Alveolar Bone

Grafting and
Reconstruction
P ro c e d u re s P r i o r t o
I m p l a n t Pl a c e m e n t
Harry Dym, DDS, David Huang, DDS*, Avichai Stern, DDS

KEYWORDS
 Alveolar bone grafting  Implantation  Nonunion
 Bone harvest

BONE ANATOMY AND HISTOLOGY

Before implant placement, adequate bone must be present. This step is fundamental
to treatment planning for implants. Understanding the basics of bone grafting and
reconstruction techniques is critical for successful implant placement.
The maxilla and mandible are derived from the first branchial arch through intra-
membranous ossification. During embryologic development neural crest cells migrate
along the cartilaginous scaffold of the jaws to begin bone formation.1 Mature bone can
be classified into two types, cortical and cancellous. Cortical bone is the dense outer
layer of bone, and is minimally porous and rigid. Cancellous (trabecular) is less dense
than cortical (compact) bone; it is housed within compact bone and is structurally
different. Both types of bone involve a thin connective tissue covering. The periosteum
is immediately superficial to cortical bone, whereas endosteum surrounds the trabec-
ular bone. Both the periosteum and endosteum are sources of osteoprogenitor cells,
which are capable of differentiation into osteoblasts.

Bone Histology
Cortical bone consists histologically of parallel series of osteons (Haversian systems).
Each osteon consists of a central Haversian canal surrounded by concentric layers of
bone, or lamellae, interspersed with osteocytes. Osteons are connected to each other
and the periosteum by oblique channels called Volkmann canals. Osteocytes, housed
in lacunae, are differentiated osteoblasts that exchange nutrients and metabolic waste

Department of Dentistry/Oral & Maxillofacial Surgery, The Brooklyn Hospital, 121 DeKalb
Avenue, Box 187, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: Ddsdavidhuang@yahoo.com

Dent Clin N Am 56 (2012) 209218

doi:10.1016/j.cden.2011.09.005 dental.theclinics.com
0011-8532/12/$ see front matter 2012 Elsevier Inc. All rights reserved.
210 Dym et al

through cytoplasmic processes via a network of small canals, or canaliculi. Trabecular

bone also forms lamellae, but lacks the arranged systems as in compact bone.
Cancellous bone is responsible for hematopoiesis, bone remodeling, and
regeneration.
There are largely 4 different cell types responsible for the generation of bone: osteo-
progenitor cells, osteoblasts, osteoclasts, and osteocytes. Osteoprogenitor cells,
which are derived from mesenchyme, are the precursors to osteoblasts. These cells
are found within the periosteum, endosteum, and compact and cancellous bone.
Osteoblasts are found within the periosteum and trabecular bone; they are respon-
sible for bone formation and produce osteoid, a collagenous matrix. Once osteoblasts
are encompassed by osteoid they have produced, they continue to differentiate into
osteocytes, which function in the maintenance of bone. Osteoclasts are derived
from monocytes and are responsible for bone resorption.

Bone Healing
Bone heals through either primary or secondary mechanisms. Primary healing involves
rigid fixation with close approximation between bone fragments. At the interface of the
adjoining ends, osteoclasts form a cutting cone that crosses the gap and resorbs
existing bone. Behind them, fibrovascular tissue and osteoblasts begin to secrete
osteoid. With maturation these become new Haversian canals. Secondary healing
involves the formation of a callus scaffold, within which osteoid is secreted and
then mineralized. This process takes place in 3 stages: inflammatory, repair, and
remodeling. In the inflammatory stage, a hematoma develops within the fracture site
while macrophages, fibroblasts, and other inflammatory cells migrate to the site.
The repair stage results in the formation of granulation tissue, ingrowth of vascular
tissue, and migration of mesenchymal cells. As vascular ingrowth proceeds, osteoid
is secreted and subsequently mineralized, which leads to the formation of a soft callus
around the repair site. The callus then ossifies, forming a bridge of woven bone. The
remodeling stage extends from months to years, with full functional strength typically
achieved in 4 to 6 months.
The physiology of bone graft healing has many similarities to primary or secondary
healing. The origin, structure, and size of the graft will dictate how the graft heals. Prin-
cipally grafts heal through a combination of 3 processes2: osteogenesis, osteoinduc-
tion, and osteoconduction. Osteogenesis is the formation of new bone from
osteocompetent cells, and is the only process whereby the graft itself can produce
new bone. Osteoinduction induces formation of bone from the differentiation and stim-
ulation of mesenchymal cells by the bone-inductive proteins. Osteoconduction is the
formation of bone along a scaffold from osteocompetent cells of the recipient site.
The structure of the bone harvest affects how the graft will incorporate into the
recipient site. Cortical block grafts heal through creeping substitution. Once the graft
is fixed to the site, osteoclasts begin to resorb the graft material through existing
Haversian systems. This process allows for ingrowth of fibrovascular tissue and the
secretion of osteoid by osteoblasts, similar to primary bone healing. The osteoid
then proceeds through mineralization and remodeling. Unfortunately, cortical block
grafts are not fully resorbed and exist as a mixture of newly formed bone around
necrotic centers.2
Bone grafts that are particulate in nature share similar processes of secondary bone
healing. Unlike cortical block grafts, particulate grafts begin with apposition of osteoid
and fibrovascular ingrowth through the existing particulate scaffold. Apposition is then
followed by resorption and replacement of graft material by more organized lamellar
bone. Due to increased vascularization, particulate grafts have greater resorption of
 Reconstruction Prior to Implantation 211

the transfer bone and a larger percentage of newly formed bone in comparison with
cortical grafts.

TYPES OF GRAFTS

Bone grafts can be categorized in many different ways. The discussion here classifies
grafts based on origin.
Autogenous grafts, taken from a second surgical site in the same patient, are
considered to be the gold standard in oral bone grafting. Autogenous bone grafts
have been shown to be superior to allogenic bone, xenogeneic bone, bone substi-
tutes, and alloplasts in terms of the function, form, and adaptability.2 Because the
bone is autogenous there is no immunogenic graft rejection. Sites of harvest can be
locoregional or distant. Autografts provide the only source of transfer of osteocompe-
tent cells. Healing occurs through osteogenesis, osteoinduction, and osteoconduc-
tion. Disadvantages of this graft include increased operating time as well as patient
discomfort and morbidity at donor sites.
Allografts are taken from different members of the same species, the most common
source being cadaveric. The antigenicity of this bone is reduced through various
processes, frequently freeze-drying. Allografts can be used in conjunction with auto-
graft to increase the volume of the autograft. Graft healing occurs through osteoinduc-
tion and/or osteoconduction. Advantages of allograft include reduced operative time
and no morbidity at the donor site. Though negligible, allografts carry the risk of
disease transmission. The risk of human immunodeficiency virus transmission is esti-
mated to be 1 case in 1.6 million.3 Hepatitis B and C can also be transmitted.4 Lastly, it
is important to discuss the nature of the allograft with the patient to ensure there is no
objection for personal, cultural, or religious beliefs.
Xenografts are derived from genetically dissimilar species, mainly bovine or porcine.
These grafts are largely osteoconductive and serve as a scaffold for creeping substi-
tution.5 Though negligible, antigenicity and infectious disease transmission are also
issues with these grafts. The advantages of xenografts include reduced operative
time and no morbidity at the donor site. By contrast, compared with allografts, xeno-
grafts provide less resorption of graft substrate and form less new bone during the first
few months.6
Alloplastic grafts are derived from inert synthetic materials. Examples include
hydroxyapatite crystals, glass ionomer, bioactive glasses, and tricalcium phosphate.
There is no cellular or protein material within these grafts. As a group these materials
provide variable resorption rates and operate through osteoconduction. Disadvan-
tages of alloplasts include increased resorption time and decreased new bone forma-
tion when compared with allografts or xenografts.5
Another type of graft that has gained popularity in recent years incorporates the use
of bone morphogenic proteins (BMPs). BMPs are a group of 20 proteins found in bone
that act as cytokines and metabologens.7 From this group, BMP2 and BMP7 induce
the formation of bone and cartilage. These proteins are produced using recombinant
DNA technology, with applications in dentistry and orthopedic surgery. Advantages of
BMP include decreased patient discomfort, no risk of disease transmission, and
decreased operative time. Disadvantages include localized swelling and increased
costs as compared with other bone grafting alternatives.

SURGICAL PRINCIPLES OF GRAFTING

The successful incorporation of bone grafts relies on many different factors. According
to Misch5 these factors are surgical asepsis, soft-tissue coverage, graft immobilization,
212 Dym et al

host site preparation, host bone-regeneration capacity, and optimization of growth

factors such as BMP.
The oral cavity, at best, is considered a clean contaminate environment, and sterile
placement of any graft is virtually impossible. Surgical asepsis refers to the lack of
acute infection to the best of the surgeons ability. Regardless of the type, grafts
can dissolve in pH of 5.5 or less. Infection within bone often results in a pH of 2 and
increases the risk of bone loss or insufficient bone volume formation. Antibiotics,
such as penicillin or clindamycin, can be mixed with the graft to decrease bacterial
contamination.5
Tension-free soft-tissue coverage helps maintain the graft by encouraging osteo-
competent cell proliferation and healing by primary intention. Proper technique for
of onlay grafts includes flap design, adequate releasing incisions, and scoring of the
periosteum. Silk or Vicryl sutures provide better strength and adaptability than does
chromic suture.
Graft mobilization may result in fibrous encapsulation and nonunion to the host
bone. By ensuring stability of the graft, the blood clot and associated growth factors
can be maintained and allowed to heal; this will lead to development of granulation
tissue with accompanying vascular supply. Without this stability, graft may be jeopar-
dized. Excessive movement disturbs the blood supply and can create a sequestrum of
the graft. To this end, it is important to ensure that no contact occurs between any
existing dental prosthesis and the soft tissue overlying the membrane or graft.
Misch5 elaborates on the process of the regional acceleratory phenomenon
whereby in response to noxious stimuli, tissue heals faster than during the normal
regeneration process. To initiate this phenomenon, holes are drilled into the site of
the host cortical bone at low speeds under copious irrigation to minimize thermal
necrosis. Perforation of the host cortical bed allows for vascular access from blood
vessels within trabecular bone, which increases the release of growth factors and
expedites revascularization.
Optimizing revascularization from the host bone provides grafts with adequate
growth factors and pluripotential perivascular cells that can differentiate into osteo-
blasts. The source of blood vessels affects the type of tissue that forms in and
around empty alveolar sockets and graft. Drilling holes in the host cortical bed
aids with transfer of osteocompetent cells. Providing a soft-tissue barrier for the graft
delays invasion from surface fibroblasts that may inhibit osteogenesis. Application of
resorbable or nonresorbable membrane is well established in promoting bone
regeneration.8
Providing local growth factors such as platelet-derived growth factor, vascular
endothelial growth factors, transforming growth factors, and bone morphogenetic
proteins can enhance formation and mineralization of bone. Platelet-rich plasma,
produced from the patients whole blood through a double-centrifuge technique,
can be utilized to increase the localized growth factors. BMP can be added by
including autograft in the site.

BONE HARVEST SITES

Autogenous bone remains the gold standard for bone grafts, its main limitation being
increased operative time and possible donor-site complications and morbidity. The
choice of donor site depends largely on the size of the defect. Intraoral bone harvest-
ing can be performed in the office under local anesthesia. Small blocks of bone can be
harvested from the mandibular symphysis, ramus, maxillary tuberosity, or exostoses.
Sittitavornwong and Gutta9 discuss these techniques. It is important during any
 Reconstruction Prior to Implantation 213

harvest procedure to ensure protection of vital anatomy such as mental nerves, maxil-
lary sinuses, and teeth.
For socket or particulate grafting, the maxillary tuberosity can provide approxi-
mately 2 cm3 of bone. After local infiltration, a crestal incision is made along the tuber-
osity. A full-thickness flap is exposed to access the site on both the buccal and palatal
aspect. Vital structures to avoid include the maxillary sinus and greater and lesser
palatine vessels. The tuberosity can then be removed with rongeurs. Lack of sinus
perforation should be verified, before simple closure.
For cortical block graft, the lateral ramus can provide 1.5  3 cm2. Incision for this
harvest is made slightly distal and lateral to the most posterior tooth, and continues
along the external oblique ridge (Fig. 1). Three complete osteotomies and one partial
osteotomy are made, with one complete superior and two complete vertical cuts
through cortical bone. The last osteotomy is made by using a round bur to create
a horizontal groove along the inferior border. The superior osteotomy is made from
the second molar region, and continues posteriorly and vertically along the ascending
ramus. The cut is approximately 5 mm medial to the external oblique ridge and
extends to the size of the defect or about 3 cm. Next, anterior and posterior vertical
cuts 12 to 15 mm in length are made in the superoinferior direction. Lastly, the inferior
groove is made with a round bur. The harvest site is then carefully separated with
a small chisel. Excessive bleeding can be controlled with pressure and hemostatic
agents.
The mandibular symphysis is another harvest site for providing monocortical grafts.
The symphysis can be approached through either a sulcular or vestibular incision
(Fig. 2). Vital structures include the bilateral mental nerves. The vestibular incision is
preferred when the anterior mandibular periodontium is less than optimal. This incision
is made anterior to the mental nerve, through the mentalis at a beveled angle at the
depth of the vestibule. This action facilitates reattachment of the mentalis during
closure, which is performed in two layers, mentalis and mucosa. The sulcular incision
is made with a bilateral distal releasing incision posterior to the mental foramen.

Fig. 1. Osteotomies for lateral ramus graft. (From Sittitavornwong S, Gutta R. Bone graft
harvesting from regional sites. Oral Maxillofac Surg Clin North Am 2010;22(3):320; with
permission.)
214 Dym et al

Fig. 2. Incisional approaches to harvesting the mandibular symphysis. Sulcular in black and
vestibular in red. (From Sittitavornwong S, Gutta R. Bone graft harvesting from regional
sites. Oral Maxillofac Surg Clin North Am 2010;22(3):319; with permission.)

Closure is through the mucosa, ensuring reapproximation of interdental papilla. Once

exposed the mandibular symphysis harvest can provide about 10  30 mm2 of mono-
cortical block bone (Fig. 3). The superior osteotomy should begin at least 5 mm below
the root apices. The vertical osteotomies should be no closer than 5 mm medial to the
mental nerves. The final depth of the osteotomies depends on the corticocancellous
block required, but is usually no more than 5 to 6 mm. An outline of the osteotomy
is marked by creating a series of dots with a small round bur around the periphery

Fig. 3. Osteotomies to outline the harvest are created with a small round bur and then
fissure bur (A, B). A thin chisel is then used to complete the harvest (C, D).
 Reconstruction Prior to Implantation 215

of the proposed site. After verification, the outline is connected with small fissure bur.
A thin chisel is then used to complete the osteotomy, freeing a block of corticocancel-
lous bone.
For larger amounts of cortical, corticocancellous, or cancellous bone, distal sites
including the tibia, anterior iliac crest, posterior iliac crest, and the calvarium can
also be harvested. Zouhary10 summarizes the amount of bone that can be harvested
from each site in Table 1.
Although all harvest sites can be safely obtained, the range of potential complica-
tions is more serious in distant-site harvests and can include ileus, gait disturbance,
fracture, dural tear, epidural or subdural hematoma, stroke, and death. Nonetheless,
the risk of complications is relatively small. Tessier and colleagues11 reported their
combined complication rate for major bone graft donor sites in their 20,000 cases;
they reported a 0.3% to 0.5% compilation rate for each type of bone harvesting.
Cases requiring larger amounts of bone to be harvested from these sites should be
referred to an oral surgeon.

BONE GRAFT

One of the important factors in determining application of the bone graft is the type
and size of the recipient defect. Misch12 elaborates on how each type of defect is
restored. In a 5-wall defect, as in an empty socket, any graft material will work.
Four-wall defects will require a graft with membrane for guided bone regeneration.
Two to 3 wall defects are best grafted with autogenous bone that can be mixed
with allograft and guided bone regeneration with a rigid membrane. A 1-wall defect
should be treated with onlay grafts or other advanced techniques for augmentation.
The extraction socket heals through formation of a blood clot which is replaced by
connective tissue. In time, woven bone replaces this tissue and then is remodeled into
lamellar bone. The entire process takes 3 to 4 months. While being preferred by
patients in the authors practice, immediate placement of implants is not always
possible, given the remaining bony contour after extraction. To make matters worse,
waiting for secondary healing to occur may not benefit the patient. Lekovic and
colleagues13 note that 60% of the alveolar width and 40% of the height may be lost
in the first 6 months after dental extraction.
To maintain the dimensions of the alveolar ridge, grafting of the empty socket has
been shown to help preserve the height and width in comparison with extractions
alone.14 Socket grafting is easier with 4 or 5 wall defects. The procedure begins
with an atraumatic extraction. Many instruments such as the periotome, luxator,
and physics forceps have been developed to aid preservation of alveolar bone. It is

Table 1
Typical noncompressed graft volumes available for harvest

Noncompressed
Corticocancellous (cm3) Cortical Block (cm)
Tibia 2540 12
Anterior ilium 50 35
Posterior ilium 100125 55
Calvarium Minimal Abundant

Data from Zouhary K. Bone graft harvesting from distant sites: concepts and techniques. Oral Max-
illofac Surg Clin North Am 2010;22(3):30114.
216 Dym et al

important to plan ahead and section the tooth or bone as needed. Once the extraction
is completed, the socket is thoroughly curetted to remove any granulation or fibrous
tissue. Active purulent drainage is a general contraindication for socket grafting. If
acutely infected, grafting should wait until the infection has resolved.
The graft is then chosen. It is important to remember that autogenous grafts are
considered the gold standard and can always be mixed other grafts if the volume is
deficient. The material is placed into the socket without forceful compacting. Lastly,
the graft is covered with a membrane and possibly relaxed soft-tissue coverage.
Membranes are generally classified as resorbable or nonresorbable. Choice of
membrane depends on the amount of time needed for socket healing. Resorbable
membranes are used when the healing time is approximately 3 months. A minor
full-thickness flap is extended beyond the crest of the buccal and lingual/palatal
cortical plate. The selected membrane is cut to size and tucked to the depth of the
buccal and palatal/lingual flap. Interrupted sutures are then passed to secure the
membrane. Alternatively, if adequate relaxation can be obtained, a buccal full-
thickness periosteal flap can be exposed and scored to obtain primary closure. The
membrane serves two functions: to contain the blood clot and the graft within the
socket, and to prevent fibrous ingrowth that would inhibit bone formation. When the
alveolar crest height has been compromised, as in loss of buccal cortical plate,
a more rigid membrane may aid regeneration of height and width of the alveolar
bone. Titanium-reinforced membranes have been used with good success.
Sclars Bio-Col technique has also been used with good success for socket preser-
vation. The prepared extraction sockets are grafted with Bio-Oss, a natural, porous
bone-grafting material. Next, the grafted socket is isolated with an absorbable
collagen material. A temporary prosthesis is then fitted over the membrane to provide
support to the membrane and help preserve the normal preextraction gingival contour.
The technique uses minimal flap elevation for primary closure.15
When the alveolar ridge is deficient in the horizontal or vertical direction, implant
placement can be problematic. Adequate alveolar height improves the support of
dental implants by decreasing the crown-to-implant ratio. Adequate width allows
the practitioner to use a larger implant, increasing the surface area of osseointegra-
tion. Onlay grafts from either regional or distal sites are often used to resolve these
problems. Once the graft is obtained, it is placed in normal saline to preserve vitality.
Blood is not a viable solution, as red blood cells lyse and create an acidic environment.
The host site is prepared in accordance with optimum surgical principles already
described. Next, the graft is shaped to conform to the deficient site, and any sharp
ledges of bone are removed with a bur under copious irrigation. Placement of the
onlay graft is preformed with a lag-screw technique, ensuring that vital anatomy is
maintained. The lag-screw technique involves predrilling holes in the graft and then
passing screws that are smaller in diameter than the drilled holes into the recipient
bed. Two titanium screws are used to prevent rotation of the graft. Allograft can
then be placed around the border of the secured graft and covered with a membrane.
The addition of allograft and corresponding membrane to the site is optional, and
depends on the size and shape of the defect and graft. The entire site is then closed
with tension-free primary soft-tissue coverage. Tissue dissection beyond the releasing
incision and scoring the periosteum of the flap will aid in advancing the tissue for
closure.
Additional advanced techniques for alveolar ridge reconstruction include interposi-
tion bone grafting, alveolar split technique, and distraction osteogenesis. Complete
operative details for these various techniques are beyond the scope of this article,
but are important options to provide for patients.
 Reconstruction Prior to Implantation 217

Interpositional bone graft, also known as sandwich osteotomy, is used for

increasing vertical height in the severe atrophic maxilla and mandible. The advantages
of sandwich osteotomy include minimal bone resorption and stability as compared
with onlay bone grafting.16 The procedure entails a vestibular incision with minimal
soft-tissue exposure to make a horizontal and two divergent vertical osteotomies.
The cut segment is then elevated, the graft inserted, and a miniplate secured to main-
tain elevation of the initial osteotomized segment. The wound is then closed primarily
and allowed to heal for from 4 to 6 months.
Alveolar ridge split osteotomies are used to widen thin ridges of less than 3 to 4 mm
and are used to gain to 2 to 3 mm of width, achieved through a crestal incision with
minimal reflection. The ridge is then spilt with small osteotomes used in increasing
size to force the direction of the split buccally. The site is then grafted and closed
primary with split-thickness dissection of the mucoperiosteal flap, or covered with
a membrane and closed with sutures. Implants often are simultaneously placed with
bone graft.
A variation of the alveolar split is the island flap osteotomy. The two techniques are
identical until the buccal bone is split. At this point, to complete an island flap the
buccal plate is fractured away from the alveolar ridge to create an island of bone
attached to the buccal periosteum. Similar to fracture of the buccal plate is a traumatic
extraction. The advantage of this flap is that it provides an environment for vertical and
horizontal augmentation. The site is then grafted and closed with a membrane. The
buccal plate is not rigidly fixed and is held in place with sutures.
Distraction osteogenesis is often used for severe defects that require more than 5
mm expansion in either horizontal or vertical dimensions. The distraction technique
involves creating an osteotomy in a bony segment adjacent to an area of deficiency.
Through a distraction device, slow-tension forces are applied between the basal bone
and the transport segment, allowing for growth of both bone and soft tissue. McCor-
mick17 proposes the 5 components of distraction osteogenesis as: (1) osteotomy of
the bone site with minimal periosteal stripping; (2) latency period of 3 to 7 days,
depending on the surgical site; (3) distraction rate of 1.0 mm per day (range 0.52.0
mm); (4) distraction rhythm of distraction twice a day is preferred; and (5) consolidation
of usually 6 to 12 weeks.

SUMMARY

Alveolar bone grafting can be very intimidating when first attempted. With careful
instruction, education, and practice, grafting can be accomplished by many practi-
tioners. Different methods incorporate similar surgical principles and lead to the devel-
opment of more advanced grafting techniques.

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