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“Sandwich” Bone Augmentation

Technique: Rationale and Report
of Pilot Cases

Hom-Lay Wang, DDS, MSD* When a tooth is lost and replace-

Carl Misch, DDS, MDS** ment by means of a dental implant
Rodrigo F. Neiva, DDS, MS*** is indicated, several factors need to
be considered during treatment
The aim of this article is to present a new technique for augmentation of deficient planning for optimal function and
alveolar ridges and/or correction of osseous defects around dental implants. esthetics of the implant-supported
Current knowledge regarding bone augmentation for treatment of osseous defects prosthesis. One key factor is the
prior to and in combination with dental implant placement is critically appraised. amount of available alveolar bone.
The “sandwich” bone augmentation technique is demonstrated step by step. Five Inadequate alveolar height, width,
pilot cases with implant dehiscence defects averaging 10.5 mm were treated with and quality may compromise ideal
the technique. At 6 months, the sites were uncovered, and complete defect fill was
implant placement and, as a conse-
noted in all cases. Results from this pilot case study indicated that the sandwich
quence, jeopardize the final clinical
bone augmentation technique appears to enhance the outcomes of bone augmen-
outcome. In addition, soft tissue
tation by using the positive properties of each applied material (autograft, DFDBA,
profile is largely influenced by the re-
hydroxyapatite, and collagen membrane). Future clinical trials for comparison of
this approach with other bone augmentation techniques and histologic evaluation maining bone height and width.
of the outcomes are needed to validate these findings. (Int J Periodontics Correction of osseous deficiencies
Restorative Dent 2004;24:232–245.) will not only allow ideal implant
placement in terms of angulation
and size, but also enable correction
of soft tissue deficiencies to improve
overall esthetics.
Regeneration of bone in a de-
*Professor and Director of Graduate Periodontics, Department of
Periodontics/Prevention/Geriatrics, School of Dentistry, University of fect is an elaborate process.1,2 New
Michigan, Ann Arbor. bone develops from the perios-
**Adjunct Clinical Professor, Department of Periodontics/Prevention/ teum and marrow-derived cells that
Geriatrics, School of Dentistry, University of Michigan, Ann Arbor; and
Private Practice, Birminghan, Michigan.
possess osteogenic potential. In
***Clinical Assistant Professor, Department of Periodontics/Prevention/ addition, three fundamental ele-
Geriatrics, School of Dentistry, University of Michigan, Ann Arbor. ments are necessary for this regen-
eration: the presence of a blood
Correspondence to: Dr Hom-Lay Wang, University of Michigan, School
of Dentistry, 1011 North University Avenue, Ann Arbor, Michigan 48109- clot, preserved osteoblasts, and
1078. Fax: + (734) 936-0374. e-mail: [email protected] contact with living tissue.3,4 The

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main limiting factor in regeneration bone formation is observed in un- allograft [DFDBA], hydroxyapatite
of osseous/bony defects seems to protected sites.13,14 Nyman et al15 [HA]) are commonly used to over-
be related to the quick population reported the first clinical cases of come this deficiency. However,
of osseous wounds by soft tissue GBR for implant dentistry; since these materials do not harbor
cells, since these cells migrate and then, GBR has become part of im- osteogenic properties and mainly
proliferate at faster rates than bone- plant therapy. Research has shown act as scaffolds for new bone for-
forming cells.5,6 As a consequence, that particulate bone grafts associ- mation (osteoconduction).
ingrowth of soft tissue disturbs or ated with barrier membranes pro- The main component of the
prevents osteogenesis in osseous vide better results than particulate SBA technique is autogenous bone,
defects. Various methods have been bone grafts alone, and that GBR pro- which constitutes the first layer,
described for bone regeneration or vides an effective means of bone applied immediately against the
augmentation: osteoinduction regeneration.15–21 However, results implant surface. During preparation
(bone-inducing substances), osteo- seem to vary considerably, possibly of implant osteotomies, a consider-
conduction (graft as a scaffold for because of use of different types of able amount of bone (osseous coag-
new bone growth), distraction grafting materials. ulum) can be collected by simply
osteogenesis (surgical fracture stim- The aim of the present article is cleaning the drills after use. If the
ulated), onlay grafts (blocks of living to introduce a new technique for autograft is not sufficient to cover
bone transplanted to recipient augmentation/correction of ridge the defect to the level of adjacent
sites), and guided bone regenera- deficiency in implant dentistry. The bone, additional bone grafts are
tion (GBR; space maintenance by “sandwich” bone augmentation needed. DFDBA is the first choice,
barriers to be filled with bone).7,8 technique (SBA) is illustrated step since it is mainly constituted of col-
The concept of GBR was devel- by step, and results from five pilot lagen, the most important organic
oped for implant dentistry based on cases are reported. component of bone tissues. DFDBA
promising results achieved using may also release bone morpho-
guided tissue regeneration (GTR) for genetic proteins (BMP), which are
periodontal defects. GBR is defined Sandwich Bone known to induce bone formation,
as “procedures attempting to regen- Augmentation Technique into the wound. The close proximity
erate or augment bone for proper among the surface of the implant,
dental implant placement.”9 Initial Rationale autograft, DFDBA, and surrounding
experiments showed that barrier- host bone creates an ideal environ-
protected osseous defects have Autogenous bone graft is consid- ment for migration and proliferation
more bone regeneration compared ered to be the ideal bone graft of osteogenic cells and subsequent
to unprotected defects.10,11 These material, since it is quickly incorpo- replacement of the graft materials by
experiments demonstrated that the rated and/or replaced by host bone newly formed bone.
roles of barrier membranes in os- and possesses osteogenic, osteoin- To ensure that the space needed
seous wounds are protection of the ductive, and osteoconductive prop- for augmentation is created/main-
blood clot from invasion by nonos- erties. The drawback of autograft tained, bovine HA is layered on top
teogenic cells, facilitation of wound use is related to availability. Intraoral of the graft materials. Generally, this
stabilization, and creation/mainte- sources for harvesting are limited layer of graft is covered up to 2 to 3
nance of the necessary space for and usually require an additional mm (buccolingual direction) beyond
new bone growth.11,12 The space surgical intervention, which in- the adjacent bone level to ensure
created by the barrier membranes is creases the risk of morbidity. Com- adequate space maintenance. In
filled with young, actively growing mercially available graft materials addition, to avoid the invasion of soft
bone by 90 days, whereas no new (ie, demineralized freeze-dried bone tissue cells into layers of graft mate-

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rials, a barrier membrane is often rec- routine periodontal or implant nomena,30 may aid faster vascular-
ommended. Absorbable collagen surgery is also a contraindication for ization of the graft by allowing blood
membranes are preferable because the SBA procedure. In addition, no vessels originating from the marrow
of their high biocompatibility with active infection can be present at spaces to more easily migrate into
oral tissues, hemostatic properties, the site to be treated. Active infec- the treatment site. This procedure
chemotactic effects on fibroblasts tions must be treated before any may result in faster population of
ensuring adequate wound closure, bone regeneration is attempted. osteogenic cells in the grafted site
and lack of need for retrieval. and facilitate bone regeneration/
To ensure the success of this augmentation.
approach, two additional factors Surgical principles The inner bone graft layer is
should be addressed. Primary im- composed of autogenous bone.
plant stability must be achieved be- The SBA technique employs three Autograft collected during oste-
fore any attempt at bone augmen- layers of bone graft materials and otomy preparation (osseous coagu-
tation, since a mobile implant is an absorbable collagen membrane lum) is applied directly against the
unlikely to achieve osseointegration. to exclude undesirable soft tissue surface of the implant, providing
Mobile implants (eg, micromove- cells from the wound. The following viable osteogenic cells and enhanc-
ments of more than 100 µm) often surgical principles must be followed ing migration of cells from the host
heal with fibrous encapsulation,22–27 for successful bone augmentation bone into the surface of the implant.
similar to the pseudoarthrosis ob- following SBA procedures. If the collected autograft is not
served in unstabilized fracture sites. The most common complica- sufficient to achieve the first layer of
Another important factor to consider tions of bone augmentation proce- bone coverage (to the level of adja-
is primary wound coverage with pas- dures are flap recession or slough- cent bone height in a buccolingual
sive tension. A sealed (primary ing.8,29 For this reason, initial surgical dimension), an additional layer of
wound coverage) environment elim- incisions should be made in kera- graft would be added. The middle
inates the negative influence of the tinized tissue, since this tissue is bone graft layer is composed of
oral microflora and promotes undis- more resistant to laceration than DFDBA or human demineralized
turbed healing. nonkeratinized oral mucosa. Ade- allograft (Puros, Centerpulse). Active
quate initial incisions and flap man- human allograft or DFDBA may
agement will dictate the capacity to release BMPs into the surrounding
Indications achieve adequate wound closure wound to induce bone formation.
without tension. The close proximity among the sur-
Indications for the SBA technique Full-thickness flap elevation is face of the implant, autograft, allo-
are horizontal alveolar ridge defects mandatory. If periosteal fibers remain graft, and surrounding host bone
and alveolar ridge dehiscence/fen- attached to the bone surface after creates an ideal environment for
estration defects.28 Other potential flap elevation, the area must be migration and proliferation of
indications are alveolar ridge aug- completely debrided before any osteogenic cells and subsequent
mentation/preservation and imme- grafting procedure is attempted. replacement of the graft materials by
diate implant placement. Partial-thickness reflection can be newly formed bone.
performed apical to the treatment The outer bone graft layer is
site to allow adequate release of the composed of dense particles of HA,
Contraindications mucoperiosteal flap, ensuring proper which acts as a scaffold/space occu-
wound closure without tension. pier because of its osteoconductive
Any medical problem that would Intramarrow penetrations, also properties. It facilitates new bone
prohibit a patient from undergoing called regional acceleratory phe- formation by preserving and/or

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Implant placement or second-stage

Table 1 Results after application of sinus bone augmentation implant surgery should not be per-
technique for correction of implant dehiscence defects*
formed before a 5- to 6-month heal-
Age Baseline implant 6 mo implant ing period.
Patient (y) Gender thread exposure (mm) thread exposure (mm)
1 36 F 13.0 0.0
2 41 F 7.0 0.0 Method and materials
9.0 0.0
3 46 M 6.0 0.0
4 39 M 13.0 0.0 Five systemically healthy patients
5 28 F 15.0 0.0 with buccal dehiscence alveolar
Mean 38 10.5 0.0 defects around dental implants were
*100% defect fill occurred at all implants. treated at the Graduate Periodontics
Clinic, School of Dentistry, University
of Michigan. Defects measured 6 to
15 mm (mean 10.5 mm) immediately
maintaining the space essential for which are normally associated with after implant placement.
bone augmentation procedures. vertical releasing incisions. Flaps Clinical data were collected at
After application of these layers united with tension are likely to the time of implant surgery and 6
of bone graft, a collagen membrane undergo secondary or even tertiary months later, during implant uncov-
is applied to cover the recipient site. healing during wound contraction.33 ering. The amount of exposed im-
Application of a barrier membrane To ensure maintenance of wound plant threads was measured using a
provides stabilization for the treat- closure during the healing process, standard North Carolina probe to
ment site and exclusion of unwanted use of long-lasting suture materials the nearest millimeter. Radiographs
cells. Collagen membranes are (eg, Vicryl, Ethicon/Johnson & as well as 1:1 magnification color
preferable because of their physio- Johnson; Gore-Tex, WL Gore) is rec- photographs were also taken. All
logic absorption process and high ommended. surgical procedures were performed
biocompatibility with oral tissues. In Postoperative care includes rins- following the principles of the SBA
addition, collagen is a hemostatic ing twice daily with warm salt water technique, discussed previously. All
agent and possesses the ability to for the first 2 weeks before switching implants were placed in a two-
stimulate platelet aggregation and to twice-daily rinsing with a solution staged approach.
enhance fibrin linkage, which may of 0.12% chlorhexidine gluconate
lead to initial clot formation, stabil- for the next 2 weeks. Systemic antibi-
ity, and maturation.31 Furthermore, otic prophylaxis is also recom- Results
collagen is chemotactic for fibro- mended (amoxicillin 500 mg 3 times
blasts in vitro.32 This property could a day for 10 days; if allergic, During the course of treatment, no
enhance cell migration and promote azithromycin 500 mg/day for 3 days adverse events occurred. Bone aug-
the primary wound coverage that is is prescribed). mentation using the SBA principles
key for bone augmentation. Sutures are generally removed achieved a mean of 10.5 mm of
The mucoperiosteal flap is then 10 to 14 days after surgery. The bone formation, or 100% defect fill
coronally repositioned for complete patient should be seen every 4 to 6 (Table 1). The tissue surrounding
wound coverage without tension. weeks for evaluation of the wound the implants was resistant to prob-
Techniques for flap release include healing progress. If initial membrane ing and hard in consistency, clini-
apical partial-thickness elevation exposure is avoided, healing nor- cally resembling natural bone (Figs
and/or dissection of the periosteum, mally proceeds uneventfully. 34 1 to 4).

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Fig 1a Sandwich bone augmentation Fig 1b Implant preparation indicates Fig 1c Pure titanium implant (3.75 mm

technique in patient 1: Flap reflection shows fenestration of buccal plate. 13 mm; Brånemark, Nobel Biocare) was
inadequate buccolingual bone width. placed with primary stability.

Fig 1d Autograft collected during Fig 1e Outer layer is bovine HA (Bio- Fig 1f Collagen membrane (BioMend
osteotomy is applied as inner layer, and Oss). Regular, Zimmer Dental) is trimmed and
middle layer consists of DFDBA. adapted.

Fig 1g (left) Flap is coronally advanced

and secured with No. 5-0 Vicryl sutures.

Fig 1h (right) Implant stage-two surgery

(6 months postsurgical) shows complete
defect fill.

Fig 2a (left) Sandwich bone augmenta-

tion technique in patient 2: Flap reflection
shows implant thread exposure (7 and 9
mm).

Fig 2b (right) Stage-two surgery (6

months postsurgical) shows complete
defect fill.

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Fig 3a (left) Sandwich bone augmenta-

tion technique in patient 3: Flap reflection
shows implant thread exposure (13 mm).

Fig 3b (right) Stage-two surgery (6

months postsurgical) shows complete
defect fill.

Fig 4a (left) Sandwich bone augmenta-

tion technique in patient 5: Flap reflection
shows implant thread exposure (15 mm).

Fig 4b (right) Stage-two surgery (6

months postsurgical) shows complete
bone fill.

Discussion possibly because of different tech- material and the barrier function of
niques and materials used.15,41–57 a collagen membrane. The barrier
Implants should be placed with Autograft has been regarded membrane would exclude un-
ideal location and angulation.35–39 as the gold standard bone graft wanted soft tissue cells, prevent
This approach may result in expo- material for GBR because of its graft exfoliation, and enhance
sure of implant threads because of osteogenic, osteoinductive, and wound stability to promote
insufficient alveolar ridge width osteoconductive properties. Never- uneventful healing.2,58–64
and/or height, which may lead to theless, intraoral sources of auto- The inner-layer autograft was
higher implant failure rates.16,28 To genous bone are limited, and the used to provide viable osteogenic
avoid these complications, bone risk of morbidity at the donor site cells to the defect. The close prox-
augmentation is generally re- exists. Commercially available graft imity between the host bone and
quired. GBR has been proposed to materials (ie, DFDBA, HA) are com- autograft allowed the creation of an
reconstruct alveolar ridge defects monly used to overcome this defi- ideal scaffold for migration and pro-
not only before, but also at the time ciency. However, these materials liferation of osteogenic cells and
of, implant placement.40 Buser et have limitations, eg, DFDBA’s low subsequent replacement of the
al29 applied the principles of GBR mechanical rigidity and relatively graft material by newly formed
in humans and found 1.5 to 5.5 mm quick absorption rate compared to bone. This scaffold could be en-
of horizontal bone formation, con- freeze-dried bone allograft and HA, hanced if needed by adding
cluding that GBR is a highly pre- and the slow absorption rate asso- another layer of human allograft.
dictable approach for ridge aug- ciated with HA. The sandwich GBR Human mineralized allograft or
mentation. However, further technique was developed using the DFDBA has been widely used as a
reports have shown varying results, positive properties of each graft bone-replacement graft based on

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its reported osteoconductive and capable of inactivating relevant

believed osteoinductive capabili- pathogens (eg, HIV and hepatitis),
ties.65–70 DFDBA permits rapid vas- ensuring the material’s safety for clin-
cular and hard tissue ingrowth and ical use.87 In addition, histologic
may help stimulate osseous regen- studies confirm that the biotolera-
eration without the need of har- bility of solvent-dehydrated grafts is
vesting autologous bone from a sec- comparable with cryo-preserved
ond site.71,72 Osteoinductive activity bone grafting materials.88 Although
is believed to occur because of its bone-formation mechanism is still
exposure of BMPs during the allo- unclear, preliminary studies demon-
graft demineralization pro- strate that this grafting material does
cess.67–69,73 DFDBA is produced by not elicit a foreign-body reaction and
acid extraction of the mineral com- is highly effective in inducing bone
ponents of bone. This process re- formation.89,90
sults in a graft material containing The outer bone graft layer, com-
collagen, noncollagenous bone posed of dense HA, ensured that
matrix proteins, and growth factors, the space created was maintained
but little residual bone mineral.73,74 during the healing process. Bovine
Hence, demineralization exposes HA (Bio-Oss, Osteohealth) has been
the bone-inductive proteins located widely used for treatment of peri-
in the bone matrix and may activate odontal and peri-implant defects,
them.22,75–79 However, recent stud- and its osteoconductive properties
ies raise concern that the amount of have been confirmed by various
BMPs present in the graft particles studies.91–94
may not be sufficient to promote Grafted areas were covered with
osteoinduction.80–85 absorbable collagen barrier mem-
Other mineralized forms of branes for exclusion of soft tissue
bone graft may be used for this pur- cells from the wound. Use of barrier
pose. A recently introduced miner- membranes in bone augmentation
alized allograft (Puros) could be an procedures enhances the amount of
alternative. It constitutes a mineral- bone formation.95–99 Lang et al100
ized bone allograft material measured the amount of alveolar
processed through a unique solvent- bone that could be regenerated with
preserved process for tissue preser- nonabsorbable membranes follow-
vation and viral inactivation, which ing different healing periods and
differs from the standard cryo-pre- found that membranes removed
served process. The bone structure between 3 and 5 months result in
that undergoes this process appears regeneration of 0% and 60%,
to remain intact compared to other whereas membranes left for 6 to 8
forms of bone treatment, providing months regenerate between 90%
excellent bone matrix and load- and 100% of the possible volume.100
bearing capabilities.86 Studies have For this reason, absorbable mem-
also shown that hydrogen peroxide branes are preferable, since they do
application during processing is not require an additional surgical

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intervention for removal, helping to and the failing implant (bone loss
maintain undisturbed wound healing with pocketing, bleeding on prob-
until bone maturation is completed. ing, purulence, and evidence of con-
Collagen membranes are preferable tinuing bone loss irrespective of ther-
because of their high biocompati- apy), as well as ridge (socket)
bility with oral tissues, hemostatic preservation. GBR around peri-
properties, and chemotactic effects implantitis is enhanced when bone
on fibroblasts promoting primary grafts are added to absorbable
wound closure.101 In addition, colla- membranes.116–118 Future studies in
gen is an important constitutive ele- these areas are needed to further
ment of the human body and there- validate application of the SBA tech-
fore is absorbable. With absorbable nique in these types of defects.
collagen membranes for ridge aug-
mentation, appreciable results are
obtained even when the membranes Conclusion
become exposed during the healing
process.102 Membrane exposure was Advances in bone reconstructive
observed 2 weeks postoperative in techniques, including the potential
the present study, but complete of barrier membrane use for osteo-
defect fill was nevertheless observed genesis, have increased the indica-
(Fig 1h). tions for implant placement. Experi-
Stability of bone formed during mental and clinical findings have
GBR has to be evaluated after im- shown that the type of adjunctive
plant placement and loading. grafting material and barrier mem-
Several reports have shown that the brane used, healing time, type and
bone regenerated with GBR remains size of the bony defect, and mem-
stable after implant loading, and the brane exposure all influence the end
success rate of these implants is result. The SBA technique seems to
comparable to those placed in maximize the outcomes of GBR by
native bone.103–109 Similar findings using the positive properties of dif-
have been reported for bone re- ferent bone graft materials. Prom-
generation into dehiscence de- ising results have been achieved by
fects.110–114 our group, encouraging the devel-
Bone regeneration is possible opment of future clinical trials for
in selected peri-implant bony comparison of this approach with
defects when appropriate surgical other bone augmentation tech-
techniques are used, implant sur- niques. Further histologic evaluation
face preparation is achieved, and is needed to validate the results
the cause of the defect is eradi- obtained via this approach.
cated.115 Other possible applica-
tions of the SBA technique may
include treatment of the ailing
implant (bone loss with pocketing
but static at maintenance checks)

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Acknowledgments 10. Linghorne W. The sequence of events in

osteogenesis as studied in polyethylene
tubes. Ann N Y Acad Sci 1960;xy:445.
The authors would like to thank Drs Paulo
Mascarenhas and Tatsumasa Itose for their 11. Melcher A, Dreyer CJ. Protection of the
involvement in documenting these cases. blood clot in healing circumscribed bone
This study was partially supported by a grant defects. J Bone Joint Surg Br 1962;44:
from the University of Michigan, Periodontal 424–435.
Graduate Student Research Fund. 12. Dahlin C, Sennerby L, Lekholm U, Lindé
A, Nyman S. Generation of new bone
around titanium implants using a mem-
brane technique: An experimental study
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