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ISSN (Print) 1013-9052
EISSN 1658-3558
The Saudi Dental Journal,
P.O. Box 52500,
Riyadh 11563,
Kingdom of Saudi Arabia
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SDJ

Current concepts in alveolar bone augmentation: A critical appraisal

Hamdan  S.  Al-Ghamdi, BDS, MSc*, Sameer A. Mokeem, BDS, MSc, PhD**, Sukumaran Anil, BDS, MDS, PhD***

Division of Periodontics, College of Dentistry, King Saud University, Riyadh
 

 
Abstract 


Augmentation of the alveolar bone is widely used in implant treatment to create predictable function and esthetics in areas with inadequate bone volume. This can be achieved by various techniques including hard tissue onlays, bone grafts, membrane techniques, bone distraction and bone expansion. The objective of this article is to discuss recent observations of the various bone grafts and bone substitutes, guided bone regeneration, combination techniques, as well as ridge preservation techniques. Despite the increase in the number of procedures that require bone grafts, there has not been a single ideal bone graft substitute. An attempt is made to review the existing bone grafts, and the developments in tissue engineering that may bring biologic alternatives to enhance the functional capabilities of the bone graft substitutes.

 

Introduction

 

Dento-alveolar bony defects are very common and poise a significant problem in dental treatment and rehabilitation. Reconstruction of dento-alveolar bony defects using minimally invasive techniques would greatly enhance the success and patient acceptance of this area of reconstructive surgery. Over the past three decades, great strides have been made in the field of alveolar bone preservation and augmentation. Review of the literature identify many techniques and materials that have been used successfully to obtain esthetically and functionally acceptable alveolar ridge for successful implant1.

Alveolar bone deficiencies may be attributed to a variety of factors, such as pulpal pathology, traumatic tooth extraction, advanced periodontal disease, implant failure, tumor, or congenital anomalies2. Alveolar bone augmentation is attributed as a highly predictable treatment option to create an appropriate bone contour in implant placement3. Emphasis is being placed on preservation of the alveolar ridge4. This has necessitated development of techniques and materials that promote predictable regenerative treatment1. Augmentation of the resorbed alveolar ridge can be achieved with hard tissue onlays, bone grafting and barrier techniques, bone distraction and bone splitting, and maxillary sinus floor elevation5. Guided bone regeneration (GBR) can increase the width and, to some extent, also the height of the alveolar bone6. Lateral widening is possible with a ridge expansion technique and block grafting approaches7. Significant vertical alveolar bone augmentation can be achieved by distraction osteogenesis techniques8. 

Regeneration refers to the reconstitution of a lost or injured part by complete res-toration of its architecture and function. Alveolar bone regeneration techniques have undergone many advances over a short period of time9. Therefore, reconstruction of alveolar bony defects using minimally morbid techniques enhanced the success and patient acceptance10. The principles of osteogenesis, osteoconduction, and osteoinduction are used to optimize therapeu-tic approaches to bone regeneration. Osteogenesis is a direct transfer of vital cells to the defective area. Osteoconduction embraces the principle of providing the space and a substratum for the cellular and biochemical events progressing to bone formation. The space maintenance allows the correct cells to populate the regeneration zone. Osteoinduction represents the principle of converting mesenchymal-derived cells to osteoblast with the subsequent formation of the alveolar bone11.

 
1.  Alveolar Ridge Defects and Resorption
 

Resorption after tooth-loss has been shown to follow a predictable pattern; the labial aspect of the alveolar crest is the principal site of resorption, which first reduces in width and later in height12. Alveolar bone is resorbed after tooth extraction or avulsion, most rapidly during the initial years. Non-traumatic loss of anterior maxillary teeth is followed by a progressive loss of bone mainly from the labial side. The magnitude of bone loss is estimated to be 40-60 % during the first 3 years following tooth-loss and then decreases to a 0.25 - 0.5 % annual loss rate thereafter13. The cause for resorption of alveolar bone after tooth-loss has been assumed to be due to disuse atrophy, decreased blood supply, localized inflammation or non-fitting prostheses pressure14.

Alveolar ridge defects are classified according to their three-dimensional morphology form, severity, and extent15. A defect limited exclusively to the bucco-lingual direction with normal ridge height has been classified as a class I or class B defect. A bone loss running in the apico-coronal direction only was described as a class II or class A defect. The defect that exists in both axes, i.e., a combined vertical and horizontal defect, has been characterized as a class III or class C defect and has a combination bucco-lingual and apico-coronal resorption of alveolar bone resulting in loss of ridge height and width16,17. The extent of alveolar ridge defect considered mild if less than 4 mm, moderate when 3 to 6 mm, and extensive when greater than 6 mm17. Various bone augmentation tech-niques have been employed to reconstruct these different ridge de-fects. The predictability of the augmentation procedures depend on the horizontal and vertical extents of the defect.


Horizontal / Vertical defects

Autogenous bone graft, in block or particle form, may be con-sidered the most advisable bony graft material to augment in vertical and horizontal dimensions18. The block of bone graft is secured to the recipient site with titanium screws. Autogenous bone graft in particle form can be applied alone or in conjunction with the barrier membrane dur-ing the GBR procedure at the time of implant placement19. In the repair of alveolar defects, grafts from the symphysis and ramus offer several benefits and making it ideal for implant placement. Ramus area provides good bone quality with fewer postopera-tive complications compared to the symphysis area20. Decalcified freeze-dried bone allograft, bone xenografts, and synthetic bone substitutes may be useful when a reduced amount of autogenous bone graft is available21.


Dehiscence/Fenestration defects

A fenestration defect is an isolated bone thickness deficiency at the labial vestibule, while a dehiscence defect is heading in an apical direction. For ideal treatment, it is important to evaluate the extent of the dehiscence/fenestration defect22. An immediate implantation at the time of extraction in combination with GBR procedure might be an ideal option for narrow and small dehiscence/fenestration defects. However, immediate implant placement could be a risky procedure in the presence of large and extensive labial defects. In such cases the treatment of choice is to perform a defect augmentation procedure initially and the implant placement at a later stage23.

 
2. Alveolar Ridge Preservation
 

Osseous deformities of the alveolar ridge resulting from tooth extraction are common. The slower healing pattern after traumatic extraction may make the placement of an implant challenging. Clinical and radiographic studies have demonstrated that marked alterations of the height and width of the alveolar ridge occur following single or multiple tooth extractions24. Longitudinal observations indicated that an estimated 25% volume loss in the first year which may increase to 40% to 60% within the first 3 years25. This percentage is more in the molar compared with the pre-molar region. Wang and Al-Shammari26 demonstrated higher percentage of residual ridge resorption in the mandible com-pared with the maxilla. The healing of sockets in the maxilla progresses faster (because of the greater vascular supply) than those in the mandible, which may lead to a faster resorption pattern27.  Alveolar ridge resorption can be minimized by ridge preservation procedures of extraction sockets using bone grafting with or without barrier membranes4.

 

3.  Osteoinduction and Osteoconduction

 

Bone augmentation materials are classified as osseous conductive and osseous inductive. Osseous inductive bone or bony substitutes take part in the formation of new bone, whereas osseous conductive materials provide a scaffold for bony regeneration without taking part in bone formation itself.

Osseous inductive material in the past has generally been autologous bone transplants. That is, bone harvested from the host and implanted into the prepared bony defects. This results in very successful bone augmentation. However, host bone is not always obtainable; hence the use of new augmentation materials has been developed having different effects on bone28. These compounds may be classified as osteoinducers, osteopromoters or bioactive peptides29.

Osteoconduction describes bone formation by the process of ingrowth of capillaries and osteoprogenitor cells from the recipient bed into, around and through a graft or bioimplant. Therefore the graft or bioimplant acts as a scaffold for new bone formation30. The use of demineralized, freeze-dried, or irradiated bovine and human bone is still a widely used osseous conductive agent with some claims of osseous induction results.



4.  Natural and Synthetic Bone Graft Materials



4.1. Autogenous bone grafts

Autogenous bone grafting is the gold standard for all techniques of osseous reconstruction of the craniofacial skeleton31. Autogenous cancellous bone grafts produce the most successful and predictable results. Free bone grafts act mostly as scaffolds and are thus more osteoconductive than osteoinductive even though osteogenic activity may have remained in the spongious part of the graft30. The major disadvantage of autogenous grafts is the need for a second surgical site and the morbidity resulting from bone harvesting.

There are essentially two forms of nonvascularized free autogenous bone grafts: cortical and cancellous32. Buchardt 30 has summarized the three essential differences between the two. Cancellous grafts are revascularized more rapidly and completely than cortical grafts. Creeping substitution of a cancellous graft initially involves an appositional bone formation phase, followed by a resorptive phase, whereas cortical grafts undergo a reverse creeping substitution process.

The cortical component can be incorporated into the fixation of the graft and can consequently be used in situations where bone is comminuted or where there are bone voids. In the craniofacial skeleton these forms of grafts may also be used to onlay areas such as decreased vertical or horizontal alveolar ridges, to improve facial contours or they can be inlayed within bone to fill bony voids. Common sites for the harvesting of cortical grafts are the cranial vault, ribs and the medial or lateral table of the anterior aspect of the iliac crest, the posterior iliac crest as well as the mandibular symphysis33.

Cancellous grafts have more widespread applications, are generally easier to manipulate and revascularize more rapidly34. The most abundant source of cancellous bone is the anterior or posterior iliac crest. Cancellous bone imparts no mechanical strength so that when it is used to reconstruct large continuity defects additional stability and rigid fixation is required. In the craniofacial skeleton these grafts are packed into bony defects such as alveolar clefts and maxillary sinus floor elevations35.

The corticocancellous graft usually produces the best results by combining the attributes of both graft forms and can be place easily into an interpositional location36. These grafts allow for mechanical stabilization while at the same time providing for good revascularization. Particulate bone grafts (corticocancellous bone) can be very advantageous for the restoration of continuity defects in the jaws .They can easily be harvested from intra oral sites using a specially designed bone harvesting device or suction trap to collect the bone chips produced by drilling in to the surface bone of a donor site.

 

4.2 Allogenic bone grafts

Allogenic bone is non-vital osseous tissue taken from one individual and transferred to another individual of the same species. There are three forms of allogenic bone: fresh frozen, freeze-dried and demineralized bone matrix (DBM). Fresh frozen bone is rarely used today for the purpose of bony reconstruction in the craniofacial skeleton because of concerns related to the transmission of viral diseases30.

Freeze-dried bone allograft (FDBA) works primarily through osteoconduction. It acts like a scaffold for natural bone to grow into. Eventually FDBA is resorbed and replace by new bone37. DFDBA (Demineralized Freeze-Dried Bone Allograft) is believed to induce bone formation due to the influence of bone-inductive proteins called bone morphogenetic proteins (BMPs) exposed during the demineralization process. DFDBA is therefore thought to be osteoinductive and osteoconductive38. Human mineralized bone (Puros®) is a new cancellous bone allograft that undergoes with solvent preservation method to preserve the trabecular pattern and mineral structure better than the freeze-drying process, thus being a more osteoconductive material39. Demineralized bone matrix (Grafton®) is processed from cadaver long bones by removing lipid, blood, and cellular components before it is frozen. Then, it is milled into elongated fibers and combined with a glycerol carrier to stabilize the proteins and improve the graft handling. It can be used in the flex form, as putty, or as matrix plugs40.

4.3 Xenografts

Xenogeneic bone grafts consist of skeletal tissue that is harvested from one species and transferred to the recipient site of another species. These grafts can be derived from mammalian bones and coral exoskeletons. Bovine derived bone has been commonly used41, even though other sources such as porcine or murine bones are available. This inorganic bone matrix then has the structure of bone making it osteoconductive without the osteoinductive abilities imparted by the organic elements. Eventually xenogenic bone should be replaced by host tissue, which would make it useful for defect or extraction site filling in the alveolus prior to dental implant placement or prosthetic rehabilitation42. Since the material is usually a powder it may require some form of retentive structure such as a membrane to keep the xenograft in the desired location43. The bovine-derived bone particulate (Bio-Oss®) was found often undergoes remodeling and resorption at a very slow rates which is more advantages for osteoconductive properties44. Coral granules (Biocoral®) derived directly from the exoskeleton of corals are used as xenogeneic transplant45. Since the use of coral-derived granules gives rise to bone with the material's eventual replacement, it could decrease morbidity by avoiding a bone graft harvested donorsite46.

 

4.4. Synthetic Bone Substitutes

Alloplastic bone substitutes are synthetic substances that have been processed for clinical use in osseous regeneration. There are three types of alloplastic substances in clinical use today: hydroxyapatite, other ceramics and polymers.

Hydroxyapatite (HA) is a ceramic and can be divided into two groups depending upon its ability to resorb47. The porous form of HA allows rapid fibrovascular tissue ingrowth, which may stabilize the graft and help resist micromotion48. HA can be machined to many shapes or consistencies. HA has several potential clinical applications including the filling of bony defects, the retention of alveolar ridge form following tooth extraction and  as a bone expander when combined with autogenous bone during ridge augmentation and sinus grafting procedures49. One of the major drawbacks is the tendency for granular migration and incomplete resorption50.

Tricalcium phosphate (TCP), bioglasses, and calcium sulphate are also used as synthetic bone substitutes51. TCP is similar to HA, being a calcium phosphate with a different stoichiometric profile52. Clinically the one disadvantage with TCP is its unpredictable rate of bioresorption. Its degradation has not always been associated with concomitant deposition of bone53.  Two products (Norian SRS® and Bone Source®) have been used for the repair of cranial vault defects.

Bioactive glasses have the ability to chemically bond with bone54. Bioactive glasses may have osteoinductive properties and have been tested in animal trials55. In order to preserve the form of the alveolar ridge after tooth-loss, bioactive glass root replicates have been introduced56. While these are able to preserve the crestal width and height of the alveolus, they may impair the later placement of dental implants due to incomplete resorption

The future of bone regeneration could lie with this class of synthetic materials57. These materials could be better utilized once their ability to resorb at variable rates and over set periods of time is better understood and an appreciation for their compatibility with the emerging bioactive agents is developed. The idea would be a completely synthetic bioimplant, which is predictably degradable and is innately osteocompetent57. Such synthetic materials could also play a very important role in tissue engineering58, serving as bioactive scaffolds.

 


4.5. Osteoactive Agents

Osteoactive agent is any material which has the ability to stimulate the deposition of bone. These may be classified as osteoinducers, osteopromoters or bioactive peptides28.


Bone morphogenetic proteins (BMP) has been shown to have osteoinductive properties59. It is recognized to be part of a larger family of growth factors referred to as the TGF-ß superfamily60. BMPs have unique properties in inducing ectopic bone formation61. BMP acts as an extracellular molecule that can be classified as a morphogen as its action recapitulates embryonic bone formation. One of the challenges in the use of BMP is in its delivery to a site of action. As a morphogen BMP is rapidly absorbed into the surrounding tissues dissipating its effectiveness. Many different carrier vehicles have been used to deliver BMP including other noncollagenous proteins, DBM, collagen, HA, PLA and or PGA combinations, calcium carbonate, calcium sulphates and fibrin glue62.


Transforming Growth Factor:  The proteins in the family of transforming growth factor ß (TGF-ß) should be considered as osteopromoters, agents, which enhance bone healing. TGF-ß is found in the same supergene family as BMP.
TGF-ß has been shown to participate in all phases of bone healing63. During the initial inflammatory phase TGF-ß is released from platelets and stimulates mesenchymal cell proliferation.
TGF-ß may be more effective than BMP in those situations where enhanced bone healing is preferred to bone induction64. Moreover, combinations of BMP and
TGF-ß, may enhance the osteoinductivity of an implant while, at the same time, making it osteopromotive. As with BMP, carrier vehicles for the delivery of TGF-ß are under development.


Platelet-Derived Growth Factor: Platelets are known to contain a number of different growth factors which are released into the tissue after injury. These include, transforming growth
factor-ß, platelet-derived growth factor, insulin-like growth factor, and fibroblast growth factor which act as differential factors on regenerating periodontal tissues65. These factors may play a role in initiating graft healing. Platelet rich plasma (PRP) is one potential source of concentrated platelets that could be used in bone regeneration66. Platelet derived growth factor (PDGF) is known to stimulate the reproduction and chemotaxis of connective tissue cells, matrix deposition67.


The Platelet-rich plasma (PRP) contains 500,000 to 1,000,000 platelets, which are mixed with a thrombin/calcium chloride (1,000units/10%) solution to form a gel. This gel can then be used in conjunction with bone regeneration materials such as HA or DBM as a source of autogenic growth factors. When used in combination with autogenous bone, PRP is reported to increase the maturation rate of a bone graft up to 2 fold and also increase the bone density of the graft68.


Enamel matrix (Emdogain®) derivative and freeze-dried protein are a group of proteins isolated from animals69. Clinical trials of enamel matrix derivative have demonstrated some potential for bone regenerative therapy; however, additional studies are needed70.


Collagen-binding peptide (Pep-Gen p-15®) has been used recently for periodontal regeneration71. P-15 is reported to attract and bind osteoblasts with the bone grafting matrix. Additional clinical and histological data are needed to establish true bone regeneration using this material72.

Stem cells: The area of tissue engineering has brought to the forefront, the possibilities of hybrids of biomaterials seeded with osteocompetent cells to be used as an implant. The "hybrid graft" could consist of a porous matrix, on which bone marrow cells could grow73. The use of bone marrow as the source of cells is logical as bone marrow contains stem cells which have the potential to differentiate along various pathways and lines, including the direction of bone producing osteocompetent cells74. The development of such hybrids, the culturing of bone cells and improvements in cell storage methods may be the way of the future and could also diminish donor site morbidity by the elimination of the donor site.

 


5. Resorbable and Nonresorbable membranes

 

A wide range of membrane materials have been used in experimental and clinical studies to achieve bone regeneration concept. These membranes are primarily  used for space making function, promote the ingrowth of osteogenic cells and to prevent migration of undesired cells75. In addition, tissue reactions resulting from the resorption of the membrane should be minimal. Other factors in the selection of membranes are the size of membrane perforations, membrane stability, duration of barrier function, enhanced access of bone and bone-mar-row-derived cells to the area of regeneration, ample blood fill of the space, and prevention of soft tissue dehiscence76.


Nonresorbable membranes  are  available as expanded polytetrafluoroethylene (ePTFE), titanium reinforced ePTFE, or titanium mesh77. The ePTFE membrane (Gore-Tex®) is considered a standard for bone augmentation78.  In situations where bone regeneration is desired in large defects, conventional ePTFE membranes may associate with space collapse prob-lems unless supported by grafting materials6. The alternative approach involves the use of membranes with a sta-ble form, such as titanium-reinforced membranes79. Maintenance of primary wound closure throughout the healing period is critical for nonresorbable mem-branes. The potential complications are soft tissue dehiscence and membrane exposure which might increase the potential for infection80.


Bioresorbable Membranes: Currently, polylactic and polyglycolic acid, copolymers and collagen membranes are the main products of bioresorbable barriers. The main advantage of resorbable membranes is that they do not require a reentry surgery to remove the membrane81. Collagen membrane (Bio-Gide®) afford an effective function of inducing platelet aggregation, which facilitates early clot formation and wound stabilization that are considered essential requirements for successful bone regeneration. Collagen membrane also may inhibit epithelial migration and promote new fibroblast attachment that aids in primary wound closure82. There are two main variables with absorbable barriers. The first relates to absorption time of the membrane. The second variable relates to the breakdown products of the absorbable membranes. Most membranes break down by hydrolysis into acids or esters. Improved soft tissue healing and less chances of membrane exposure are some of the advantages of using absorbable membranes80.


Acellular dermal allograft (AlloDerm®) is derived through a process of removing the epidermal layer and all cells within the dermis. AlloDerm has also been incorporated in ridge preservation and endosseous implant surgical applications. It is also used as a barrier membrane with particulate bone grafting materials83.

 


6.  Procedures to Augment Existing Alveolar Bone

    

There are a number of techniques, which enable the surgeon to maximize the available bone in the craniofacial skeleton without harvesting a bone graft. An appreciation of these existing techniques and strategies will help us understand the future application of tissue engineering to dento-alveolar and craniofacial osseous reconstruction. These techniques serve to minimize reconstructive morbidity, as there is no graft donor site:

Osteocondensation is one such technique. It can reshape the morphology of the alveolar bone of the maxilla, for example, by compacting it in various directions using the condensing chisels or plungers. The procedure can establish a new contour for the bone being condensed. This allows the clinician who is placing dental implants to more optimally house a dental implant, resulting in better primary stability in areas of poor bone quality. Orthopedic surgeons have practiced osteocondensation since the early 1960s84. The major advantage of this technique is that an implant bed is created with either minimal drilling or no bone removal and with osteotomes, which compress the bone85. There are implants, which produce osteocondensation and are called press-fit fixtures86. In the craniofacial skeleton, osteocondensation is best performed in the maxilla.

The main advantage of osteocondensation is that it can achieve an increase the width of alveolar bone and sinus floor elevation without opening the lateral sinus wall87. The technique was further developed to include the use of D-shaped osteotomes and chisels which produced lateral widening of the alveolar ridge with osteocompression, increasing the density of cancellous bone85,88. The ridge expansion osteotomy is achievable using osteotomes which have concave tips and sharpened edges. The instruments are shaped to allow progressively larger osteotome tips to fit into the opening created by the previous osteotome. Instruments are sensitive to changes in bone texture and density and allow excellent tactile sensation for the surgeon. The minimum alveolar width necessary for lateral alveolar widening by compression is 2-3 mm assuming that spongy bone is found between cortical layers86.

Lateral widening by completely exposing the labial cortex has also been introduced89. The major benefit of crestal widening is that it allows the thin alveolar bone to be utilized for implantation without grafting90. Esthetics and implant positioning are improved and wider implants can also be used. The bone can be moulded to some extent due to its plasticity85. Bone compression is achieved along with an increase in the density of trabeculations of the adjacent site91.

Crestal split technique: Alveolar ridges can also be widened using the crestal split technique using osteotomes and chisels to produce a "greenstick fracture" at the base of the alveolus. The remaining periosteum is left intact and attached to the bone. This pedicled buccal cortex is repositioned and a new implant bed is created without any drilling. The thickness of the osseous ridge may be augmented by modifying the morphology of the preexisting bone with the split-crest technique or ridge expansion with osteotomes92. Scipioni et al.93 reported a 5-year success rate of between 88% and 93% for the split-crest technique in single-tooth implant placement. The ridge expansion technique requires preparation of the implant site by means of a series of cylindrical osteotomes of increasing diameter. This pro-cedure expands the bone tissue by compressing the cancellous bone. The implant is positioned when the required diameter of the implant site is reached94.

Distraction osteogenesis: The distraction osteogenesis (DO) technique has also been adapted for limited augmentations of the alveolar crest prior to implantation. Some systems use hardware, which expands the jaw over time, and then is removed at the time of dental implant placement95. The implant itself can be used as the distraction device96. The daily rate of alveolar crest distraction ranges from 0.25-0.5 mm and is initiated from two days to one week after the primary osteotomy. DO is continued up to 30 days and the final gain will be between 4 and 7 mm90,97.

Distraction osteogenesis has been applied to achieve vertical bone augmentation before implant placement98. The surgical technique requires a full-thickness facial flap to gain access to the bone surface. The lingual flap is left in place to preserve blood supply to the trans-ported bone segment. A horizontal osteotomy is then performed by means of an oscillating saw and burs, and the distractor is secured. Vertical cuts are then made to mobilize the bone segment to be distracted. The flap is sutured, and a provisional prosthesis is applied. After that, the distractor is gently activated to achieve progressive bone separa-tion, until the required height of bone is obtained. The distractor is removed after that and the im-plant is placed99. Distraction osteogenesis may be attempted to augment bone thickness horizontally100. Potential risks of this technique include distractor instability, flap dehiscence, premature consolida-tion, and bone segment fracture. Appliances allowing three-dimensional DO have been introduced95. The benefits of DO are that donor site morbidity from harvesting of bone grafts and dehiscences of grafted bone are avoided101.

Guided Bone Regeneration (GBR) is a technique in which bone growth is enhanced by maintaining the space and preventing soft tissue in-growth into the area utilizing either a resorbable or non-resorbable barrier membrane. GBR has become a predictable surgical technique to enhance new bone formation in alveolar ridge augmentation, even though it is being highly technique sensitive and requires high surgical skill2. Improvements in this technique have led to its wide-scale clinical applica-tion to augment horizontal and vertical defects, treat implant fenestra-tion or dehiscences, and permit immediate implant placement in large alveolar sockets4,102. The main surgical goal in the application of GBR is protecting the space for bone regeneration under-neath the membrane barrier, permitting blood clot stability and migration of osteogenic cells, and excludes soft tissue penetration9,103. Different tech-niques have been developed to achieve this goal. Buser et al.104 pro-posed the use of mini-screws to cre-ate and maintain the space under-neath nonresorbable barriers. Metallic membranes or membranes supported by a titanium mesh have been tested successfully31,105-107.

Summary

 

 

Bone augmenting procedures have become widely used in implant treatment. The aim of augmentation is to create predictable function and esthetics in cases with insufficient bone quantity. Management of such compromised situations is a challenge and has resulted in a number of clinical protocols involving augmentation techniques and procedures, ranging from minor augmentation of localized defects to major augmentation procedures involving onlay, distractions and sinus lifts. In almost all these cases there is a need for bone material or bone substitutes. Even though extensive research during the last decade has focused on developing alternative materials, autogenous bone is still regarded as the ideal material for bone augmentation.

 
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