distraction
osteogenesis (MISR 98.2%, MCR 22.4%). In edentulous patients, there is evidence
that bone block grafts can be used (MISR 87.75%), and that Le Fort I osteotomies
can be applied (MISR 87.9%), but associated with a high complication rate. The
objective of extracting specific indications for each procedure could not be fully
achieved due to the heterogeneity of the studies available. Further studies on bone
0901-5027/050606 + 020 $36.00/0 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Indications for bone augmentation procedures 607
augmentation procedures should report precise preoperative and postoperative Key words: alveolar bone augmentation;
measurements to enable a more exact analysis of the augmentation procedure, as indications; dental implants; systematic review.
well as to provide the clinician with the rationale for choosing the most indicated Accepted for publication 18 December 2013
surgical approach. Available online 19 January 2014
The treatment of partial and total edentu- one-stage and two-stage augmentation The focused question was adapted using
lism with dental implants has become a procedures is the stability of the augmen- the PICO criteria: ‘‘In patients with inade-
routine treatment modality in contempor- ted bone volume, allowing adequate func- quate ridge dimensions requiring dental
ary dental practice. Nevertheless, tooth tion and optimal aesthetics, as expressed implant treatment, which would be the
loss is frequently associated with subse- by implant survival, bone stability, and preferred bone augmentation procedure
quent bone loss, often resulting in inade- soft tissue stability. for each clinical situation?’’ (Table 1).
quate bone dimensions for dental implant Hence numerous combinations of tech-
placement in a prosthetically ideal posi- niques and materials may be used and Materials and methods
tion.1,2,3 Alveolar ridge resorption in par- have been described in the literature.4–6
tially and totally edentulous patients may Usually a surgical technique should be Search strategy
interfere with the safe and correct posi- chosen in relation to the anatomical base- A critical review of the literature was
tioning and placement of implants. When line situation, the expected outcome based conducted to select pertinent full-length
ridge resorption occurs, bone augmenta- on scientific evidence, and the expected articles published in English. The most
tion is essential to guarantee adequate complication rate, as well as the expected recent electronic search was undertaken
bone volume, to provide patients with success rate of the treatment with a given on 1 June 2012.
proper inter-arch dimensions, and to technique. It is not yet clear which proce- The electronic Medline (PubMed) and
assure a satisfactory aesthetic result. dure is an adequate choice for each parti- Cochrane Library search covered all
Numerous reconstruction procedures cular clinical situation, providing human clinical trials conducted from
have been proposed to increase alveolar satisfactory and stable bone dimension 1990 to 2012 in which the above-men-
bone dimensions, both vertically and hor- increase, long-term implant survival and tioned bone augmentation procedures
izontally, in order to obtain a sufficient stability, and a competent prosthetic reha- were performed. Additionally, a hand
ridge volume for adequate implant place- bilitation. search of journals included the following:
ment and prosthodontic rehabilitation.4–6 The objective of the present review was Clinical Oral Implants Research, Clinical
These techniques include: (1) guided bone to explore, based on current publications, Implant Dentistry and Related Research,
regeneration (GBR); (2) bone block grafts; whether it is possible to extract clinical Journal of Oral Implantology, Interna-
(3) distraction osteogenesis (DO); (4) indications for the various bone augmen- tional Journal of Oral and Maxillofacial
ridge splitting or expansion; (5) osteo- tation procedures based on defect type and Implants, International Journal of Period-
tomies of the ridge or the jaws; and (6) dimensions. ontics and Restorative Dentistry, Journal
combinations of the above. Some clinical situations, such as of Oral and Maxillofacial Surgery, Inter-
Several materials may be used in the immediate placement of implants in national Journal of Oral and Maxillofa-
aforementioned procedures, including extraction sockets and sinus floor eleva- cial Surgery, Clinical Oral Investigations,
autografts, allografts, xenografts, and allo- tion, were not analyzed in the present Implant Dentistry, Journal of Periodontol-
plasts, as well as different barrier mem- review. Both clinical procedures have ogy, Journal of Clinical Periodontology,
branes or osteosynthesis materials. been addressed in numerous review papers Journal of Craniofacial Surgery, Journal
In some cases, bone augmentation pro- and the indications have been thoroughly of Oral Rehabilitation, Journal of Pros-
cedures can be performed simultaneously discussed.4,7–13 thetic Dentistry, and Oral Surgery, Oral
with implant insertion, whereas in other The Preferred Reporting Items for Sys- Medicine, Oral Pathology, Oral Radiol-
clinical situations a healing period of tematic Reviews and Meta-Analyses ogy, and Endodontology. Only publica-
the reconstructed ridge is needed, requir- (PRISMA) were adopted throughout the tions in English on bone augmentation
ing a delayed, non-simultaneous implant process of the present systematic procedures were included in this systema-
placement. The long-term goal of both review.14 tic review.
Table 1. PICO criteria for the systematic review. Search terms

Population (P) Patients who underwent bone augmentation procedures during A combination of the following search
preparation
terms was utilized: bone atrophy, bone
or at the time of implant placement
Intervention (I) Horizontal and vertical bone augmentation procedures for partially loss, alveolar ridge bone loss, alveolar
edentulous patients, bone augmentation procedures in edentulous ridge deficiency, fenestration, dehiscence,
patients horizontal defect, vertical defect, pre-
Comparison (C) Lack of indications for different bone augmentation procedures prosthetic surgery, bone augmentation,
Outcome (O) Mean amount of augmentation, implant survival rate in the augmented horizontal bone augmentation, vertical
bone, and occurrence of complications bone augmentation, GBR, resorbable
Focused question In patients with inadequate ridge dimensions requiring dental implant membrane, non-resorbable membrane,
treatment, which would be the preferred bone augmentation procedure autogenous bone graft, allograft, xeno-
for each clinical situation? graft, alloplastic, distraction osteogenesis,
608 Milinkovic and Cordaro
ridge splitting, split crest, Le Fort I osteot- Data collection and analysis group of clinical situations. In view of the
omy, bone graft, bone block, bone trans- heterogeneity of the data, it was not pos-
Two independent reviewers screened titles
plantation, follow-up, humans, dental sible to perform an assessment of the risk
and abstracts obtained through the
implant, single-stage surgery, two-stage of bias within studies.
described search. The screening was per-
surgery, clinical trial, randomized con- The mean survival and complication
formed on a printout of the titles and
trolled clinical trial, controlled clinical trial, rates were calculated by weighted means.
abstracts according to the following cri-
prospective study, retrospective study.
teria: human trials, longitudinal studies,
clinical outcomes. Results
Selection criteria Two reviewers evaluated the full-texts
of studies of possible relevance. Any dis- Partially edentulous patients: horizontal
The study protocol defined inclusion and defects
agreement was discussed and resolved,
exclusion criteria for study eligibility. Due
and authors were contacted to provide, Horizontal bone augmentation may be
to a reduced number of randomized con-
if possible, missing data. Kappa values achieved with different techniques,
trolled clinical trials, all clinical study
for measuring agreement between two including GBR, the use of bone blocks,
types on human models were included
authors were equal to 0.86, thus reflecting or ridge expansion techniques.
in this review (randomized controlled clin-
excellent inter-author agreement. To assess if there is a clinical situation
ical trials (RCT), controlled clinical trials
(CCT), prospective studies (PS), and ret- that indicates the preferred use of a surgi-
rospective studies (RS)). Studies reporting Outcome measures cal technique, some data are necessary.
not all outcome measurements but provid- Dimensions of the residual ridge at base-
The following treatment outcomes were line, bone augmentation achieved, and
ing information on the augmentation pro-
recorded for the included studies: (1) eventually implant outcome must be
cedure amount were also included.
Defect size pre- and postoperatively reported. It was decided to include only
and/or the amount of augmentation studies providing the aforementioned data.
Inclusion criteria (reported as defect fill or linear bone gain).
(2) Survival and success rate of implants
The following inclusion criteria were GBR and simultaneous implant placement
placed in the augmented sites. (3) Implant
applied: (1) Type of studies: all human for horizontal augmentation
failure rate. (4) Complication rate.
clinical trials published in English, report-
All the included studies were grouped An initial electronic search identified 938
ing on bone augmentation procedures dur-
and summarized according to: type of titles when using the selected key words in
ing preparation or at the time of implant
edentulism (partially edentulous or eden- terms of GBR techniques for bone aug-
placement. (2) Type of defect: fenestration,
tulous), defect type (fenestration, dehis- mentation. After final selection based on
dehiscence, horizontal and vertical ridge
cence, horizontal or vertical defect), and the abstract and full-text analysis, apply-
defects in partially edentulous and edentu-
type of augmentation procedure applied. ing all the inclusion criteria, 15 full-text
lous jaws. (3) Data included in the studies
As a result of the former rationale, the articles were extracted and included in this
for partially edentulous patients: preopera-
results were grouped into partially eden- systematic review (Table 2). Out of the 15
tive dimensions, postoperative dimensions
tulous patients and edentulous patients, as studies included, four were RCT, one was
of the ridge, or amount of augmentation,
outlined below and shown in Fig. 1. a CCT, eight were PS, and two were RS.
combined with a description of the defect.
(4) Data included in the studies for edentu- Regarding the type of defect, six papers
lous patients: ridge and defect description, Partially edentulous patients reported on augmentation of dehiscence
amount of augmentation. (1) Horizontal augmentation group: GBR and fenestrations, seven on dehiscence
with simultaneous implant placement; only, one on fenestrations only, and one
GBR with non-simultaneous implant pla- on alveolar ridge defects.
Exclusion criteria In total, 683 patients received 1091
cement; bone blocks; ridge splitting and
The following exclusion criteria were expansion. (2) Vertical augmentation implants simultaneously with GBR aug-
applied: (1) Augmentations performed group: GBR with simultaneous implant mentation procedures. Five studies
on implants placed at the time of tooth placement; GBR with non-simultaneous reported on the use of resorbable mem-
extraction (type 1, International Team for implant placement; bone blocks; distrac- branes for GBR, five on the use of non-
Implantology (ITI) classification) were tion osteogenesis. resorbable membranes, and in three stu-
excluded. (2) Sinus augmentations per- dies both resorbable and non-resorbable
formed without an additional ridge aug- membranes were used; in one study no
mentation procedure. (3) Studies not Edentulous patients membrane was applied within the GBR.
fulfilling the above-mentioned inclusion Horizontal and vertical augmentation One study reported on the use of titanium
criteria. (4) Studies designed as case groups: GBR with simultaneous implant mesh as a membrane. In this study,15 15
reports. (5) Studies describing techniques placement; bone blocks; ridge expansion; patients were treated with 20 implants.
without reporting clinical outcomes. (6) distraction osteogenesis; maxillary osteo- Dehiscences were reconstructed with
Studies providing only histological data. tomies. autograft and covered with titanium mesh
(7) Studies describing bone augmentation as a membrane. Even though mesh should
procedures as a treatment modality fol- be considered only a space maintaining
Statistics
lowing peri-implantitis, trauma, or tumour device and not a barrier membrane, this
ablation, or therapy for various medical No attempt was made to perform a meta- study has been included in this group.
syndromes. (8) Publications in which the analysis of the data reported in the papers Various bone augmentation materials
same data were published by the same included in the present review, due to the were used during the GBR procedures.
groups of authors. heterogeneity of the data within a similar In four of the included studies, the use
Fig. 1. Flowchart of the study selection process.PE: partially edentulous patients; Ed: edentulous patients; GBR: guided bone regeneration; GBR
sim: guided bone regeneration and simultaneous implant placement; GBR non sim: guided bone regeneration and non-simultaneous implant
placement; Split crest: ridge splitting/expansion; DO: distraction osteogenesis; Le Fort I: maxillary ridge augmentation and grafting in edentulous
patients with Le Fort I osteotomy.
of autogenous bone was reported without polytetrafluoroethylene (e-PTFE) mem- search when using the selected key words
the need for a secondary donor site, seven brane, 12.5% of exposure. In a study in terms of GBR techniques for bone
studies described the use of xenografts, by Blanco et al., dehiscence occurred augmentation. A refined search narrowed
one study the use of allograft, and two in 11.5%.20 In a study by Hammerle the selection to five full-text articles,
studies a combination of the various graft- and Lang, complications such as infec- which were extracted and included in this
ing materials. In two studies, no bone tion and necrosis occurred in 20%.21 In systematic review. Five studies met all the
augmentation material was used; only the study of De Boever and De Boever, inclusion criteria, providing adequate data
the non-resorbable membrane was applied complete defect coverage was found in on preoperative and postoperative defect
to the defect.16,17 13 out of 15 patients (86.6%),22 and in dimensions (Table 3). Out of the five
The average preoperative dimension of the study by Widmark and Ivanoff, it was studies included, one was an RCT, one
a dehiscence and fenestration defect observed in 67%.23 Park et al. described was a CCT, and three were PS.
within the studies included was: dehiscence of the graft or membrane Defects treated within these studies
4.95 mm in horizontal dimension and exposure in 24% of the sites.24 In a study were described as presenting an initial
5.83 mm in vertical dimension. The aver- by Dahlin et al., exposure was noticed ridge width that was not sufficient to place
age size of a postoperative defect around one implant (2.5%), and another a standard-dimension dental implant.
decreased to 1.01 mm in horizontal one implant (2.5%) was lost.25 Four stu- In total, 124 patients received 214
dimension and 1.36 mm in vertical dimen- dies reported no dehiscence.26–29 The implants following the healing period after
sion, with a mean defect fill of 81.9%. mean complication rate was 4.99%. GBR augmentation procedures. Both
Regarding the complications with the The average healing time prior to resorbable and non-resorbable membranes
procedures used, Dahlin et al. reported an implant loading was 6.8 months. The were used in the analyzed articles. In three
occurrence of flap dehiscences and graft mean implant survival rate for implants publications, a resorbable membrane was
exposure of 13%16 and Zitzmann et al. of simultaneously placed with the GBR pro- used, in one of them a non-resorbable
16% when using a resorbable membrane cedure for horizontal augmentation was membrane was applied, and one study
and 24.4% with a non-resorbable mem- 92.2%. reported on the use of both resorbable
brane,18 while Lorenzoni et al. reported and non-resorbable membranes.
the presence of dehiscence and mem- Regarding the bone augmentation mate-
GBR and non-simultaneous implant
brane exposure, but did not define the rial applied, in two articles, the use of
placement for horizontal augmentation
frequency.17 In one study,19 defects trea- autogenous bone was reported, one study
ted with a collagen membrane had 17.4% Nine hundred and thirty-eight titles were described the use of xenografts, one study
of exposure, and with an expanded extracted during the initial electronic the use of allograft, and one study the
610
Table 2. GBR with simultaneous implant placement for horizontal augmentation.
Implant
Augmentation Preop. Postop placement Healing Follow-up
Study Defect Type of No. of No. of (horizontal/ Grafting dimension .dimension Defect Implant (sim/ Loading time period Early Complication Survival Success
Milinkovic and Cordaro

Study type* typey edentulismz patients implants Site§ Techniqueô vertical) material** Membraneyy (mm) (mm) fill (%) type non-sim)zz protocol (months) (months) failure rate (%) rate (%) rate (%)
1 Dahlin et al. CCT Deh/Fen PMx, PMd 45 55 Max/Mand GBR H Membrane Non-res Defect size H 1.2 mm 77 Brånemark Sim ND 4.5 24 3.64 13.00 84.7/93 ND
199516 H 4.6 mm
2 Fugazzotto RS Deh/Fen ND 331 626 Max/Mand GBR H Allograft + Non-res Deh 2–14, ND ND IMZ Sim ND 7.5 24 0.64 1.1 98.9 97.6
199726 alloplast Fen 2–12
3 Zitzmann RCT Deh/Fen 8 EMx, 25 43 Max/Mand GBR H Xenograft Non-res/ Measured Measured in 92 Brånemark Sim 4 Mand 5 55–70 2.4 24 97.6 ND
et al. 199718 2 EMd, Res in mm2 mm2 1.1/2.1 78 6 Max 16
12 PE 15.8/15.7
4 Peleg et al. PS Fen PE 22 44 Max/Mand GBR H ABG Res Mean 3.67 Mean 0.25 87 Melsungen Sim/ ND 5.6 ND ND 0 ND ND
199929 Sulzer Non-sim
Calcitek
5 von Arx and PS Deh PE 15 20 Max/Mand GBR H ABG Ti mesh V 6.2 V 0.4 93.5 Straumann Sim 8.6 6.6 ND 0 5 95 ND
Kurt 199915
6 Lorenzoni RS Deh Single PE, 82 145 Max/Mand GBR H Membrane Non-res V 2/10 ND ND Frialit Sim 6 6 18 0 ND 100 ND
et al. 199917 multiple
PE, Ed
7 Carpio RCT Deh/Fen PE 25 25 Max/Mand GBR H/V ABG Non-res/ H 4.36/3.6, H 2.7/1, 54 Implant Sim ND 6 ND 22 12.5 ND ND
et al. 200019 23 23 Res V 4.2/4.4 V 2/2 61 Innovations 16.7 17.4
8 Widmark and PS Deh/Fen 14 PE 21 12 Max/Mand GBR H ABG None 8.42 exposed 1.55 82 Nobel Sim ND 6 ND 0 ND 100 ND
Ivanoff 200023 single, threads exposed Biocare
3 PE, threads
4 ED
9 Nemcovsky PS Deh PE 21 28 Max/Mand GBR H Xenograft Res Defect size Defect size 97 Steri-Oss/ Sim 6–8 7 ND 12 None 100 ND
et al. 200028 H 4.3/4.07, H 0.7/0.66, Calcitek
V 6.7/6.36 V 0.6/0.79
10 Hammerle PS Deh PE 10 10 Max/Mand GBR H Xenograft Res H 0.5, V 3.6 H 0, V 2.5 86 Straumann Sim 6–7 6.5 ND 0 20 100 100
and
Lang 200121
11 Blanco PS Deh/Fen PE 19 26 Max/Mand GBR H ABG/allograft/ Non-res V 3/12 V 0/2 60 Brånemark/ Non-sim ND 2–3 60 1 ND 96.1 96.1
et al. 200520 none Straumann
12 De Boever PS Deh PE (single) 13 16 Max/Mand GBR H Xenograft Non-res V 3/9 V 0/2 97 Straumann Sim 4 4 42 ND 6 94 ND
and
De Boever
200522
13 Park RCT Deh PE (single) 22 26 Max/Mand GBR H Allograft Res V 6.58, V 1.42, 83 Zimmer Sim 6 6 12 ND ND ND ND
et al. 200824 H 3.48 H 1.61
14 Jung RCT Deh PE 37 ND Max/Mand GBR V/H Xenograft Res V 5.95, ND 94.9 Straumann Sim 6 6 12 ND ND ND ND
et al. 200927 V 4.5 96.4
15 Dahlin PS Alv ridge PE 20 40 ND GBR V/H Xenograft Non-res/ V 3.51 V 2.38 67 Brånemark Sim 7 7 53–72 ND 5 97.5 ND
et al. 201025 defects Res
ND, no data; V, vertical; H, horizontal; Preop., preoperative; Postop., postoperative.
*
Study type: RCT, randomized controlled clinical trial; CCT, controlled clinical trial; PS, prospective study; RS, retrospective study.
y
Defect type: Deh, dehiscence type defect; Fen, fenestration type defect; Alv ridge defects, alveolar ridge defects.
z
Type of edentulism: PMx, partially edentulous maxilla; PMd, partially edentulous mandible; EMx, edentulous maxilla; EMd, edentulous mandible; PE, partially edentulous; Ed, edentulous.
§
Site: Max, maxilla; Mand, mandible.
ô
Technique: GBR, guided bone regeneration.
**
Grafting material: ABG, autogenous bone graft.
yy
Membrane: Res, resorbable; Non-res, non-resorbable; Ti mesh, titanium mesh.
zz
Implant placement: Sim, simultaneous; Non-sim, non-simultaneous.
rate (%) rate (%)

Early Complication Survival Success
93.3
90.9
96.1
application of a collagen sponge as graft-
ND
ND
ND
ing material.
The average preoperative dimension of
100
100
100
ND
ND
a ridge width in the included studies was
2.9 mm. The average width of a post-
Trans. par.
operative ridge increased to 6.2 mm,
rate (%)
13.3
resulting in a mean linear bone gain of
0
0
3.31 mm.
When discussing the complication rate,
non-sim) protocol (months) (months) failure
ND
ND
0
0
three studies reported no complications
during the healing period.30–32 Chiapasco
Healing Follow-up
18–36
period
22.4
ND
8.5
et al. reported membrane exposure in

12
12 13.3%.33 Meijndert et al. reported fistulae

in two patients and transitory paresthesia
9–10
time
6–8
12
in one patient (13.3% and 6.6%, respec-

3
tively, of the sample),31 while Geurs

Loading
9–40
et al.34 reported fistulae in 6% of the cases,

ND
6
all successfully resolved. The mean com-

yy
placement
plication rate was 11.9%.

Implant
Non-sim
Brånemark, Non-sim
Non-sim
Non-sim
Non-sim
Non-sim
(sim/
The average healing time before the

implant placement was 7.7 months. The
Straumann
Straumann
Straumann
Straumann
mean implant survival rate for implants

Implant
type
non-simultaneously placed with the GBR

ND
procedure for horizontal augmentation

of 2–5
Linear
was 100%. The implant survival rate

.dimension bone
gain
Gain
H width of ND
2.5
2.7
3.7
was not reported in two studies.30,31

4
5.2 crestal,
7.5 apical
Postop
crest 6.9
the crest
(mm)
H width
Gain of
of the
H 5.5
Bone blocks for horizontal augmentation

2–5
7.7
7.5
of the crest
2.3 crestal,
dimension
An initial electronic search resulted in 239

4.3 apical
Preop.
crest 3.2
(mm)
H width
H width
1–3 top
titles when using the selected key words in

of the
of the
crest
3.17
2.73
H3
terms of bone block grafts used for bone

Membrane**
augmentation. After the final selection

(ePTFE)
1. None
Non-res
(PGA)
based on abstract analysis, eight full-text

2. Res
3. Res
Res
Res
Res
Res
Membrane: Res, resorbable; Non-res, non-resorbable; ePTFE, expanded polytetrafluoroethylene; PGA, polyglycolic acid.
articles met all the inclusion criteria and

were included in this systematic review
Table 3. GBR with non-simultaneous implant placement for horizontal augmentation.
+ membrane
ND, no data; V, vertical; H, horizontal; Preop., preoperative; Postop., postoperative; Trans. par., transitional paresthesia.
materialô
membrane
Grafting
Xenograft
3. DBBM
2. ABG +
(Table 4). Out of the eight studies

Allograft
Collagen
1. ABG
sponge
(chin)
included, two were RCT, one was a

ABG
ABG
Study type: RCT, randomized controlled clinical trial; CCT, controlled clinical trial; PS, prospective study.
CCT, two were PS, and three were RS.

Augmentation
RCT/CCT, control group also presented in the table, but not included in the results and evaluation.
Regarding the inclusion criteria for each

(horizontal/
vertical)
study, some authors33–37 described initial

H
Grafting material: ABG, autogenous bone graft; DBBM, deproteinized bovine bone mineral.
horizontal defects numerically, usually as

a ridge width less than 4 mm. In the
Technique§
remaining studies, the precise numerical

blocks
Bone
GBR
GBR
GBR
GBR
GBR
initial defect description was missing, and

the initial inclusion criterion was usually a
Mand
Mand
Mand
Mand
Max/
Max/
Max/
Max/
Sitez
Max
Max
‘horizontal defect’ or ‘atrophic ridge’.

Nevertheless, all included studies reported
type* typey edentulismy patients implants
No. of No. of
ND
on precise preoperative ridge dimensions.

27
30
44
98
15
In summary, 171 patients received 353

implants within a staged approach. The
16
15
15
15
51
12
Implant placement: Non-sim, non-simultaneous.
bone augmentation procedure used to cor-

Type of edentulism: PE, partially edentulous.
rect the horizontally insufficient ridge was

Type of
(anterior
the use of bone blocks alone (four studies)

max)

PE
PE
PE
PE
PE
or along with additional GBR procedures

(four studies). For the additional GBR
Study Defect
procedure, five studies reported on the

application of autogenous bone chips,
CCT
RCT
PS
PS
PS
while two studies used an allograft, and

in one study a xenograft was applied. Four
et al. 19993 zz
et al., 199832
et al. 200531
et al. 200834
et al. 200830
studies reported on the use of resorbable

5 Hammerle
2 Chiapasco
3 Meijndert
membranes,33,37–39 one on the application

1 Parodi
4 Geurs
Study
of a non-resorbable membrane,35 and in

**
yy
zz
ô
*
§
y
z
two studies no membrane was used to

612
Table 4. Bone block grafts for horizontal ridge augmentation.
Linear bone Implant
Defect Augmentation gain at placement Healing Follow-up
Study assessment Defect Type of No. of No. of (horizontal/ Donor Grafting Preop. Postop implant Implant Implant (sim/non- Loading time period Early Complication Survival Success

Study type* at inclusion type edentulismy patients implants Sitez Technique§ vertical) site materialô Membrane** dimension .dimension insertion type surface sim)yy protocol (months) (months) failure rate (%) rate (%) rate (%)
1 Buser PS H less H PE 40 66 Max/ Bone H Mand ABG Non-res 3.5 7 3.5 Straumann Rough Non-sim 3.5 8.9 ND ND 2.5 ND ND
et al., than 5 Mand blocks + (symphysis,
199635 GBR ramus)
2 von Arx RS H 2.5–5, H PE 18 27 Max/ Bone blocks H/V Mand ABG Ti mesh According According According Straumann Rough Non-sim 7.2 5.2 12 0 0 100 ND
et al. in 5 cases Mand with Ti mesh (symphysis, to Misch to Misch to class
199836 less the 2.5 ramus) Class: B15, Class:
C7, CW 5 A25, B2
3 Chiapasco CCT H <4 H PE 15 28 Max/ GBR H ABG Non-res 3.17 ND 2.7 Brånemark/ Rough- Non-sim 6 6–8 18–36 0 13.3 100 93.3
et al. Mand (ePTFE) Straumann machined
199933
H <4 PE 15 44 Max/ Bone H Ilium, ABG Res 2.5 7.5 4 Brånemark/ Rough- Non-sim 6 6–8 22.4 0 Trans. 100 90.9
Mand blocks calvarium, Straumann machined par.
chin
4 Cordaro RCT Onlay H/V PE 15 40 Max/ Onlay H/V Ramus, ABG, No ND ND 5 Straumann Rough Non-sim 6 6 12 0 0 100 ND
et al. blocks Mand chin bone
200241 needed chips
5 Wallace PS Deficient H ND ND ND Max Blocks + H No Allograft Res 3.89 H 8.39 4.56 ND ND Non-sim 4 5 ND ND 0 ND ND
and Gellin maxillary PRP and
201039 ridges PDGF
6 Acocella RS Severe H ND 15 30 Max ABG bone H Mandibula ABG No 3.53 7.73 3.83 ND ND Non-sim ND 3–9 12 ND 6.6 ND ND
et al. bone blocks
201040 defects
7 Cordaro RCT H defects H PE 22 27 Mand Onlay H Mand, None Res 2.55 6.73 3.93 Straumann Rough Non-sim 3 4 24 ND 3.7 ND ND
et al. blocks ramus and Biomet
201137 3i
28 Onlay Mand, Xenograft 3.19 7.74 3.67 Non-sim 3 4 24 10.7
blocks + ramus
GBR
8 Nissan RS H and V 3 mm PE 31 63 Max Blocks + V No Allograft Res ND ND 4.3 MIS, Rough Sim 30% 3 6 34 5 20 95.2 ND
et al. defect V/H GBR Biomet 3i
201138 with a
staged
approach
ND, no data; V, vertical; H, horizontal; Preop., preoperative; Postop., postoperative; Trans. par., transitional paresthesia.
*
Study type: RCT, randomized controlled clinical trial; CCT, controlled clinical trial; PS, prospective study; RS, retrospective study.
y
z
§
Technique: GBR, guided bone regeneration; Ti mesh, titanium mesh; PRP, platelet-rich plasma; PDGF, platelet-derived growth factor; ABG, autogenous bone graft.
ô
**
Membrane: Res, resorbable; Non-res, non-resorbable; Ti mesh, titanium mesh; ePTFE, expanded polytetrafluoroethylene.
yy
cover the bone blocks40,41. In one study36 the present systematic review (Table 5). of importance needed to assess if there is a
a titanium mesh was used as a membrane. Out of the six studies included, two were clinical situation that indicates the pre-
In only one study38 were implants placed PS and four were RS. ferred use of a single surgical technique.
simultaneously with the bone augmenta- In summary, 943 implants were placed Therefore, it was decided to include only
tion procedures (in 30% of patients). In in 307 patients, with a simultaneous studies providing the above-mentioned
five of the above-mentioned studies, bone approach. Only in one study42 were both data.
blocks were harvested from the mandible simultaneous and delayed (staged) Great care was taken to include only
(ramus or chin). One study described the approaches performed. The bone augmen- those studies reporting the treatment of
use of bone blocks harvested from iliac tation procedure used for the correction of ridges where a circumferential defect (of
crest, calvarium, or chin. Two studies the horizontally insufficient ridge was a various heights) could be expected when
reported on the use of allogeneic blocks. sagittal osteotomy with a ridge expansion placing implants in a prosthetically ideal
All the patients treated within selected technique. The purpose of the aforemen- position.
studies for horizontal bone augmentation tioned procedure is to widen the narrow
were partially edentulous. crest, in order to place standard-diameter
GBR and simultaneous implant placement
The initial mean ridge width (grouping dental implants that also maintain the
for vertical augmentation
all studies) was 3.2 mm, with a range of osteotomized segment. In four studies,
2.5–3.89 mm. The healing time after the additional grafting material was used to An electronic search revealed 938 titles
bone augmentation procedure ranged from fill in the remaining space.43–46 when using the selected key words in
3 to 9 months, with an average healing The healing time after the bone aug- terms of GBR techniques for bone aug-
time of 5.6 months. The mean linear hor- mentation procedure ranged from 2 to 6 mentation. A refined Medline search nar-
izontal bone gain at implant placement months, with an average healing time of rowed the selection to four full-text
ranged from 2.7 mm to 5.0 mm, with an 4.5 months. Baseline ridge width was a articles and these were extracted and
average bone gain of 4.3 mm. The mean mean of 3.37 mm (with a range from mean included in this systematic review (Table
width of the reconstructed ridge at implant 2.4 mm to 4.29 mm within the different 6). Out of the four studies included, one
placement was 7.51 mm. studies). The horizontal bone dimensions was an RCT, two were PS, and one was an
Regarding healing and donor site com- increased from a mean 3.37 mm to a mean RS.
plications, uneventful healing was of 6.33 mm. Regarding the type of defect, studies
reported in three studies36,39,41 with no In a large sample study by Sethi and were included if they described an aug-
signs of dehiscence or infection. In the Kaus, 2.7% (12 implants) were lost,42 in mentation of the circumferential vertical
larger sample study,35 flap dehiscence was eight cases because of infection and in defect.
recorded in 2.5%, only in one patient, and four cases because of non-integration. Within the included studies, 62 patients
it was solved. In a study by Acocella One study reported a mandibular buccal received 122 implants simultaneously
et al.,40 only one graft exposure was found plate fracture in one patient (2.22% of the with GBR augmentation procedures. Both
(6.66%). In a study by Cordaro et al.,37 sample).47 In another study, two implants resorbable48 and non-resorbable mem-
when using only autogenous bone blocks, (0.9%) could not be placed due to fracture, branes49,50 were used. In one study, both
dehiscence occurred in one case (3.7%), and 3.5% of implants showed lack of resorbable and non-resorbable membranes
and when an additional membrane was integration.44 In a study by Sohn et al., were used.51
added, a flap dehiscence was noted in three in the group of immediately placed Various bone grafting materials were
cases (10.7%). Regarding the donor site, implants, fracture occurred in five of 23 used during the GBR procedures. In two
Chiapasco et al. reported uneventful heal- cases (21.7%), and buccal bone resorption of the included studies, the mixture of
ing of the donor sites calvarium and man- was resolved with an additional bone graft autogenous bone and xenograft was
dibular ramus, whereas a transitional in one case (4.34%).46 In the delayed reported, while one study described the
hypoesthesia was noted in 53.3% of cases group, healing was uneventful. In the use of autogenous bone graft, and one
in which the chin was a donor site.33 study of Gonzales-Garcia et al., neither study compared the results when only a
Cordaro et al.41 reported transitional dehiscence of the suture nor wound infec- blood clot, allograft, or autograft was
hypoesthesia when the chin was used as tion was observed in any of the patients.45 applied.
a donor site that was resolved after 3–4 No total fracture of the buccal plate was The average preoperative vertical
months. The mean complication rate was observed either. In one study, no compli- dimension of the defect was reported only
6.3%. cations were reported, while an additional in two studies and the mean was 4.1 mm.
The mean implant survival rate was bone graft was performed in 97.3%.43 The The average linear bone gain, when asses-
98.4%. Only one study reported a success mean complication rate was 6.8%. sing all the included studies, was 3.04 mm.
rate of 90.9%.33 The mean implant survival rate was The healing time before loading ranged
97.4%. from 4 to 12 months.
The mean complication rate, usually
Ridge splitting or expansion for horizontal
related to membrane exposure, was
augmentation Partially edentulous patients: vertical
13.1%. The mean implant survival rate
defects
One hundred and eleven titles were was 98.9%.
extracted within the initial electronic Vertical bone augmentation is described
search when using the selected key words with the application of various techniques.
GBR and non-simultaneous implant
in terms of ridge expansion/splitting tech- These techniques are GBR, the use of bone
placement for vertical augmentation
niques for bone augmentation. After the blocks, and distraction osteogenesis.
final selection based on abstract and full- Dimensions of the residual ridge at An electronic search resulted in 938 titles
text analysis, six full-text articles met all baseline, bone augmentation achieved, when using the selected key words in
the inclusion criteria and were included in and eventual implant outcome are the data terms of GBR techniques for bone aug-
surface non-sim)yy protocol (months) (months) failure rate (%) rate (%) rate (%)
period Early Complication Survival Success
mentation. After final selection based on
95.4
96.5
ND
ND
ND
ND
abstract and full-text analysis, applying
the inclusion criteria, only two full-text
97.3
96.5
98.8
100
100
97 articles were extracted and included in this
systematic review (Table 7).
Fracture in
Sim 21%
These two studies included 23 patients
2.22 who received 37 implants placed in a
ND
ND
3.5
0
second-stage surgery. One study was an
(Max)
2.73
RCT52 and the other was a PS, which also

2.7
0.9
1.2
0
Healing Follow-up
reported GBR with simultaneous implant

placement, since the authors had used both
54
20
12
35
28
16
approaches.49
Implant Implant (sim/ Loading time
The mean initial dimension of the pre-

3–4
2–6
4–5
operative defect was 5.6 mm. The mean

6
6
vertical bone gain after the GBR proce-
3–4
3–5
dure was applied was 5.2 mm (at the time

6
6
placement
of implant placement, 9–12 months after

Implant
Non-sim
augmentation).52 In another study,49 the

Rough Sim,
Sim
Straumann Rough Sim
Osseotite, Rough Sim
Sim
Sim
initial vertical defect was 3.85 mm and

3.45 mm of bone gain could be achieved.
ND
ND
ND
The mean linear bone gain for the eval-

uated studies was 4.3 mm. The healing
type
Leader
Screw
type
ND
ND
ND
time after the bone augmentation proce-

measured
dure ranged from 6 to 12 months.

Defect
on CT
fill
scans
The survival rate of implants placed

3.35
ND
ND
ND
ND
ND
within these studies was 100%. In one

dimension
on CT scans measured
Postop.
study, membrane exposure was noted in

on CT
scans
4.29 measured 7.63
8%.52 The mean complication rate was

ND
5.2
7.1
5.7
6
6.95%.
dimension
Preop.
3–4 mm
Bone blocks for vertical ridge

2.4
4.2
3.2
2.5
materialô Membrane**
augmentation
Non-res
None
None
Res
ND
Four hundred and thirty-nine titles were

No
extracted during an initial electronic

Autograft +
PRP + PRF
Grafting
Autograft,
search when using the selected key words

xenograft
allograft
in terms of the use of bone blocks for

None
None
None
PRP
vertical ridge augmentation. A refined

ND, no data; V, vertical; H, horizontal; Preop., preoperative; Postop., postoperative; CT, computed tomography.
Augmentation
(horizontal/
Medline search narrowed the selection

vertical)
to six full-text articles that met all the

Type of edentulism: PMd, partially edentulous mandible; PE, partially edentulous; Ed, edentulous.
H
inclusion criteria and contained adequate

Table 5. Ridge spitting/expansion for horizontal ridge augmentation.
data for direct or indirect width gain

and delayed
Mand (ultrasonic)
typey edentulismz patients implants Site§ Technique
Mand Immediate
Max/ Split crest
Max/ Split crest
Max/ Split crest

expansion
expansion
split crest
Max Modified
dimensions (Table 8). Out of the six stu-

Max Ridge
dies included, three were RCT, one was a

Mand
Mand
PS, and two were RS.

Regarding the type of defect, in two
Type of No. of No. of
Grafting material: PRP, platelet-rich plasma; PRF, platelet-rich fibrin.
studies there was no uniform defect

449
110
230
63
21
33
37
description. Three studies38,53,57 described

defects as horizontal and vertical and
45
57
32
15
150
Study type: PS, prospective study; RS, retrospective study.
included sinus floor elevation when

Membrane: Res, resorbable; Non-res, non-resorbable.
required, while in one study,54 defects

PE and
Defect type: H, horizontal; HD, horizontal defect.

PE, Ed
PE, Ed
PE, Ed
single
were described as those where at least

tooth
PMd
ND
4 mm of vertical augmentation was

(3–5 mm)
Defect
needed.
HD
HD
HD

H
In total, 186 patients received 270

defined ridges;
implants. In all six studies, a non-simul-

alveolar width
Ridge greater
full thickness
transmucosal
assessment
than 1.5 mm
Horizontally
Assessed by
probing, no
ridge width
Defect
Between 2
taneous implant placement was realized,

more than
and 4 mm
3–4 mm
but one of the studies involved53 implants

2 mm
flap
ND
that were placed at the time of augmenta-

Study
type*
tion or after a healing period. The bone

RS
RS
RS
6 Anitua et al. RS
PS
PS
augmentation procedure used for the cor-

et al., 200647
Kaus 200042
et al. 201145
4 Sohn et al.
2 Chiapasco
Szmukler-
5 Gonzalez-
1 Sethi and
rection of both vertically and horizontally

3 Blus and
Moncler
200644
201046
201343
Garcia
Study
insufficient ridges was bone blocks. In

**
yy
ô
*
§
y
z
four studies, bone blocks were harvested

rate (%) rate (%)

97.5
from the mandibular region (ramus or
ND
82
91
86
chin). One study described the use of
autogenous bone, both from the ramus
93.8
100
100
100
and iliac crest. In one study, bone defects
were reconstructed with the use of allo-
geneic bone blocks.
rate (%)
6.25
1.5
8.3
19
26
18
The healing time after the bone augmen-
9
tation procedure ranged from 0 to 6 months,
with a mean healing time of 4.1 months.
5.88
protocol (months) (months) failure
3.1
0
0
0
The average vertical bone gain at implant
placement was recorded as 4.75 mm.
Healing Follow-up
12–60
period
Regarding complications, Sethi and

ND
12
6
Kaus reported minor complications in

donor sites that were resolved, with no
7–12
time
4–6
ND
4.6
complications and uneventful healing at

the recipient site.55 Bahat and Fontanessi
Loading
7–12
reported graft loss in five patients (8%)

4–6
ND
that was resolved by regrafting.53 In total,

the implant failure rate was 7% in this
yy
placement
Implant
non-sim)
(sim/
Sim
Sim
Sim
Sim
study, but no loss was observed in patients

treated with mandibular grafts, only in
Brånemark
Brånemark
Brånemark
Brånemark
patients treated with sinus and veneer

Implant
Osseotite
Friadent
type
graft, or sinus and J graft. Another study

reported exposure in one patient (12.5%),
and mean graft resorption at the time of
fill (%)
dimension dimension Defect
4.825
ND
2.4
2.1
4.2
2.2
2.5
implant placement (after 4–5 months) of

0.6 mm.56 Roccuzzo et al. reported expo-
Mean 0.5
Postop.
(mm)
sure of titanium mesh in four of 12 cases

Minus
0.125
ND
ND
ND
(33.3%). In one case a titanium membrane

was removed, in one case it healed spon-
Mean 4.7
Mean 3.5
Preop.
(mm)
taneously, and in two cases re-grafting was

ND
ND
ND
needed to solve the complication.54 In a

Membrane**
control group where no titanium mesh was

used, at second-stage surgery, graft disco-
Non-res
Non-res
Non-res
louration was observed in three of 12 cases

Res
Res
(25%) and was resolved by the removal of a

Xenograft +
materialô
Grafting
superficial part of the graft. In another

xenograft
Allograft
ABG +
study, out of 49 implants in total, six were

ABG
ABG
ABG
ABG
Clot
Table 6. GBR with simultaneous implant placement for vertical augmentation.
placed simultaneously with the grafting

Study type: RCT, randomized controlled clinical trial; PS, prospective study; RS, retrospective study.
procedure.57 Graft exposure was noted in

Augmentation
(horizontal/
vertical)
only one of the 16 patients, but it healed

V
V
V
spontaneously. No persistent paresthesia

was observed. In the study of Nissan
Technique§
et al., a total of 29 bone block grafts were

GBR
GBR
GBR
GBR
GBR
placed, out of which 62% were used to

correct a horizontal defect and 38% to
Mand
Mand
Mand
Mand
Max/
Sitez
correct both vertical and horizontal defects.

Six out of 29 blocks failed (20%). The
edentulismy patients implants
implant failure rate was 5% in this study.38

No. of
17
24
26
15
43
55
32
It is clear that vertical augmentation

Membrane: Res, resorbable; Non-res, non-resorbable.
with bone blocks is associated with a high

No. of
11
11
11
11
complication rate. The average implant

6

survival rate was 96.32%.

Type of
Implant placement: Sim, simultaneous.

PE
PE
PE
PE
Distraction osteogenesis (DO) for vertical

augmentation
Applegate—
Defect type
Kennedy
Class II
Class I/
An electronic search revealed 345 titles

when using the selected key words in
V
terms of distraction osteogenesis for bone

Study
type*
RCT
RS
PS
4 Llambes PS
augmentation. After final selection based

on abstract and full-text analysis, applying
1 Simion
2 Simion
200150
200749
200751
200748
Study
et al.,
3 Merli
et al.
et al.
et al.
the basic inclusion criteria, seven full-text

**
yy
ô
*
§
y
z
articles were extracted and included in this

rate (%) rate (%)

systematic review (Table 9). Out of the final selection based on abstract and full-
ND
ND
seven studies included, two were RCT, text analysis and on applying the basic
100 four were RS, and one was a PS. inclusion criteria, nine full-text articles
100
In total, 125 patients received 351 were extracted and included in this sys-
implants after the distraction osteogenesis tematic review (Table 10). Out of the nine
rate (%)
procedure. All implants were placed in a studies included, two were CCT, one was a
0
second-stage surgery, after a consolidation PS, and six were RS.

period that ranged from 1 to 3 months. The types of defects observed were
(sim/non-sim)yy protocol (months) (months) failure
The average vertical dimension achieved described as severely resorbed or atrophic

0
after distraction osteogenesis was 7.08 mm maxilla or mandible, but the precise
Healing Follow-up
period
(range from 4.58 mm to 10.9 mm). Regard- numerical description or classification of

12–72
ing notable complications, one study the defect of a ‘severely resorbed’ eden-
ND
reported 2.9% of persistent hypoesthesia.58 tulous jaw was not provided. The criterion
time
In one study, secondary bone grafting was for the assessment of augmentation suc-
6–9.5
12
needed in 64.2%, and a 10% implant failure cess in edentulous jaws was the possibility
Loading
rate was observed due to poor bone qual- of placing implants of an average diameter
ND
ity.59 Lingual inclination as a complication of 4.0 mm. Five of the included studies
1
was reported in two studies, at a rate of reported on the augmentation procedure

placement
18%60 and 22.2%.56 Two studies report the

Implant
for the edentulous maxilla, two studies on

Nobel Biocare Non-sim
Zimmer/Nobel Non-sim
absence of major complications.61,62 In one the edentulous mandible, and two studies
study, there was no evidence of complica- were evaluations of augmentation proce-
tions.63 The mean complication rate was dures in both the maxilla and mandible.
Implant type
22.4%. In total, 247 patients received 669

Biocare
The mean implant survival rate was implants. In three studies, a non-simulta-
98.22%, with a success rate of 93.3%. neous implant placement was realized,
fill (%)
dimension Defect
while in six studies, implants were placed

3.45
5.24
simultaneously with bone augmentation

Edentulous patients
procedures.
Postop.
(mm)
Mean
In edentulous jaws, alveolar bone augmen- The initial situations were described as
(on radiographs) 0.32
0.4
tation is usually achieved by block bone one of the following: a severely resorbed
grafting, osteotomies, distraction osteogen- maxilla with flat palatal vault, atrophic
dimension
Preop.
(mm)
Mean 5.56
esis, and GBR and ridge splitting/expan- maxilla, extensive bone maxillary resorp-
sion. For the edentulous patients, data tion, resorbed anterior mandible, severe
3.85
reporting on ridge and defect description, mandibular atrophy, and Classes V and VI
Membrane**
as well as the amount of augmentation, or deficient anterior mandible. No clear

Xenograft + Non-res
Non-res
were considered as sufficiently relevant numerical descriptions of pre- and post-

Table 7. GBR with non-simultaneous implant placement for vertical augmentation.
to be included in the present review. operative defects were provided.

Regarding GBR procedures, ridge split- One study reported on the use of addi-
materialô
Grafting
Xenograft
ting/expansion, and distraction osteogen- tional GBR.69 In one of the included stu-
ABG
esis, after final selection based on abstract dies, bone blocks were harvested only
and full-text analysis and on applying the from the mandibular region.70 Four stu-
Augmentation
(horizontal/
vertical)
basic inclusion criteria, some full-text arti- dies reported on the use of bone blocks
V
cles (four for GBR, five for ridge splitting/ harvested from iliac crest, two studies
expansion, and four for distraction osteo- from calvarium, and two studies reported
type* Defect type edentulismy patients implants Sitez Technique§
genesis) were retrieved, but could not be the use of bone blocks from different
Study type: RCT, randomized controlled clinical trial; PS, prospective study.
GBR
GBR
included in the present systematic review, donor sites (ilium, calvarium, chin). All
since the data on edentulous and partially the patients treated within selected studies
Mand
Mand
edentulous jaws could not be sepa- for bone augmentation were fully edentu-
Max/
rated.17,18,23,44,45,47,58,60,64–68 lous.
No. of No. of
Studies describing and reporting on pro- The mean survival rate of implants was
12
25
cedures such as bone block grafts for 87.75%.

Implant placement: Non-sim, non-simultaneous.
augmentation of edentulous ridges, or In regard to complications, they were

3
20
Le Fort I osteotomy, are present in the associated with the donor site, or with
literature. These procedures have been infection and/or exposure with subsequent
Membrane: Non-res, non-resorbable.
Type of

PE
PE
included in the present review, when ana- partial graft loss at the recipient site.
lyzing bone augmentation procedures in Regarding the donor site, the prevalence
edentulous patients. of complications was reported as: 8%,71
Applegate—
11.1%,72 10%,73 and 10%.70

Kennedy
Class II
Class I/
Regarding recipient site complications,

Horizontal and vertical ridge
V
one paper reported on graft failures for the

Study
augmentation in edentulous patients with

2 Todisco RCT
following techniques: sinus 8%, onlay

1 Simion PS
block grafts
15%, veneer 7%, saddle and inlay—no
200749
201052
Study
et al.,
An electronic search resulted in 60 titles failure.74 Another study reported on the

**
yy
ô
*
§
y
z
when using the selected key words. After following: out of the 10 extensive bone
rate (%) rate (%)

period Early tion rate Survival Success
89.5
maxillary reconstructions, two required
100
ND
ND
ND
ND
93
additional bone augmentation at the time
98.31
of dental implant placement, two had a
95.2
100
100
100
ND
93
minimal graft exposure, and one opera-
Complica-
tion partially failed and required partial

(%)
12.5
6.25
graft removal.70 The complications in
ND
33
33
25
0
0
another study were dehiscence in 30%,
surface non-sim) protocol (months) (months) failure
infection in 10%, and partial transplant
ND
1.7
5
loss in 20%, all resolved.75 In one study it
Healing Follow-up
12–96
32–48
was seen that the three non-integrated
ND
22
38
41
34
implants (8.1%) and those with bone loss
were all situated in bone grafts in the
Loading time
0–6
4–5
4.5
4.7
4.6
anterior region.69 In another study it
3
6
was noted that in all patients treated,
3–5
ND
ND
the maximum resorption of the graft

6
3
was still less than the initial gain in
yy
placement
Rough Sim 30%

mplant
Non-sim
Non-sim
Straumann Rough Non-sim
height.72 Some authors have reported

(sim/
Sim,
the complication frequency in total as

10% and 32%, respectively.76,77
Implant
Straumann Rough
ND
ND
The mean complication rate was 21.9%.

Biomet 3i
Implant
type
MIS,
Maxillary ridge augmentation and grafting

ND
ND
in edentulous patients with Le Fort I

V/3.2 H
Postop. Defect
H 5.1,
V 3.9
width
7.9H 5.6H,
materialô Membrane** dimension dimension fill
4.3V
osteotomy
48%
gain
5.1
5.3
4.8
3.6
5.5
An electronic search revealed 76 titles

ND
ND
ND
ND
ND
ND
when using the selected key words for

Le Fort I osteotomy techniques for bone
for different
dimensions
augmentation of edentulous patients. A

treatment
Preop.
Different
refined Medline search narrowed the

2.9H
ND
ND
ND
ND
ND
selection to six full-text articles, which

met all the inclusion criteria and
Ti mesh
were included in this systematic review

None
Res
Res
ND
No
Ramus AB blocks No
(Table 11).
and chips
(horizontal/ Donor Grafting
xenograft
All six studies included were RS. Initial

Allograft
allograft
Ramus, ABG +
ramus/
blocks
blocks
Ilium/
Ramus/ ABG
Ramus/ ABG
ABG
defects were described as Class VI accord-

ing to Cawood and Howell78 in all the
studies, except the study by Li et al.81, in
site
chin
chin
chin
ND
ND
Technique: ABG, autogenous bone graft; DO, distraction osteogenesis; GBR, guided bone regeneration.
which initial defects were severely

Augmentation
atrophic maxillae with skeletal Class III.

vertical)
H/V
H/V
H/V
Additionally, in the study of Kahnberg

V
V
V
et al.,79 Classes III, IV, and V defects

Table 8. Bone grafts for vertical and horizontal ridge augmentation.
Blocks +
were also treated with the aforementioned

type edentulism patients implants Site Technique
blocks
blocks
blocks
blocks
blocks
GBR
Bone
ABG
ABG
ABG
ABG
procedure.
DO
In total, 131 patients received 906

Mand
Mand
Mand
Mand
Mand
Mand
Max/
Max/
Max/
z
Max
implants after the osteotomy. The ilium

Grafting material: ABG, autogenous bone graft; AB, autogenous bone.
was always used as the donor site. In all

Study Defect Type of No. of No. of
118
329
but two of the studies,80,81 implant place-

ND
19
21
49
63
ment occurred in a second-stage surgery

(non-simultaneous). One study reported
60
62
12
12
16
31
8
Membrane: Res, resorbable; Ti mesh, titanium mesh.
on the use of a resorbable membrane.82

y
In the study of Chiapasco et al.,83 addi-

posterior
posterior
tional buccal onlay grafts were placed

PE,
PE,
PE
PE
PE
PE
PE
(with intraorally harvested autogenous

3 mm
V/H H
bone blocks and a non-resorbable mem-

H/V
5 Cordaro Sinus defect + RCT H/V
V/H
V
RCT V
V
4 Roccuzzo At least 4 mm RCT V
brane).
*
type
The average implant survival rate was

RS
RS
PS
87.9%.
H and V ridge
augmentation
with a staged
assessment
Fontanessi ridge defect
sinus defect
with or w/o
Defect
With regard to complications, implant

approach
2 Bahat and H and V
V defect
vertical
needed
failure was observed in 21%,80 18%,81

H and
defect
1 Sethi and ND
3 Chiapasco ND
17%,79 5.4%,84 and 5.3%.83 Regarding

other complications, the presence of sinus
20075 zz
200155
200153
200754
201057
201138
6 Nissan
Study
et al.,
infections was noted in 24%,79 and sinus

Kaus
et al.
et al.
et al.
**
yy
zz
ô
*
§
y
z
cysts in 26%.84 In one study, the procedure

618
Table 9. Distraction osteogenesis—partially edentulous patients.
Implant
Augmentation Consoli- placement Healing Follow-up
Defect Study Defect Type of No. of No. of (horizontal/ Grafting Preop. Postop. Defect Implant Implant Latency dation (sim/ Loading time period Early Complication Survival DO Success
assessment* typey type edentulismz patients implants Site§ Techniqueô material** Membrane yy dimension dimension fill/gain (days) Distraction (months) non-sim)zz protocol

Study vertical) type surface (months) (months) failure rate (%) rate success rate
1 Gaggl 7 severe PS V PE, Ed 34 62 Max/ DO V ND ND 4.86V ND 5.02 V ND Rough/ ND ND ND Sim 6 ND 9 2 14 ankylosis, 96 ND ND

et al., atrophy Mand machined persisting
200058 EMd, hypoesthesia,
3 severe pathologic
atrophy probing
EMx, depth
16 ridge
defect
after trauma,
9 alveolar
ridge
defect single
tooth loss; all
with a residual
ridge of 7 mm
2 Rachmiel Trauma, RS V PE 14 23 Max/ DO V ND ND ND ND 8–13 Screw- Rough/ 10–16 0.8/day 1 Non-sim ND 6 13 1 ND 100 97 ND
et al. post- Mand Vent machined
200163 extraction,
anodontia:
anterior
mandible,
single tooth
gap
3 Jensen Anterior RS V Anterior 28 84 Max/ DO V ND ND ND ND 6.5V, Osseotite Rough 7 1 mm: 2 Non-sim 6 2 36 9.60 ND 96.7 ND
et al. maxillary max Mand 2H 3/week
200259 defects with
at least 4 mm
of vertical
bone loss
4 Chiapasco Vertical RCT V PE 6 25 Max/ GBR V ABG Non-res ND ND 4.58 Brånemark Machined None / / Sim, 5.3 5.3 36 0 30 100 / 61.5
et al. alveolar 5 Mand 5.08 Non-sim 5.4 7 75
200461 §§ ridge defects
V 10 34 Max/ DO V / / ND ND 6.9 Brånemark/ Machined/ 7 1 mm/day 2–3 Non-sim 3–5 6–7 31 0 20 100 97.2 94.1
Mand Straumann rough
5 Marchetti Anterior RS V PE 10 36 Max/ DO ND ND ND ND ND 10.9 Friadent/ Rough 7 1 mm/day 70 days Non-sim 3–6 2.5–6 24 2.78 Inclination 97 ND ND
et al. Max/ Mand Mand BioHorizons/ on 1,
200762 defect 3i additional
trauma, ABG block
tumour in 1
resection,
atrophy
Class VI
6 Chiapasco PE mandible RCT V PE 8 19 Mand ABG V AB No ND ND 5.1 Straumann Rough ND ND ND Non-sim 3–5 4–5 38 ND Paresthesia, 100 / 91.25
et al. associated blocks blocks partial
200756 §§ with vertical and graft loss
alveolar chips (50%)
ridge defects
V PE 9 21 DO V ND ND 5.3 Straumann Rough 7 0.5 mm/ 2–3 3 41 ND Lingual 100 ND 96.4
day inclination,
incomplete
distraction
(30%)
7 Robiony Class V RS V PE, Ed 12 47 Mand DO V ABG No ND ND 7.38 ND ND 15 0.5 mm/ 2 Non-sim 6 Immediately 60 ND ND 97.9 ND 91.5
et al. (ilium) + day after
200860 PRP consolidation
*
Defect assessment: EMx, edentulous maxilla; EMd, edentulous mandible; PE, partially edentulous.
y
z
Type of edentulism: PE, partially edentulous; Ed, edentulous.
§
ô
Technique: DO, distraction osteogenesis; GBR, guided bone regeneration; ABG, autogenous bone graft.
**
Grafting material: ABG, autogenous bone graft; AB, autogenous bone; PRP, platelet-rich plasma.
yy
Membrane: Non-res, non-resorbable.
zz
§§
Table 10. Bone grafts for vertical and horizontal ridge augmentation—edentulous patients.
Implant
Augmentation placement Healing Follow-up Complicat
Defect Study Defect Type of No. of No. of (horizontal/ Grafting Preop. Postop. Defect Implant Implant (sim/ Loading time period Early ion rate Survival Success
Study assessment type* type edentulismy z
patients implants Site Technique §
vertical) Donor site materialô Membrane** dimension dimension fill type yy
surface non-sim) protocol (months) (months) failure (%) rate (%) rate (%)
1 Adell Severely RS H/V EMx 23 124 Max Bone H/V Ilium ABG No ND ND ND Brånemark Machined Sim 9 9 12–120 8.1 20 73.8 ND
et al., resorbed blocks 9
199071 maxilla
with flat
palatal
vault
2 Jensen ND RS H/V Severely 26 107 Max Bone H/V Ilium/chin ABG No ND ND ND Brånemark Machined Sim 6 0–6 1–16 ND 10 90.2 ND
and resorbed blocks
Sindet- maxilla,
Pedersen 9 EMx
199177
3 Donovan ND RS H/V Ed 24 124 Max/ Bone H/V Calvarium ABG No ND ND ND Brånemark Machined Sim 6 6 6–46 7 32 91.4 ND
et al. Mand blocks
199476
4 Triplett Deficient RS H/V 70 sinus 99 65 Max/ Bone H/V Ilium/ ABG ND ND ND ND ND Machined Sim 6 6 12 10 25 ND 90.7
and Show alveolar grafts, Mand blocks calvarium/
199674 process 32 onlay, chin
14 veneer,
9 saddle,
4 inlay
5 McGrath Resorbed RS H/V EMd 18 36 Mand Bone H/V Ilium ABG ND ND ND 69 Brånemark HA-coated Sim 8 8 12–32 9 11 91.6 91.6
et al. anterior edentulous blocks
199672 mandible
6 Neyt et al. Atrophic RS
H/V Severe 17 123 Max Onlay H/V Ilium ABG None ND ND ND IMZ, Machined Sim 6 6 12 8.1 10 92 92.7
199769 maxilla edentulous maxilla BB + Brånemark
atrophy GBR
7 Lundgren Only inlay CCT H/V EMx 10 + 10 70 Max Bone H/V Ilium ABG No ND ND ND Brånemark Machined Non-sim 9 9 12–32 17 20 83 ND
et al. grafting blocks
199773 (nose and
sinus),
inlay–onlay
8 Schwarz- Extensive CCT H/V PMx 10 ND Max Bone H/V Mandibula ABG Res ND ND ND ND ND Non-sim ND ND ND ND 60 ND ND
Arad and bone, (extensive blocks
Indications for bone augmentation procedures

Levin maxillary grafting),
200570 resorption EMx
9 Smolka Severe PS V EMd 10 20 Mand ABG V Calvarium ABG ND 6.4 8.6 11.8 ND ND Non-sim 3 6 21.3 10 20 100 ND
et al. mandibular blocks
200675 atrophy,
Class V
and VI
*
Study type: CCT, controlled clinical trial; PS, prospective study; RS, retrospective study.
y
Type of edentulism: PMx, partially edentulous maxilla; EMx, edentulous maxilla; EMd, edentulous mandible; Ed, edentulous.
z
§
Technique: BB, bone blocks; GBR, guided bone regeneration; ABG, autogenous bone graft.
ô
**
Membrane: Res, resorbable.
yy
619
rate (%) rate (%)

period failure Complication Survival Success
82.9
95.8
was not sufficient to correct the unfavour-
ND
ND
ND
91
able intermaxillary relations in 10%, and
in six patients (30%) a Le Fort I osteotomy
94.6
94.5
ND
79
82
83
was combined with vestibular onlay both
in the mandible and in the maxilla in order
In 2 patients
all implants
Dehiscence
Sinus cysts
lost, grafts
remained to improve the facial contour and to cor-
exposure
rate
in 25%
rect the alveolar bone atrophy.82
Graft
12%
10%
ND
5.3 ND
It is clear that there is a high incidence
Healing Follow-up Early
of complications with this invasive

(%)
4
21
18
18
approach.
non-sim)** protocol (months) (months)
12–144
Studies reporting on techniques such as

11–24
13–62
GBR, ridge expansion/splitting, and dis-

60
45
66
traction osteogenesis did not meet all the
9–12
8–12
time
inclusion criteria, since data for the eden-

3–4
3–5
4–8
tulous and partially edentulous patients

Loading
could not be separated. Data on the studies

9–12
8–12
4–8
ND
6
can still be reported briefly.

placement
Implant
Brånemark Machined Non-sim
Non-sim
Non-sim
Non-sim
(sim/
Discussion
Brånemark Machined Sim
Sim
The clinician should be aware of the out-

machined
machined
Implant
surface
Rough/
Rough/
comes of different treatment options in

ND
ND
most clinical situations in order to assess

Straumann
what is the best treatment option in each

Implant
Friadent,
type
Nobel,
clinical situation.
IMZ
ND
ND
Most papers published on the topic have

advancement
not focused on the baseline situation that

Defect fill
actually provides an indication for the

maxilla
4.2 cm
ND
ND
ND
ND
ND
augmentation, but have reported on the

outcome of the augmentation itself, or on
Procedure
success
97.4
the outcome of implant treatment and

100
100
100
100
100
prosthetic rehabilitation. Authors have

Membraneô
mostly focused on demonstrating the

effectiveness of the procedures per se.5,6
Res
ND
ND
ND
ND
ND
The aim of this systematic review was

to assess if there is evidence to outline
buccal onlay
In 5 patients
material§
Grafting
additional
xenograft
which alveolar bone augmentation techni-

ABG,
grafts
que is indicated in the different clinical

ND
ND
ND
HA
situations. To achieve the above-men-

(horizontal/ Donor
Ilium
Ilium
Ilium
Ilium
Ilium
Ilium
site
tioned objective, a decision was made to

autogenous bone graft.
evaluate only papers describing the clin-

Augmentation
vertical)
ical situation before augmentation.

H/V
H/V
H/V
H/V
H/V
H/V
Ed, edentulous.
As a result, few papers could be

included and evaluated within the present
edentulismy patients implants Sitez
Max
Max
Max
Max
Max
Max
review. Most of the articles included have

reported results for a rather small group of
No. of No. of
patients. Moreover, some larger studies

59
92
139
181
281
154
Table 11. Le Fort I osteotomy—edentulous patients.
reported treatment outcomes related to

Grafting material: HA, hydroxyapatite; ABG,
Type of edentulism: PE, partially edentulous;
different types of augmentation (vertical,

12
20
25
15
39
20
horizontal) in different clinical situations

2 Ed/10 PE
(edentulous, partially edentulous, single

Study type: RS, retrospective study.
Type of
tooth gap), presented together. Hence,

data reported in the present review are
Ed
Ed
Ed
Ed
Ed
Membrane: Res, resorbable.
numerically limited.
sagittal discrepancy)
increased inter-arch
maxillary retrusion,
sagittal, transverse,
III, IV, V, and VI
Severely atrophic
VI (unfavourable
(Cawood and
It is certain that the reported outcomes

maxilla, skeletal
Defect type
VI (reduced V
Howell)
intermaxillary
relationships)
of the overall treatment, and not only of

VI (relevant
dimension,
or vertical
distance)
Class III
Site: Max, maxilla.
the augmentation, are important as well.

The aim of the present review was not to
VI
evaluate the outcomes of different techni-

Study
type*
RS
RS
RS
RS
RS
RS
ques. This issue has been extensively ana-

lyzed in previous reviews.4,5
et al. 199979
et al. 200084
et al. 200783
et al. 201282
5 Chiapasco
3 Kahnberg
6 De Santis
4 Stoelinga
1 Isaksson
Another limitation is due to the fact that

2 Li et al.
199380
199681
Study
et al.,
most of the clinical trials have been carried

**
ô
*
§
y
z
out by experienced clinicians, specifically

trained in periodontology, oral or maxil- hypoesthesia in 2.9%, additional grafting the data regarding partially edentulous
lofacial surgery, and the reported clinical needed in 64.4%, mean complication rate defects).
results probably could not be achieved by 22.4%). In the treatment of edentulous patients,
a less experienced general practitioner in Some specific clinical indications may it was possible to extract the data for the
the same manner. be confirmed by the present review for use of bone block grafts and Le Fort I
When comparing the treatment out- certain clinical procedures in partially maxillary osteotomies. It can be con-
comes with the initial clinical situation edentulous patients. In horizontal defects cluded that: (1) There is evidence for
and the different techniques in partially with a crest wider than 4 mm, when we the use of bone block grafts in edentulous
edentulous patients, it may be concluded expect a dehiscence at implant placement, ridge augmentation, for the treatment of
that: (1) There is strong evidence to sup- GBR at the time of implant placement is severely resorbed maxillae and mandibles.
port the use of GBR at the time of implant effective. When the crest is less than A survival rate of 87.75% can be expected,
placement when a dehiscence or fenestra- 3.5 mm, thus interfering with the achieve- with complications related to the donor
tion defect is present. (2) There is evidence ment of primary implant stability, a staged site in 8–11.1%, and related to partial or
to support the use of staged GBR for approach is essential and either GBR (with total graft loss in 8–20%. (2) Le Fort I
horizontal augmentation in preparation less augmentation potential) or bone osteotomy is widely used in the treatment
for implant placement (that takes place blocks (that provide wider reconstructions of atrophic edentulous patients. Severely
after healing of the bone reconstruction) but may need a harvesting procedure) may resorbed jaws, presenting Class IV to VI
when the residual crest is 2.9 mm or wider. be used successfully. Ridge splitting or atrophy,78 can be treated with this
A mean gain of 3.31 mm can be expected expansion can be used in the latter situa- approach, which is very demanding, and
with 11.9% of complications related to tion, but this technique is associated with a an implant survival rate of 87.9% can be
membrane exposure. (3) Evidence is pre- higher complication rate and smaller expected. The main objectives of the pro-
sent when bone block grafts are used in the amount of augmentation achieved when cedure are two-fold: three-dimensional
augmentation of horizontal defects, within compared to the aforementioned techni- repositioning of the maxilla to create an
a two-stage approach, when the initial ques. ideal inter-occlusal relationship, and bone
width of the ridge is 3.2 mm. A linear Regarding the vertical defects, the use augmentation. Many studies79,80,84
bone gain of 4.3 mm at the time of implant of GBR simultaneously with implant pla- reported that patients were rehabilitated
placement can be seen with this approach, cement is feasible when the initial vertical with overdentures despite the maxillary
with a mean complication rate of 6.3% defect is 4.1 mm, whereas a GBR proce- repositioning surgery, suggesting that sub-
related to graft exposure. (4) There is dure with a non-simultaneous implant pla- optimal inter-occlusal relationships were
support for the use of the ridge expan- cement can be performed when the initial achieved.
sion/splitting technique in the augmenta- defect is 4.7 mm. In cases in which at least In relation to atrophic edentulous jaws,
tion of horizontally deficient ridges (mean 4 mm of vertical reconstruction is needed, available data indicate that all the proce-
ridge width 3.37 mm). With this techni- bone block grafts can be used, with a dures assessed are successful in terms of
que, a linear bone gain of 2.95 mm can be possibility of vertical bone gain of bone augmentation, providing a high
observed with a complication rate of 0.9– 4.7 mm. Nevertheless, this procedure is implant survival rate (lower at least than
26% (mean complication rate 6.8%), due associated with a high risk of complica- in partially edentulous patients), with
mainly to fracture of the buccal bone. (5) It tions. Distraction osteogenesis is another implants placed in the augmented bone.
is feasible to treat vertical defects with possibility for alveolar ridge vertical aug- However, the evaluation of available data
means of GBR simultaneously with the mentation, where a 7-mm vertical bone demonstrates poor methodological quality
implant placement, when the initial cir- gain could be expected, but caution should in terms of description of the preoperative
cumferential vertical defect is 4.1 mm. A be taken in making the choice of the right and postoperative dimensions of the ridge,
vertical bone gain of 3.04 mm can be technique as regards the relatively high as well as the amount of augmentation
achieved with this approach, with mem- complication rate, as well as the complex- achieved.
brane exposure in 13.1% of the treated ity of the procedure itself (Table 12). It may thus be concluded that the pre-
cases. (6) The use of GBR with a non- The main limitations of the former sent review could not extract clear indica-
simultaneous implant placement is feasi- results are that it was not possible in all tions for each augmentation technique,
ble when initial vertical defects are papers to separate data for single tooth gap still leaving the clinician the ultimate
4.7 mm. After the healing period, a linear from the ones for multiple missing teeth. responsibility for the final choice.
mean bone gain of 4.3 mm is observed, When discussing the treatment of eden- Future studies should better describe the
with a 6.95% rate of membrane exposure tulous patients, many papers describing clinical situation before augmentation,
during the healing period. (7) The use of different surgical techniques pooled providing adequate ridge measurements
bone block grafts in vertical ridge aug- together the treatment of edentulous and before and after the augmentation proce-
mentation produces mean linear bone gain partially edentulous jaws, thus making it dure. This kind of data reporting should
of 4.7 mm when at least 4 mm of vertical impossible to analyze the respective become mandatory in all studies dealing
augmentation is needed. A high complica- results separately. This is likely the case with bone augmentation procedures, thus
tion rate can be expected (graft exposure when authors are reporting on localized enabling better interpretation of the results
in 12.5–33.33%, graft loss in 8–20%, defects within an edentulous jaw that does and allowing the reader to conclude in
mean complication rate 8.1%). (8) There not present a diffuse atrophy. which possible clinical indication a spe-
is evidence for the use of distraction osteo- A precise description of the defect is cific bone augmentation technique could
genesis in vertical augmentation. A 7-mm rarely present in papers dealing with the be applied.
vertical dimension increase can be reconstruction of edentulous atrophic
achieved with this approach, with a rela- jaws. Consequently, broader selection cri-
Funding
tively high complication rate (lingual teria were used for the inclusion of the
inclination in 18–22%, persistent papers (when compared to the analysis of None.
Preop., preoperative; Postop., postoperative; H, horizontal; V, vertical; GBR, guided bone regeneration; Sim, simultaneous implant placement; Non-sim, non-simultaneous implant placement; Exp,
Complications Competing interests
mean (%)
4.99
6.95
11.9
13.1
22.4
6.3
6.8
8.1
None declared.
Ethical approval
Not required.
additional grafting 64.4

Complications (%)
Lingual inclination
hypoesthesia 2.9,
18–22, persistent
Patient consent
Exp 12.5–33.33
Fracture 0.9–21
Graft loss 8–20

Not required.
Exp 2.5–24
Exp 2.5–10
Exp 13.1
Exp 13
Exp 8
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84. Stoelinga PJ, Slagter AP, Brouns JJ. Reha- Address: Italy
bilitation of patients with severe (Class VI) Iva Milinkovic Tel.: +39 381 64 2041811
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2000;29:188–93. Rome

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Int. J. Oral Maxillofac. Surg.

2014; 43: 606–625

Systematic Review Paper

Are there specific indications for I. Milinkovic, L. Cordaro

the different alveolar bone

Table 1. PICO criteria for the systematic review. Search terms

Milinkovic and Cordaro

rate (%) rate (%)

et al. reported membrane exposure in

12 13.3%.33 Meijndert et al. reported fistulae

in one patient (13.3% and 6.6%, respec-

tively, of the sample),31 while Geurs

et al.34 reported fistulae in 6% of the cases,

all successfully resolved. The mean com-

plication rate was 11.9%.

The average healing time before the

mean implant survival rate for implants

non-simultaneously placed with the GBR

procedure for horizontal augmentation

was 100%. The implant survival rate

was not reported in two studies.30,31

Bone blocks for horizontal augmentation

An initial electronic search resulted in 239

titles when using the selected key words in

terms of bone block grafts used for bone

augmentation. After the final selection

based on abstract analysis, eight full-text

articles met all the inclusion criteria and

(Table 4). Out of the eight studies

included, two were RCT, one was a

CCT, two were PS, and three were RS.

Regarding the inclusion criteria for each

study, some authors33–37 described initial

horizontal defects numerically, usually as

remaining studies, the precise numerical

initial defect description was missing, and

‘horizontal defect’ or ‘atrophic ridge’.

on precise preoperative ridge dimensions.

In summary, 171 patients received 353

Implant placement: Non-sim, non-simultaneous.

bone augmentation procedure used to cor-

Technique: GBR, guided bone regeneration.

rect the horizontally insufficient ridge was

the use of bone blocks alone (four studies)

Site: Max, maxilla; Mand, mandible.

or along with additional GBR procedures

procedure, five studies reported on the

while two studies used an allograft, and

studies reported on the use of resorbable

membranes,33,37–39 one on the application

of a non-resorbable membrane,35 and in

two studies no membrane was used to

Milinkovic and Cordaro

RCT52 and the other was a PS, which also

reported GBR with simultaneous implant

The mean initial dimension of the pre-

operative defect was 5.6 mm. The mean

dure was applied was 5.2 mm (at the time

of implant placement, 9–12 months after