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CONTINUING EDUCATION

Volume 34 No. 11 Page 114

Surgical Techniques to
Increase Bone Augmentation
Success
Authored by Randy R. Resnik, DMD, MDS

Upon successful completion of this CE activity, 2 CE credit hours may be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
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CONTINUING EDUCATION

Surgical Techniques to infection need to be removed. Bone grafting in the presence of


pathology will most likely lead to increased morbidity of the
Increase Bone Augmentation graft and recipient site bone loss. Prior to grafting, whether in
a fresh extraction socket, residual ridge, or maxillary sinus, all
Success evidence of active infection needs to be eradicated. When bone
becomes infected, a low pH results in rapid solution-mediated
resorption, which decreases bone formation and increases the
Effective Date: 11/01/15 Expiration Date: 11/01/18 morbidity of the graft.1 Therefore, prior to bone grafting, it is vi-
tal that all signs of infections are eliminated.
Surgical asepsisBy definition, bone grafting in dental implan-
About the Author tology has been classified as a clean-contaminated surgical proce-
dure with an associated 15% infection rate.2 However, if proper
Dr. Resnik is a leading educator, clinician, and
asepsis and prophylactic antimicrobial treatment is utilized, the
researcher in the field of prosthodontics and oral infection rate may decrease to less than 1.0%.3 To minimize post-
implantology. He is a graduate of the University operative infection, a controlled, well-monitored aseptic surgical
of Pittsburgh, with a specialty degree in prostho
dontics, surgical fellowship in oral implantology,
setting is beneficial. The aseptic component should include proper
and a masters degree in radiology. He is a clinical disinfection and draping procedures for patients, sterile gloves, and
professor of oral implantology at Temple Univer gowns worn by surgical members, and strict sterility of instrumen-
sity, staff member at Allegheny General Hospital,
and surgical director of the Misch International
tation and grafting materials.
Implant Institute. He maintains a private practice Use of prophylactic antimicrobialsPostoperative infections may
in Pittsburgh limited to oral implantology. He can lead to a multitude of complications including pain, swelling, bone
be reached via email at rresnik@verizon.net.
graft loss, and recipient site bone loss. Antibiotic prophylaxis has
Disclosure: Dr. Resnik reports no disclosures. been shown to be effective in reducing postoperative infections af-
ter bone grafting procedures. The use of a beta-lactam antibiotic
(amoxicillin) pre- and postoperatively will provide adequate sys-

I
n implant dentistry today, bone grafting has become a com- temic coverage. Another modality for antimicrobial prophylaxis
mon treatment modality. It is imperative to have adequate is the use of 0.12% chlorhexidine digluconate (Peridex [3M ESPE]).
hard- and soft-tissue volume to allow for ideal implant Chlorhexidine gluconate is a potent antibacterial, which causes
placement, decreased morbidity, and increased success rates for lysis by binding to bacterial cell membranes. It has high substan-
both the surgical and prosthetic phases of treatment. The bone tivity, which at high concentrations exhibits bactericidal qualities,
grafting options of materials and techniques are very numerous thereby causing bacterial cytoplasm precipitation and cell death.
in implant dentistry. Consistent bone grafting success has been Unfortunately for allograft bone grafts, there exists minimal
difficult to achieve on a continuous basis because practitioners immediate blood supply with an absence of the hosts cellular
often use similar techniques, regardless of the existing condi- defense mechanisms. This results in the graft site being prone
tions, bone volume, and graft loca- a b c
tion. Thus, this article will discuss
techniques and principles that will
increase bone grafting success rates
with decreased complications.

REMOVE ALL SIGNS OF


INFECTION/SURGICAL ASEPSIS
It is imperative that bone grafting is
completed free of any existing pathol-
ogy, and that bacterial contamination
is minimized via surgical asepsis and
antimicrobial prophylaxis.
Figure 1. Local antimicrobial: (a) cefazolin (one gm)diluted with 2 mL of saline (500 mg/mL) with one mL
Removal of pathologyPrior to bone used per site, which will maintain a concentration within MIC90 of the bacteria; (b) clindamycin (300 mg/2
grafting, all signs of pathology and mL) of solution with one mL used per site; and (c) antibiotic added to allograft material.

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CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


a b c d

Figure 2. (a) A large, broad-based flap design to minimize tension on graft site, and (b) post-op Bio-Oss (Geistlich) zenograft. (c) When lack of attached
tissue exists, an incision should be made toward the lingual to maximize attached tissue on facial, and (d) vertical releases should be made over bone
and lateral to the margins of the membrane (CopiOs Pericardium Membrane [Zimmer Dental]).

to infections, and the osteogenic induction may


a b
be greatly reduced by the infectious bacteria.4 To
minimize the possibility of infection, local admin-
istration of antibiotics should be used within the
graft material. The parenteral use of the pure form
of antibiotics (eg, Ansef, Cleocin) is recommended
to be added to the graft to decrease the possibility
of infection from early contamination. Numer-
ous studies have shown no deleterious effects on
bone growth from locally delivered antibiotics.5,6
Figure 3. Regional acceleratory phenomenon: (a) decortication with fissure bur (702 L [Salvin
Because the incidence of allergy is high with pen- Dental Specialties]) and (b) completed decortication showing bleeding holes.
icillin containing antibiotic drugs, the parenteral
form of cefazolin (Ancef) or clindamycin (Cleocin) is selected. is not present, soft-tissue grafting should be completed. Another
Orally administered capsules and tablets should not be used option would be the placement of an acellular dermal matrix (eg,
within the graft, because they contain fillers that are not favorable alloderm). Additionally, when inadequate keratinized tissue is
for osteogenesis (Figure 1). present, the incision should be made more toward the lingual as
to preserve as much attached tissue on the facial as possible. This
FLAP DESIGN allows for greater resistance to muscle pull and will decrease inci-
The flap design is extremely important to the success of the bone sion line opening.
graft. If basic principles are not adhered to in the design of the flap, Margins over host boneThe margins of the wound should
the bone graft may be placed at risk. always be over host bone, as this allows for better healing,
Maintain blood supply to reflected flapa broad-based incision prevents loss of graft material, and allows the periosteum to
should be completed to maintain blood supply and to allow for regenerate faster. The incision margins should be lateral to the
elevation, retraction, repositioning, and suturing without tension. membrane position, as this will decrease the possibility of mem-
The facial flap, which is the most common flap reflected for a bone brane exposure or incision line opening (Figure 2).
graft, contains mostly unkeratinized mobile mucosa. The vertical
release incisions should be made to the height of the mucogingi- PREPARATION OF THE RECIPIENT SITE
val junction, with the facial flap only reflected approximately 5 The recipient site should always be prepared with the regional
mm above the height of the mucogingival junction. The larger the acceleratory phenomenon (RAP) technique to improve and accel-
bone graft site, the larger and more distal the vertical incisions. erate healing processes. RAP is a local response to a noxious stimu-
This will decrease the possibility of tearing the tissue, allows for lus (decortication), which may result in healing 2 to 10 times faster
increased blood supply to the graft area (broad-based), and allows than normal.7 The recipient site should be decorticated by placing
for the margins of the flap to be over host bone, instead of the graft. pilot holes in the cortical bone, which allows for trabecular bone
The soft-tissue reflection distal to the graft site should be ideally blood vessels to increase revascularization and integrate bone
split thickness as this maintains the periosteum on the bone. This growth factors to the graft site.8 This will include platelets, which
will improve early vascularization to the incision line. release growth factors such as platelet-derived growth factor and
Adequate attached tissueGraft sites should have an adequate transforming growth factor along with increasing osteogenic
zone of attached keratinized tissue. If adequate attached tissue cells to the graft site. The decortication will also allow for better

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CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


a b c d e

Figure 4. (a) Socket graft with Puros and CollaTape membrane (Zimmer Dental), (b, c) Mineross + Alloderm membrane (BioHorizons), (d) titanium mesh
membrane, and (e) polytetrafluoroethylene (PTFE) membrane.

integration of the graft to the host bone. The technique includes leucocytes, cytokines, and circulating stem cells that are gradually
the use of a small fissure bur drill (eg, 702 L [Salvin Dental Spe- released to accelerate physiologic healing. It is easily obtained and
cialties]) with copious amounts of irrigation to prevent thermal does not require any biochemical blood handling.10 After drawing
trauma (Figure 3). blood and placing in a centrifuge for 12 minutes, the coagulation
cascade will be triggered. The end result is a fibrin clot in the middle
GRAFT CONTAINMENT AND MAINTAINING SPACE layer, situated between the accelular platelet-poor plasma and the red
For the graft to heal and form new bone, it must be contained blood cells. Thus, when the fibrin clot (PRF) is used as a membrane,
at the site of the defect. The concept of bone growth is based on it will protect the wound and serves as a matrix to accelerate heal-
space (anatomic size and contour of the desired augmentation) ing. When the PRF is mixed with the graft material (allograft),
and maintenance (space must exist long enough for bone to fill in the fibrin clot will act as a biological connector between all the
the desired area). A barrier membrane is used to prevent soft-tis- elements of the graft, while also acting as a matrix that initiates
sue growth into the graft. There exist many options available angiogenesis, stem cell accumulation, and migration of osteopro-
today in implant dentistry to contain the graft. The ideal partic- genitor cells to the graft. Thus, the synergistic effects of the fibrin
ulate containment system would maintain the graft, assist with matrix and growth factors allow for the enhanced healing of the
maintaining space, prevent exposure to the oral environment hard and soft tissues. Studies have shown PRF with freeze-dried
and soft-tissue ingrowth, and also possess the ability to slowly bone allograft (FDBA) heal faster than FDBA alone.11
resorb or easily be removed.9 Many resorbable membranes are
available which are derived from zenogenic collagen sources Recombinant Human Bone Morphogenetic Proteins
or cadaver dermis. These membranes are popular because they The rhBMP-2 are a group of sequentially arranged amino acids
are slowly resorbed; however, they are not ideal for space main- and polypeptides that are osteoinductive proteins, acting to initi-
tenance. Non-resorbable membranes include various forms of ate, stimulate, and amplify bone morphogenesis. BMPs stimulate
polytetrafluoroethylene (PTFE) and titanium mesh. They are ex- mesenchymal stem cells to induce bone formation via differenti-
cellent for graft containment as well as space maintenance. How- ation to osteoblasts, which form and mineralize new bone. BMP-2
ever, they do have the disadvantage of needing to be removed via has been purified, sequenced, and cloned, and is marketed as
a second surgical procedure (Figure 4). rhBMP-2 (Infuse Bone Graft [Medtronic]). Infuse Bone Graft con-
sists of 2 components: a 1.5 mg/mL concentration of rhBMP-2 and
USE OF BONE GROWTH FACTORS an absorbable collagen sponge. Studies have shown rhBMP-2 with
The use of bone growth factors in implant dentistry has been titanium mesh to be an effective treatment for augmentation of
shown to be advantageous, as they enhance bone healing and the posterior mandible prior to implant placement.12 The new
improve success rates. The types and various techniques for bone formed by rhBMP-2 has been shown to be similar to native
implementing these factors into grafting procedureseg, plate- bone and can withstand the stresses of implant placement and
let-rich fibrin (PRF), recombinant human bone morphogenetic prosthetic function13 (Figure 5).
proteins (rhBMP-2)have increased substantially.
TENSION-FREE SOFT TISSUE
Platelet-Rich Fibrin Incision line opening is the most common postoperative com-
PRF is an autologous fibrin matrix that is used as a healing bioma- plication to be reported during intraoral bone grafting.14 When
terial in implant dentistry. This fibrin matrix incorporates platelets, the incision line breaks down, the graft often will become

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CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


a b c d e

f g h i

Figure 5. Platelet-rich fibrin (PRF) protocol: (a, b) Draw 10 mL of blood with vacutainer; (c) place in centrifuge for 10 minutes at 3,000 rpm; (d) resultant
3 layers: top layerplatelet-poor plasma, middle layerPRF, and bottom layerred blood cells; (e) PRF middle layer removed; (f) placed in Salvin
Bio-Compress forceps which creates a one-mm thick membrane; (g) liquid and/or fragments of PRF placed with allograft; (h) PRF membrane placed
over graft; and (i) rhBMP-2 + collagen sponge.
contaminated or infected, leading to decreased vascularization and material should be used. The suture material of choice
and lack of bone growth.15 The most common reason for incision should have high tensile strength so that muscle pull and ten-
line opening is tension on the incision line. When tension-free sion are resisted with low probability of inflammation and
soft-tissue closure is obtained, the graft area will heal by primary wicking effect. Thus, plain gut, chromic gut, and silk should
intention, which encourages osteo-competent cell proliferation. not be used. Polyglycolic acid (PGA, vicryl), because it maintains
To obtain primary wound closure, the tissue must be manipulated sufficient tension during the first 2 weeks and has been shown
to remove all tension. to have minimal tissue reaction, is an ideal suture material for
Stretching the tissueThe submucosal space technique devel- bone grafts.17 Another alternative is the use of nonresorbable
oped by Misch in 1980 is an effective method to expand the tissue PTFE monofilament sutures (ie, Cytoplast PTFE suture). These
over graft sites. An incision (one to 2 mm deep) is made through sutures are biologically inert, high tensile strength, nonwicking,
the periosteum parallel to the crestal incision, approximately 3 and have excellent knot security.
to 5 mm above the vestibular height of the mucoperiosteum. Tis- The sutures should be placed approximately 3 mm from the
sue scissors (eg, Metzenbaum) are then used in a blunt dissection margin of the tissue. Sutures placed less than 3 mm away increase
technique to create a tunnel apical to the vestibule and above the possibility of tearing the flap. Also, care should be exercised to
the unreflected periosteum. The scissors are placed in a closed make sure that sutures are placed approximately 3 to 5 mm from
position and pushed through the initial scalpel incision approx- each other and not too tight, as this may lead to tissue ischemia and
imately 5 to 10 mm deep, then opened. This submucosal space a devitalized zone. No allograft material should be present within
is parallel to the surface mucosa (not deep toward the overlying the incision line as this may delay healing. After the tissues are su-
bone) and above the unreflected periosteum. Ideally, the facial tured, the incision line is inspected for any open areas or particles
flap should be able to advance over the lingual flap margin by 5 (Figure 7).
mm (Figure 6).16
PROVISIONAL RESTORATION
IDEAL SUTURING Bone graft stabilization is paramount to predictable bone aug-
To maintain closure of the graft site, the ideal suturing technique mentation to ensure blood clot adhesion and the introduction of

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CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


a b c a b

Figure 6. (a) Periosteum stretching and incision with 15 blade, (b) blunted tissue scissors placed in Figure 7. (a) Non-ideal closure as primary closure
the incised tissue and blunt dissection performed, and (c) tissue should be free of tension and able is not obtained and high tension is present on the
to stretch approximately 5 mm over lingual tissue margin. suture line. (b) Ideal suturing with primary closure
and no tension present.

a b c d

Figure 8. Snap-On Smile (DenMat): (a) bone graft site, (b) Snap-On Smile Prosthesis, (c) prosthesis in place exhibiting no pressure on graft site, and
(d) Essix Appliance (DENTSPLY Raintree Essix) example.

associated growth factors for predictable healing. As little as 20 m practices. As the discipline of implantology grows, the prevalence
of movement will result in a nonfixated graft and fibrous encap- of bone grafting will become more significant. Restoring the lost
sulation as the graft cannot develop a blood supply for new bone hard-tissue volume to allow ideal implant placement is crucial
formation. Graft immobility is vital to capillary ingrowth and graft to decrease the morbidity of implants and the restorations they
revascularization. One of the most common and challenging road- support. Bone augmentation comprises a wide range of materials,
blocks to implant treatment acceptance is the patients perception donor sites, and surgical approaches, with new advances arriving at
of the temporization (provisionalization) of the edentulous areas a staggering rate. With all of the materials and varying techniques
after bone grafting. In most cases, pressure directly or indirectly on available today, the practitioner must have a solid understanding
the surgical site can lead to bone loss and increased morbidity of of adjunct techniques to increase the success of bone grafting.F
the graft site. Ideally, no provisionalization after surgery is the best
treatment. However, because of patient requests, many types of References
provisionalization techniques are being utilized. The 2 prosthesis 1. Misch CE, Misch-Dietsh F. Keys to bone grafting and bone graft
types that minimize pressure on the graft site are the Essix Appli- ing materials. In: Misch CE. Contemporary Implant Dentistry. 3rd
ance (DENTSPLY Raintree Essix) and the Snap-On Smile (DenMat) ed. St. Louis, MO: Mosby; 2008:467 (chapter 21).
concept. The thermoformed Essix Appliance is easily fabricated, 2. Altemeier WA, American College of Surgeons Committee on
inexpensive, and prevents pressure from being placed on the graft Control of Surgical Infections. Manual on Control of Infection in
Surgical Patients. 2nd ed. Philadelphia, PA: Lippincott; 1984.
site. A Snap-On Smile is a noninvasive partial or full-arch remov-
3. Peterson LJ. Antibiotic prophylaxis against wound infec
able prosthesis that is placed over the patients dentition. This tions in oral and maxillofacial surgery. J Oral Maxillofac Surg.
interim prosthesis is aesthetic, has excellent retention, no impinge- 1990;48:617-620.
ment on the soft tissues, and allows the adjacent teeth to absorb the 4. Urist MR, Silverman BF, Bring K, et al. The bone induction princi
occlusal force (Figure 8). ple. Clin Orthop Relat Res. 1967;53:243-283.
5. Mabry TW, Yukna RA, Sepe WW. Freeze-dried bone allografts com
SUMMARY bined with tetracycline in the treatment of juvenile periodontitis. J
Oral implantology has grown into a widely accepted and ever Periodontol. 1985;56:74-81.
expanding discipline. Due to this phenomenon, more and more 6. Beardmore AA, Brooks DE, Wenke JC, et al. Effectiveness of local
clinicians are offering dental implant surgery in their respective antibiotic delivery with an osteoinductive and osteoconductive

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CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


bone-graft substitute. J Bone Joint Surg Am. 2005;87:107-112. 12. Misch CM. Bone augmentation of the atrophic posterior mandi
7. Melcher AH, Accursi GE. Osteogenic capacity of periosteal and ble for dental implants using rhBMP-2 and titanium mesh: clinical
osteoperiosteal flaps elevated from the parietal bone of the rat. technique and early results. Int J Periodontics Restorative Dent.
Arch Oral Biol. 1971;16:573-580. 2011;31:581-589.
8. Fiorellini JP, Buser D, Riley E, et al. Effect on bone healing of bone 13. Boyne PJ, Lilly LC, Marx RE, et al. De novo bone induction by
morphogenetic protein placed in combination with endosseous recombinant human bone morphogenetic protein-2 (rhBMP-2)
implants: a pilot study in beagle dogs. Int J Periodontics Restor- in maxillary sinus floor augmentation. J Oral Maxillofac Surg.
ative Dent. 2001;21:41-47. 2005;63:1693-1707.
9. Block MS. Treatment of the single tooth extraction site. Oral 14. Misch CM, Misch CE. The repair of localized severe ridge defects
Maxillofac Surg Clin North Am. 2004;16:41-63, vi. for implant placement using mandibular bone grafts. Implant
10. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): Dent. 1995;4:261-267.
a second-generation platelet concentrate. Part IV: clinical effects 15. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration
on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol around titanium dental implants in dehisced defect sites: a clini
Endod. 2006;101:e56-e60. cal study. Int J Oral Maxillofac Implants. 1992;7:233-245.
11. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin 16. Misch CE. Contemporary Implant Dentistry. 3rd ed. London,
(PRF): a second-generation platelet concentrate. Part V: histo England: Elsevier Health Sciences; 2008:858 (chapter 36).
logic evaluations of PRF effects on bone allograft maturation 17. Yaltirik M, Dedeoglu K, Bilgic B, et al. Comparison of four
in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. different suture materials in soft tissues of rats. Oral Dis.
2006;101:299-303. 2003;9:284-286.

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Surgical Techniques to Increase Bone Augmentation Success


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POST EXAMINATION QUESTIONS


1. When bone becomes infected, a low pH results in rapid 5. Regional acceleratory phenomenon (RAP) is a local
solution-mediated resorption, which decreases bone response to a noxious stimulus (decortication), which may
formation and increases the morbidity of the graft. result in healing 2 to 10 times faster than normal.
a. True b. False a. True b. False

2. If proper asepsis and prophylactic antimicrobial treatment 6. Incision line opening is the least common postoperative
is utilized, the infection rate may decrease to less than complication to be reported during intraoral bone grafting.
1.0%. a. True b. False
a. True b. False
7. Bone morphogenetic proteins (BMPs) stimulate mesenchy-
3. Numerous studies have shown many serious deleterious mal stem cells to induce bone formation via differentiation
effects on bone growth from locally delivered antibiotics. to osteoblasts, which form and mineralize new bone.
a. True b. False a. True b. False

4 The larger the bone graft site, the larger and more distal 8. Graft immobility is not really vital to capillary ingrowth and
the vertical incisions. graft revascularization.
a. True b. False a. True b. False

7
CONTINUING EDUCATION

Surgical Techniques to Increase Bone Augmentation Success


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