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British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx

Review
Clinical outcomes of dental implants after use of tenting for
bony augmentation: a systematic review
F. Pourdanesh a , M. Esmaeelinejad b,∗ , F. Aghdashi a
a Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b Department of Oral and Maxillofacial Surgery, School of Dentistry, Semnan University of Medical Sciences, Semnan, Iran

Accepted 30 October 2017

Abstract

The reconstruction of severely atrophic ridges is often challenging and complicated. We searched the Medline, Embase, and Cochrane
databases for articles up to October 2015 that reported the success of all types of tenting for bony regeneration. We extracted data on the size
and site of the defect, the number of patients, vertical and horizontal augmentation, survival of dental implants, and complications. Thirteen
studies were included, which yielded data on 423 patients with 1111 dental implants. Follow-up periods were more than five years, severely
resorbed mandibles were augmented vertically by up to 10 mm, and the survival rate of the implants was over 97%. The mean (SD) gain in
horizontal width by screw tenting was 3 (0.63) mm, and over 97.6% of dental implants in cortical tenting investigations survived. A tenting
approach may reduce the need for large autogenous bone grafts in the reconstruction of severely atrophic ridges and local bony defects, and
improves the survival of implants.
© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Alveolar ridge augmentation; Atrophy; Bone grafting; Dental implants

Introduction provides bone with properties similar to those of the recipient

site.8,9
Bony regeneration and reconstruction in patients with Tenting has been advocated for the initial reconstruction
severely atrophic ridges have been always controversial, and and subsequent regeneration of maxillofacial defects. Various
although many techniques have been suggested there is no techniques have been reported, the first of which was the
consensus about the most efficient technique.1 The rehabil- tent-pole technique.10 The two other modifications, cortical
itation of edentulous patients with severely atrophic ridges autogenous tenting and screw tenting, are usually used for
is difficult and surgeons need experience in the field.2 Auto- smaller oral defects. Studies have shown that they can all be
genous bone is still the gold standard for reconstruction,3,4 used to augment bone effectively.10–12
but resorption, particularly of iliac bone grafts, is a serious Although several reviews and trials have been done in
drawback.5,6 The quantity and quality of regenerated bone the field of bony regeneration and reconstruction of atrophic
must be considered.7 Although several techniques can be ridges and defects of the jaw,13–17 we know of no compre-
used, it can be difficult to find an appropriate technique that hensive review of the different tenting techniques in oral and
maxillofacial surgery. We therefore systematically reviewed
the long-term outcomes of dental implants after the use of
∗ Corresponding author. Tel: +98 21 66 05 04 80; Fax: +98 21 22 43 99 tenting to repair severely atrophic ridges and local bony
76. defects.
E-mail address: [email protected] (M. Esmaeelinejad).

https://doi.org/10.1016/j.bjoms.2017.10.015
0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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systematic review. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.015
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2 F. Pourdanesh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx

Methods Three studies related to the tent-pole technique

(Table 2).10,24,25 All patients (mean (range) age 62 (44–81)
Focused question years) had severely atrophic mandibles. The mean (range)
gain in bony height was 8.25 (4–13) mm. The follow-up
The PICO (population, intervention, comparison, and out- period ranged from 4.9 to 6 years and the survival rate of
come) question was stated as follows: In partially or the implants was more than 97%.
completely edentulous patients with inadequate bone for Four papers evaluated the effects of screw-tenting on bony
implant insertion (P), does the tenting technique (I) in com- augmentation (Table 3).11,13,26,27 The mean (range) age of the
parison to other methods of vertical bone augmentation or patients was 50 (22–73) years, and the mean (range) gain in
no augmentation (C), increase bony height and implant sur- bony height was 5.68 (0.5–10) mm. All the implants survived.
vival/success rates (O)? Six papers related to cortical autogenous tenting
(Table 4).12,14,15,28–30 The mean (range) age of the patients
was 50 (20–73) years, and the augmented ratio was more than
Search strategy
5 mm. The mean (range) gain in bony height was 4.46 (less
than 2–6) mm, and the survival rate of the implants was more
This review followed the preferred reporting items for
than 97%.
systematic review and meta-analysis protocols (PRISMA-
P) 2015 statement.18 We searched the Medline, Embase,
Scopus, and Cochrane databases to find studies that were
Discussion
published up to October 2015. The terms used included
“Tenting technique” OR “Screw tenting” OR “Tent-pole” OR
The vertical augmentation of atrophic ridges has always been
“Bone screw”[Mesh] “Cortical tenting” AND the Mesh terms
controversial, and no regenerative technique has been effec-
related to bony reconstruction, which included “Severely
tive in all cases.31,32 The tenting technique, which originated
atrophic ridge” AND “Alveolar ridge augmentation” OR
from the principles of guided bone regeneration, involves
“Mandibular ridge augmentation”.
raising the periosteum like a tent to allow osteoblasts to
We assessed the abstracts of all the papers to exclude those
migrate into the gap to start osteogenesis. The gap that is
that were not related, and then read the full texts. Clinical tri-
made is then filled with osteoconductive or osteoinductive
als and human studies with no language restriction, which
materials, and in some cases, both. The migration of epithe-
were published up to October 2015 and which evaluated
lial cells can be prevented by the application of a barrier-like
the effects of the tenting technique to augment intact ridges
collagen membrane or other component.33 The technique is
(without fracture) in systemically healthy and non-syndromic
divided into three categories that depend on the method that
patients, were included. Case reports, letters to the editor,
is used to keep the periosteum up.
technical notes, grey literature, reviews, and animal studies,
were excluded.
Ten-pole technique

Data extraction In this procedure dental implants are used to make a gap
between the periosteum and the bone (Fig. 2), and in most
All searches and data extraction were done independently by cases the gap is filled with bone grafts.34 It was first described
two of the authors and checked by the third. The quality of the by Marx et al and was the first modification of the tenting
articles was assessed by the third author as a part of the data technique.10
extraction process. The title of the journal and the authors’ Three studies investigated its effects on bony augmenta-
identity were blocked out before review of the final articles tion in patients over 62 years of age with severely atrophic
to prevent reviewer bias. The data, which were recorded on mandibles. Although the anterior mandible was recon-
a pre-prepared data collection form, included the number of structed, the whole mandibular ridge was severely atrophic,
patients and dental implants, mean age of the patients, site and posterior iliac bone grafts were harvested for recon-
and size of the defect, and the material used to fill the gap; struction. Long-term follow up showed minimum resorption.
also the mean augmentation rate, follow-up period, survival Survival of the dental implants, which were placed at that
of implants, major complications, and other important results same time, was good.
and findings. These were then categorised in tables. The major complications were transient or permanent
paraesthesia of the inferior alveolar nerve and the need for a
second operation such as vestibuloplasty. The other impor-
Results tant disadvantage was incorrect angulation of the implants.
Marx et al reported that they were not able to make prostheses
Fig. 1 shows the selection process. Table 1 shows the reasons in 5.1% of the cases because the inclination was incorrect.10
why five papers that were closely related to the topic were Use of the technique resulted in gains of up to 10 mm
excluded.19–23 Thirteen articles were finally included. in bony height. Long-term follow up (more than five years)

Please cite this article in press as: Pourdanesh F, et al. Clinical outcomes of dental implants after use of tenting for bony augmentation: a
systematic review. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.015
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F. Pourdanesh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx 3

Fig. 1. The PRISMA flow chart of search strategy.

Table 1
Excluded articles.
First author, year and reference Title Reason for exclusion
Berberi 201519 Horizontal and vertical reconstruction of the severely Technique used for tenting was different
resorbed maxillary jaw with subantral augmentation and a from usual method
novel tenting technique with bone from the lateral buccal wall
Oliveira 201520 Implant-supported rehabilitation after treatment of atrophic Investigation was on fractured mandibles
mandibular fractures: report of two cases
Korpi 201321 Tent-pole approach to treat severely atrophic fractured Investigation was on fractured mandibles
mandibles using immediate or delayed protocols: preliminary
case series
Wannfors 200922 Augmentation of the mandible via a “tent-pole” procedure Study evaluated tenting in an unusual case
and implant treatment in a patient with type III osteogenesis (osteogenesis imperfecta)
imperfecta: clinical and histologic considerations
Lypka 200823 Dental implant reconstruction in a patient with ectodermal Study evaluated tenting in an unusual case
dysplasia using multiple bone grafting techniques (ectodermal dysplasia)

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systematic review. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.015
 4

YBJOM-5292;
systematic review. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.015
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No. of Pages 9
Table 2

F. Pourdanesh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Studies on the results of tent-pole methods.
First author, year, No. of Age (range) Site of defect Size of defect Material used Augmentation Follow up Survival rates Other findings Major
and reference patients/implants (years) for (mm) period (years) of implants complications
augmentation
Marx 200210 64/356 65/44–81 Anterior of Mean vertical Iliac bone 10.2 4.9 99.5% No fractures Paraesthesia

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mandible height 4.8 mm graft with with 5.1% of the
PRP implants were
not used
prosthodonti-
cally
Vestibuloplasty
required in
17.2% of cases
Korpi 201224 22/88 62/51–72 Anterior of Mean vertical Iliac bone Mean (SD) 6 97.7% No dehiscence Paraesthesia
mandible height 6 mm graft 6.3(1.59) or infection Wrong
inclination of
implants
Vestibuloplasty
required in
5.6% of cases
Kuoppala 201325 17/67 68/54–77 Anterior of Severely Iliac bone Up to 10 5 97% Occlusion was Paraesthesia
mandible resorbed graft stable and Loosening of
mandibles vertical height the attachment
of occlusion component
acceptable in
82.4% of cases

NM: not mentioned; PRP: platelet-rich plasma.

 YBJOM-5292;
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No. of Pages 9
Table 3
Studies that evaluated the results of screw tenting.

F. Pourdanesh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
First author, year, No. of Age (range) Defect site Defect size Material used Augmentation Follow up Survival of Other findings Major
and reference patients/implants (years) for (mm) period implants complications
augmentation
Le 201026 15/32 50.06 Posterior Less than Allograft 9.7 16.8 months 100% Mean bone Wound
(22–63) mandible/anterior 3 mm of height content of dehiscence

ARTICLE IN PRESS
maxilla specimens and screw
43% exposed
Mean content
of vital bone
81%
Simon 201027 3/9 52.6 Maxilla and Augmentation Allograft Dental implant 6.3 months 100% Uneventful No dehiscence
(46–58) mandible of ridge placed in healing with or other major
needed for augmented substantial complications
insertion of ridge augmentation
implants
Chasioti 201311 3/5 50.33 Anterior Complete loss Allograft Up to 5 mm 3 to 6 months 100% Used only in No dehiscence
(47–54) maxilla of facial wall increase in small defects or other major
bony width and extraction complications
sites
Caldwell 201513 24/33 50.2 Maxilla and Buccolingual Allograft/ Mean (SD) 24.4 weeks 100% Mean graft Postoperative
(25–73) mandible ridges too allograft+ 3.33 (0.83) resorption infections at
small for autograft gain in width 13.89% 12.5% of sites
placement of in allograft Unable to
standard- group; 3.09 in place dental
diameter combination implants in
implants graft group some cases
because of
severe
resorption

5
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YBJOM-5292;
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Table 4
Studies that reported the results of cortical autogenous tenting.
First author, year, No. of Mean age Defect site Defect size Material used Augmentation Follow-up Survival rates Other findings Major

No. of Pages 9
and reference patients/implants (range) (years) for (mm) period of implants complications
augmentation (months)
Le 200814 10/42 49.9 (32–68) Anterior max- Resorbed Allograft Width of ridge 14–32 97.6% Specimen that Postoperative
illa/posterior alveolar ridges increased up was harvested wound
mandible missing a to 6 from infection or

F. Pourdanesh et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
minimum of 4 particulate dehiscence are
adjacent teeth graft consisted possible but
and not able to of dense not seen in this
place a 3.3 mm viable bone series
diameter (type 1 or 2)

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implant
Khojasteh 201212 102/237 52.4 (20–73) Maxilla and Not enough Allograft/ Mean (SD) 11–38 97.9% Greatest Wound
mandible bone for 8 mm xenograft/ 5.75 (2.22) vertical dehiscence,
implants with synthetic vertically increase in the infection,
a 2 mm safety materials posterior exposure of
distance to maxilla graft, and
anatomical failed graft
structures
Morad 201328 6/12 55.8 (49–62) Posterior Not enough Xenograft plus Mean (SD) 5.2 4 (before – Bone quality No
mandible bone for 8 mm autogenous (0.76) implants on both sides complications
implants with bone vertically inserted) D2/D3 in all
a 2 mm safety patients
distance to
mandibular
canal
Stimmelmayr 22/42 47.6 Mostly Not enough Autogenous Mean (SD) 3.3 8.8 100% Mean Wound
201429 anterior bony width for bone chips (0.9) resorption dehiscence
maxilla and dental horizontally 0.8 mm
mandible implants
Stimmelmayr 17/30 46 (29–63) Anterior Vertical Particulate Mean (SD) 4.8 14.6 100% Slight vertical Wound
201430 maxilla resorption of autograft (1.4) vertically resorption dehiscence
alveolar ridge (0.5 mm)
made it
unsuitable for
insertion of
implants
Khojasteh 201615 118/158 54.85 Posterior Xenograft NM 38 98.73% Success of Bony
mandible implants resorption
71.52%

NM: not mentioned.

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Fig. 2. Three-dimensional picture of tent-pole technique (a = basal bone; b = iliac bone graft; c = dental implant; d = periosteum).

with 62 (44–81) years). The gaps were filled with allografts

(demineralised freeze-dried bone) in almost all the cases, and
dental implants were successfully inserted in the augmented
ridge after healing. The major complications were dehiscence
or infection of the wound, and exposure of the screw.11,13,26
The gains in bony height were smaller than those reported
with the use of the tent-pole technique except in the study by
Le et al.26 The technique is best suited to defects in the ante-
rior maxilla, whereas the tent-pole procedure is best used
in the posterior mandible. The tent-pole technique is used
to gain bony height, but screw-tenting is used mostly for
horizontal augmentation.
The findings of these studies suggest that screw tenting
may be the best technique to augment the width of a short-
span alveolar ridge before the placement of implants. As bony
Fig. 3. Diagram of screw-tenting technique. resorption is relatively high, the technique is not appropri-
ate for vertical augmentation, or the horizontal augmentation
showed that augmentation was reliable and the implants suc- of atrophic ridges (3-dimensional reconstruction), or large
cessful. The mean follow-up periods in these studies were defects.11,13
longer than those reported for other tenting techniques, and
gains in bony height were considerably better. The results Cortical autogenous tenting
show that this is the most reliable technique for the recon-
struction of severely atrophic mandibles, but there are serious This technique (sometimes referred to as the shell
concerns about sensory dysfunction and labially-positioned technique36,37 ) was first described by Le et al,14 who fixed a
implants. block of cortical bone with titanium screws a few millimeters
Another drawback is the need for an extraoral incision (the from the bone to make the gap, which was filled with bony
other two techniques use an intraoral approach). Although materials.
more complicated than the other two, the technique can result Six papers described its use, mostly in the posterior
in more vertical height, and may be the only method suitable mandible, and the mean age of the patients was similar to
for the reconstruction of severely atrophic mandibles. In their that in the screw-tenting studies. The gap between the bony
review of the tent-pole technique, Daga et al34 reported an block and the surface of the alveolar ridge was filled with
increase in the height of the alveolar ridge that was stable. different materials including allograft, xenograft, and auto-
genous bone. The survival rate of the implants was more than
Screw-tenting 97.6% in all the studies. Several complications were reported,
including wound infection, exposure or failure of the graft,
In this method, titanium screws are used to make the gap. The and bony resorption.12,14,15,30,38
gap is filled with bony materials, and a membrane is used to Khoury et al used a different version of the technique
prevent the migration of epithelial cells (Fig. 3).35 Four stud- for the 3-dimensional reconstruction of atrophic mandibular
ies reported the outcome after the technique was used, mostly ridges.37 They split a cortical bone graft that had been har-
in atrophic maxillary ridges, but also in short-span, partially vested from the lateral ramus of the mandible into two, fixed
edentulous ridges. The mean (range) age of the patients was the two strips 3-dimensionally, and filled the space beneath
lower than that in the tent-pole studies (50 (22–73) compared them with bony materials.

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YBJOM-5292; No. of Pages 9
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Please cite this article in press as: Pourdanesh F, et al. Clinical outcomes of dental implants after use of tenting for bony augmentation: a
systematic review. Br J Oral Maxillofac Surg (2017), https://doi.org/10.1016/j.bjoms.2017.10.015