9

Bone Grafting

Bone regeneration or, simply, pre‐implant bone grafting is an important aspect of

dental implantology. In fact, bone regeneration is often mandatory following
tooth extraction and prior to implant placement, and there are several reasons for
this. The successful placement of implants requires sufficient bone volume of
high biological quality for the implant to osseointegrate prior to its subsequent
restoration. Specifically, the rule of 6’s applies where 6 mm of bone is necessary
in a vertical and horizontal dimension. When an implant is treatment planned, it
is generally because the patient’s tooth is deemed non‐restorable. This “hopeless”
prognosis is reached based on several factors including caries at or below the
bone level, failing endodontic treatment, perio‐endo lesions, advanced
periodontal disease, and tooth fracture. All of these conditions potentially affect
the underlying hard and soft tissue.
Other factors necessitating bone grafting include post‐extraction resorption of
the edentulous ridge, the presence of bony defects due to trauma or infection as
well as the need to place implants in specific sites for proper functionality.
Further, in esthetic areas, a satisfactory emergence profile of the soft tissue
requires a bony base because it is well‐established that soft tissue follows its hard
tissue base. Finally, in situations where there has been significant loss of bone
and the tooth is deemed unsalvageable, guided bone regeneration (GBR) is used
to facilitate bone regeneration when the bone thickness in the jaw is insufficient
for implant placement.
In other words, bone grafting or GBR has two primary purposes:

• To meet the criteria of bone volume for implant placement, or

• To improve the results of an implant prosthesis by allowing a more ideal
position of the implant.

The ADA Practical Guide to Dental Implants, First Edition. Luigi O. Massa and J. Anthony von Fraunhofer.
© 2021 The American Dental Association. Published 2021 by John Wiley & Sons, Inc.

65
66 The ADA Practical Guide to Dental Implants

(a) (b)

(c) (d)

(e)

Figure 9.1 (a) Tooth #30 with severe bone loss. (b) Tooth extracted and graft of mineral-
ized cortico‐cancellous bone placed with a non‐resorbing membrane. (c) Implant placed five
months post‐GBR. (d) Implant level impression. (e) Final restoration.

A typical example of a situation requiring GBR is shown in Figs. 9.1a,b,c,d,e,

covering the replacement of a “hopeless” situation with tooth #30.
The basic rules of bone grafting in an extraction site with a wall defect (gener-
ally, the defect will occur on the buccal plate) are the following:

1. Raise a flap to visualize the defect.

2. Carefully curette all granulation tissue out of the socket and create blood flow.
3. Irrigate with sterile saline.
 Bone Grafting 67

4. Place barrier membrane along defect.

5. Place bone graft material.
6. Close site with
a. Primary closure which entails advancement of the flap to cover the graft – a
resorbable or non‐resorbable membrane can be utilized. If a non‐resorbable
membrane is utilized, it must be retrieved at the time of re‐entry.
b. Secondary closure – a non‐resorbable membrane is generally utilized to
“cover” the graft. Generally, the non‐resorbable membranes are made to
withstand the acids and enzymes in the oral cavity.

Bone Grafting
Graft materials are discussed in detail in Appendix C but for convenience, a few
comments are made here. There are basically four classes of material utilized
for GBR:

• An allograft – a tissue graft from a donor of the same species as the recipient
but not genetically identical.
• An autograft – a graft of tissue harvested from the patient, e.g., bone harvested
from the iliac crest or patella plane for gap filling or sinus lifting.
• A xenograft – tissue harvested from a species other than human.
• Synthetic graft material.

Theoretically, autografting is the optimal approach to bone grafting but, as

this procedure usually involves an ancillary surgical procedure to harvest the
bone, it is not the preferred approach despite certain inherent advantages. The
first of these advantages is that there is no need for sterilization or sanitization of
the graft material. Second, the risk of rejection by the recipient site is minimized
although it must be borne in mind that once bone is harvested from the donor
site and separated from its vascular supply, that bone may die before it can heal.
Although rejection is uncommon, it can still occur because the transplanted
material will be “foreign” to the recipient site.
Similar considerations regarding rejection apply to allografting and xenograft-
ing. In both cases, sanitization/sterilization is necessary to ensure a pristine and
bacteria‐free implantation. On the other hand, the advantage of both these
approaches is that the particle sizing of the grafting materials and their sanitiza-
tion/sterilization are performed prior to their use, and they are commercially
available. As noted, graft materials are discussed in detail in Appendix C.
Regarding the selection of a graft material, the general consensus is:

• Survival rates of implants placed into grafted areas are comparable with
survival rates of implants placed into pristine bone [1].
• Bone quality at the recipient site determines the type of graft material to be
used. Cortical bone is inferior to cancellous bone at the recipient bed. Cells
within cancellous bone are responsible for at least 60% of bone healing capacity.
The periosteum in a young, healthy patient contributes an additional 30%
whereas cells in cortical bone only contribute about 10% to overall bone
healing.
68 The ADA Practical Guide to Dental Implants

When bone resorbs after extraction, the cancellous bone shrinks relative to cor-
tical bone. As the cancellous component of the jawbone diminishes, there is a cor-
responding decreasing in the reservoir for osteoblasts. However, computerized
tomography (CT) can indicate the ratio of cancellous to cortical bone at the recipi-
ent site prior to surgery, this ratio facilitating graft material selection as follows:

1. Only cortical bone: autograft.

2. Cortico‐cancellous bone: selection depends on which predominates but if
there is a preponderance of cancellous bone, the choice is less critical.

Ridge Preservation
There is strong clinical evidence that ridge preservation techniques are usually
effective in limiting post‐extraction horizontal and vertical bone loss when
compared to healing that relies solely on a blood clot. In fact, ridge preservation
significantly maintains ridge width and height (refer to Figs. 9.1a,b,c,d,e). The
prevailing opinion is that most graft materials are effective for this purpose with
only slight differences being found between them.
“External” augmentation procedures, regardless of whether they are horizon-
tal or vertical, on the alveolar ridge are more difficult than “internal” augmenta-
tion in areas like the maxillary sinus. The consensus is that augmentations of
vertical alveolar ridge defects generally have lower rates of successful healing
outcomes than those for horizontal defects. However, for both horizontal and
vertical ridge augmentation procedures, the use of autogenous bone blocks
appear to result in greater bone gain than found with particulate allograft materi-
als. The good thing is that the survival rates of implants placed in well‐healed
horizontally and vertically augmented alveolar ridges are high.
It should be noted that whereas autogenous onlay bone‐grafting procedures
performed to allow implant placement are effective and predictable for the
correction of severely resorbed edentulous ridges, survival rates are somewhat
lower than those of implants placed into pristine bone.
The confounding factors regarding implant survival in grafted sites include:

• Poor blood supply, trauma, or extensive surgery in the area, all of which
adversely affect the implant prognosis.
• Post‐surgical complications and poor implant prognoses are higher in smokers.
• General diseases that affect bone metabolism, e.g., uncontrolled diabetes, head
and neck radiation and bisphosphonate therapy, appear to be relative contra‐
indications for bone augmentation or at least may be somewhat predictive of
long‐term implant failure.

Membranes
GBR is commonly used in combination with membranes during implant place-
ment, the primary purpose being to exclude non‐osteogenic tissues from inter-
fering with bone regeneration following GBR therapy.
Many types of membrane have been introduced for both experimental and
clinical application (see Appendix C). This development has led to many research
 Bone Grafting 69

and clinical papers regarding the properties and biological outcomes with differ-
ent membranes [2]. Membranes are usually provided with a porous structure but
the optimal porosity and, indeed, the precise role of membrane porosity in the
barrier function of GBR membranes is still uncertain. It appears, however, that in
addition to providing a barrier function, membranes may actively participate in
the regenerative processes occurring within the defect during GBR.
The clinician about to place a membrane has to decide between resorbable and
non‐resorbable materials, and several factors come into play in this decision,
Table 9.1.

Table 9.1 Selection of barrier membranes.

Factor Resorbable Non‐resorbable

Cost Higher cost Less costly
Longevity in situ 4–6 months Permanent
Retrievability Unnecessary Retrieval necessary

At this time, it is unknown whether resorbable or non‐resorbable membranes

have better clinical properties and performance. However, because the bone graft
ideally should be left undisturbed for four to six months in order to achieve the
most predictable pre‐implant bone regeneration, then using resorbable mem-
branes and eliminating the need to remove a non‐resorbable membrane might
appear to be sensible. It is important to note that it may be preferable to achieve
primary closure over a membrane because membrane exposure in general has a
higher complication rate [3].

GBR Clinical Sequence

Fig. 9.2 shows a common clinical situation where GBR is necessary to provide a
satisfactory implant site.

Step 1. Elevate flap using releasing incisions (Fig. 9.3)

Step 2. Decorticate deficient bone plate to increase blood supply to graft (Fig. 9.4)
Step 3. Place membrane (e.g., cytoplast resorbable regenerative tissue matrix
(RTM)/Kontour™).
Step 4. Place graft material (e.g., Directgen™ mineralized cortico‐cancellous
particulate)
Step 5. Suture implant site using non‐traumatic sutures (e.g., cytoplast PTFE non‐
resorbable) with tension‐free closure (Fig. 9.5).

The clinical application of the above procedures is shown in Figs. 9.6 – Fig. 9.9.

Crestal Sinus Augmentation

Another common clinical situation is the need for crestal sinus augmentation,
i.e., when the proposed implant site does not satisfy the requirement of 6 mm
minimum vertical bone height
70 The ADA Practical Guide to Dental Implants

(a)

(b)

(c)

Figure 9.2 (a) and (b) Radiograph and clinical photograph of a narrow ridge.
(c) Schematic diagram of a narrow bone ridge requiring GBR prior to implant placement.

Figure 9.3 Reflecting a flap.

 Bone Grafting 71

Figure 9.4 Decorticated deficient buccal plate.

Figure 9.5 Suture flap after membrane and graft placement.

Figure 9.6 Clinical situation before and after 9 months of healing.

Figure 9.7 Implant placed.

Figure 9.8 Implant level impression.

Figure 9.9 Final screw‐retained restoration placed.

 Bone Grafting 73

Figure 9.10 Fractured root #14.

Figure 9.11 Schematic diagram of a sinus lift.

Step 1. Establish bone height with pilot drill and radiographs – note that the cor-
tical bone of the sinus floor “feels” different than the soft medullary bone of
the posterior maxilla.
Step 2. Trephine to the established bone height.
Step 3. Fracture the cortical floor (Fig. 9.11).
Step 4 (with the example shown in Fig. 9.10) with an extraction site and osteot-
omy as seen in Fig. 9.12:
Step 5. Close‐up of sinus membrane (Fig. 9.13).
Step 6. Place implant (Fig. 9.14a).
74 The ADA Practical Guide to Dental Implants

Figure 9.12 Extraction site and osteotomy.

Figure 9.13 Close-up of sinus membrane.

Note
The appropriate codes for insurance reimbursement (when applicable) for GBR
therapy prior to implant placement are:

D6104: Bone graft at time of implant placement

D7953: Socket preservation
D4266: GBR resorbable
D4267: GBR non resorbable

It is also of the greatest importance that the clinician addresses the ­following
when planning any form of implant placement with or without bone grafting:

a. Provide the patient with a clear and concise presentation regarding the
intended procedures and the reasons underlying the proposed treatment.
b. An educated patient will not only be more compliant and motivated, but also
be an enthusiastic source of referrals.
c. Ensure that the patient clearly understands the procedures involved and their
cost, i.e. provide the patient with a clear and simple price structure.
d. Train staff regarding both the implant procedure and the need and desire to
provide optimal patient care.
 Bone Grafting 75

(a)

(b)

(c)

Figure 9.14 (a) Implant placed. (b) Implant grafted and sutured. (c) Two‐week follow‐up
after suture removal. (d) Impressing the implant. (e) 12‐month post‐operative radiograph.
76 The ADA Practical Guide to Dental Implants

(d)

(e)

Figure 9.14 (Continued)

Conclusions
In Implant Dentistry, bone grafting is used to develop or enhance the potential
surgical site. Socket preservation is performed at the time of extraction to develop
the site for future implant placement. If there is a wall defect, barrier membranes
are used to retard epithelial ingrowth into the graft material. The sinus can be
augmented either vertically through the osteotomy or horizontally through a
­lateral wall to increase bone volume for implant placement. The mastery of
­grafting techniques allows nearly all sites to have the potential for implant
placement.

References
1. Duong, T.T., Gay, I., Diaz‐Rodriguez, J. et al. (2016). Survival of dental implants placed
in grafted and non‐grafted bone: a retrospective study in a university setting. Int. J. Oral
Maxillofac. Implants 31 (2): 310–317.
2. Elgali, I., Omar, O., Dahlin, C., and Thomsen, P. (2017). Guided bone regeneration:
materials and biological mechanisms revisited. Eur. J. Oral Sci. 125: 315–337.
3. Machtei, E.E. (2001). The effect of membrane exposure on the outcome of regenerative
procedures in humans: a meta‐analysis. J. Periodontol. 72 (4): 512–516.