Received: 24 January 2022 Revised: 20 March 2022 Accepted: 22 March 2022

DOI: 10.1111/jerd.12911

CLINICAL ARTICLE

Applications of maxillary tuberosity block autograft

Juan Zufía DDS1 | Francesc Abella Sans DDS, PhD2

1
Private Practice, Madrid, Spain
2 Abstract
Department of Restorative Dentistry and
Endodontics, Universitat Internacional de Objective: Autogenous bone grafts are considered the gold standard due to their
Cataluña, Barcelona, Spain
compatibility and osteogenic potential to induce new bone formation through osteo-
Correspondence genesis, osteoinduction, and osteoconduction. The aim of this paper was to describe
Francesc Abella Sans, Department of
clinical applications of the maxillary tuberosity block autograft in small and moderate
Restorative Dentistry and Endodontics,
Universitat Internacional de Cataluña, C/Josep localized defects of the alveolar process around implants and teeth.
Trueta s/n, Sant Cugat del Vallès, Barcelona
Clinical Considerations: Maxillary tuberosity is often used as a particulate graft for
08195, Spain.
Email: [email protected] augmentation of deficient alveolar ridge or maxillary sinus prior to or simultaneously
with implant insertion, but not as a bone block graft. The maxillary tuberosity block
autograft may also provide a valuable bone source for challenging situations such as
immediate implant placement into types II and III extraction sockets, treatment of
horizontal and vertical bone defects with simultaneous implantation, reconstruction
of circumferential defects around implants, and preservation of alveolar ridge.
Conclusions: The advantages of the maxillary tuberosity include intraoral cortico-
cancellous autogenous graft with fewer intraoperative difficulties, no need for donor
site restoration, less morbidity, and an excellent correction of localized alveolar ridge
defects.
Clinical Significance: Within the limitations of the presented case reports, the use of
maxillary tuberosity block autograft has shown to be successful in alveolar ridges
augmentation that lack both width and height.

KEYWORDS
autogenous bone, bone block graft, clinical applications, guided bone regeneration, maxillary
tuberosity

1 | I N T RO DU CT I O N from intraoral or extraoral sites is the gold standard for bone recon-
struction due to its osteogenic (containing bone-forming cells), osteo-
Alveolar ridge defects stemming from periodontal disease, atrophy, inductive (containing bone-inducing substances), and osteoconductive
and trauma may produce deficient bone volume or adverse vertical, properties (serving as a scaffold for bone formation).4,5 Autogenous
transversal, and/or sagittal interarch relationship(s), demanding bone also has the exclusive advantage of retaining cell viability and
implant placement.1 Many surgical procedures have been described to containing osteoblasts and osteoprogenitor stem cells, which trigger
2,3
augment deficient bone volume. The most widely used materials in true osteogenesis.5
block grafting procedures include xenografts, allografts, alloplastic, Extraoral bone block grafts, such as the iliac crest, offer a suffi-
and autogenous bone. Of these materials, autogenous bone harvested cient amount of bone, although there are several drawbacks,

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Esthetic and Restorative Dentistry published by Wiley Periodicals LLC.

J Esthet Restor Dent. 2022;34:1015–1028. wileyonlinelibrary.com/journal/jerd 1015

including higher treatment costs, morbidity at the donor site, and the 2.1 | Immediate implant placement into type II
need for a second surgical site.6 Quality and quantity of bone and extraction sockets
high predictability outcomes are key factors for selecting optimum
donor sites.7 Despite the limited amount of available bone that can Maintenance of the supporting tissues during dental extraction is
be harvested from intraoral sites, the primary benefit is its harvesting indispensable for immediate implantation and provisionalization.23
potential with minimal morbidity. Moreover, harvesting from the Nevertheless, implant placement in a fresh extraction socket
same surgical site may shorten the surgical intervention and mini- is often related with the occurrence of peri-implant defects at the
mize the surgical field.8,9 The main intraoral donor sites are primarily time of surgery. When the facial soft tissue is present preopera-
the mandibular ramus and the symphysis (chin).10 However, these tively, but there is a partial or completely absent buccal plate
sites have limited accessibility and are associated with considerable of bone over the affected tooth, the tooth extraction socket is
complications and postoperative morbidity such as neurovascular referred to as a type II socket.24 The aim of this clinical case was to
11,12
injury and neural dysfunction. Both autogenous block grafts illustrate a technique to restore a type II socket defect using
(chin and ramus) pose the inherent procedural challenges of using a corticocancellous bone and a soft tissue graft harvested from the
saw or bur to remove a block graft from what is frequently dense maxillary tuberosity.
cortical bone and to undertake a partial postoperative regeneration
of the donor site.13
For several years, bone from the maxillary tuberosity has been 2.1.1 | Case report 1
harvested in particulate form for augmentation procedures and has
the benefits over other intraoral donor sites in that the harvesting is A 38-year-old systemically healthy woman was referred by an
trouble-free and involves minimum complications.14–16 To our knowl- endodontist to our surgical practice for an implant consultation.
edge, Tolstunov was the first to introduce the potential of the maxil- Her medical history was non-contributory. Clinical examination rev-
lary tuberosity block graft in treating localized maxilla bone defects ealed a 12 mm probing depth and a sinus tract in the mucogingival
15
for implant placement. In 2013, da Rosa et al. presented the imme- junction of the maxillary right central incisor (Figure 1A). Radiograph-
diate dentoalveolar restoration (IDR) technique, consisting of an ically, a radiolucent image was observed in the cervical and middle
immediate implant placement combined with a corticocancellous third of the tooth, leading to a diagnosis of external resorption
block graft harvested from the tuberosity and positioned in the gap (Figure 1B). After the necessity of tooth extraction was confirmed, it
17
between the implant and the buccal mucosa. One year later, the was decided to perform a small volume cone beam computed
same team described an adaption of the IDR technique entailing tomography (CBCT) to evaluate the bone conditions around the
immediate implantation, reconstruction of the buccal bone wall, and hopeless tooth and to plan the anchoring of the implant. The CBCT
restoration of the gingival recession in a single way with a triple graft cross-sectional images confirmed a total loss of buccal bone wall
(cancellous and cortical bone and soft tissue graft) from the maxillary associated with the buccal and mesial position of the external
tuberosity.18 resorption (Figures 1C–E). Likewise, the bone availability of the
In planning bone augmentation, the surgeon should use an accu- maxillary tuberosity was determined by visual inspection, digital
rate cone beam computed tomography (CBCT) to calculate the dimen- palpation, and CBCT. The proposed treatment was an immediate
sions and volumes of intraoral donor sites and their surrounding bone defect restoration using corticocancellous bone and a soft
anatomical structures.7 The use of the maxillary tuberosity, if large tissue graft harvested from the maxillary tuberosity.
enough and appropriate for a block graft, seems to be a relatively The affected tooth was removed atraumatically using a flapless
uncomplicated and useful alternative. This corticocancellous autoge- extraction with care not to disturb the interproximal papillae and buc-
nous graft involves fewer intraoperative and postoperative complica- cal soft tissue (Figure 1F). The socket was then debrided with surgical
tions, with no need to repair the donor site, and has excellent capacity curettes, and the infected tissue was removed (Figure 1G–H). A sup-
to correct localized alveolar ridge defects.15 However, few case raperiosteal tunnel was made on the buccal and palatal aspect of the
reports have described the use of this procedure for bone regenera- socket using a microsurgical blade (1.25 mm Crescent Sharpoint; Sur-
15,17,18,19–22
tion in localized bone defects. The aim of this paper was gical Specialties Corporation, Wyomissing, PA). Subsequently, the
to describe the clinical applications of the maxillary tuberosity block buccal defect was measured to harvest an adequate graft with the
autograft in small and moderate localized defects of the alveolar pro- same anatomical shape. Once the recipient socket was prepared, an
cess around implants and teeth. immediate implant was placed (3.8 mm in diameter and 13 mm in
length Camlog Screw Line; Camlog Biotechnologies, Wimsheim,
Germany) by a palatal approach with ideal three-dimensional
2 | CASE REPORTS (3D) positioning and the final insertion torque was 40 Ncm (Figure 1I).
The final implant position was 3 mm apical to the gingival margin.
One clinician (Juan Zufía) performed all the surgical and prosthetic To avoid contaminating the graft while handling the materials
procedures in the cases presented below. used to manufacture the crown, each step of the provisionalization
ZUFÍA AND ABELLA SANS 1017

F I G U R E 1 Immediate implant placement into type II extraction socket. (A) Clinical examination showed a 12-mm probing depth and a sinus
tract in the mucogingival junction of the maxillary right central incisor (tooth 11). (B) Radiolucent image in the cervical and middle third of tooth
11 compatible with an external resorption. (C–E) Small volume cone beam computed tomography (CBCT) images confirmed a total loss of buccal
bone wall associated with the buccal and mesial position of the external resorption. (F) Extraction of the affected tooth where the extension of
the external resorption can be observed. (G) Absence of buccal bone wall confirmed after extraction. (H) Periodontal probe through the sinus
tract after removal of infected tissue. (I) Immediate implant placement (13 mm  3.8 mm, Camlog Screw Line; Camlog Biotechnologies,
Wimsheim, Germany): the implant was anchored in palatal bone and 3 mm apical to the gingival margin

was performed before the bone graft procedures. After applying anes- The flap was raised in the tuberosity area and its connective tis-
thesia to the maxillary tuberosity, a full thickness crestal incision was sue extracted using a 15c blade. A small portion of this connective tis-
made following the distal contour of the maxillary right second molar. sue was preserved with the intact epithelium to ensure the primary
This incision was followed by a palatal release incision to access closure of the wound in the donor area. Then, the bone graft was
the donor area, thus replicating the profile of the defect in the harvested from the underlying bone by using a 1 cm wide flat chisel
recipient area. (Bontempi; Quirurgical Bontempi; Barcelona, Spain) and a surgical
1018 ZUFÍA AND ABELLA SANS

F I G U R E 2 (A) Connective
tissue graft and bone block
harvested from the right
maxillary tuberosity. (B) After
placing the triple graft to the
level of the implant platform.
Note the connective tissue graft
was in contact with the internal
part of the gingival flap. (C) A
screw-retained resin provisional
crown, relined over a
polyetheretherketone (PEEK)
anti-rotation abutment, was
placed out of occlusion.
(D) Correct accommodation and
maintenance of the soft tissue
s14 days post-surgery.
(E) Occlusal view tooth extraction
and implant placement at
4 months. (F) Three-year follow-
up: facial view. (G,H) CBCT
examination showing stable
buccal bone plate at 3 years.
(I) Three-year clinical control
showing healthy and stabilized
peri-implant soft tissues

hammer (Figure 2A). The corticocancellous graft was manipulated coronal aspect (Figure 2F–H). The peri-implant soft tissues appeared
using a rongeur to reproduce the shape of the peri-implant bone healthy, and the probing depths ranged from 3 to 4 mm with no
defect. Next, the triple graft was carefully inserted to the level of the bleeding on probing (Figure 2I).
implant platform, leaving the connective tissue graft in contact with
the internal part of the gingival flap (Figure 2B). The connective tissue
graft was stabilized by suturing it to the gingival flap. Finally, a screw- 2.2 | Immediate implant placement into type III
retained resin provisional crown, relined over a polyetheretherketone extraction sockets
(PEEK) anti-rotation abutment, was placed out of occlusion, esta-
blishing the ideal emergence profile to accommodate the soft tissues Reasons for tooth extraction and immediate implant placement
and to promote a thicker and more stable gingival tissue margin include, among others, prosthetic failures, periodontal reasons,
(Figure 2C,D). endodontic causes, and vertical root fractures.25–27 A type III
At 4 months, the implant was finally restored with a titanium extraction socket is associated with soft tissue recession and
abutment base (Camlog®; Camlog Biotechnologies GmbH, Basel, buccal plate loss before extraction. Typically, treatment of sockets in
Switzerland) and a zirconia crown with a buccal cut-back design for this classification are very challenging and require soft tissue
feldsphatic veneering (Figure 2E). At 3 years post-surgery, the aes- augmentation with additional grafts of connective tissue, or connec-
thetic result was stable, and no increase in gingival recession was tive tissue and bone, in a pre-planned approach to rebuild lost tissue.
observed at the buccal surface of the implant. Radiographic examina- This clinical case describes a procedure that uses maxillary tuberosity
tion showed a stable buccal bone plate with 2 mm of thickness in the block autograft for restoring the buccal bone wall and soft tissue
ZUFÍA AND ABELLA SANS 1019

F I G U R E 3 Immediate implant placement into type III extraction socket. (A) Initial clinical evaluation of the affected maxillary left lateral
incisor. (B) A small volume CBCT scan confirmed the total absence of the buccal bone wall. (C) Atraumatic extraction of the hopeless tooth using
Benex extraction system (Benex; Helmut Zepf Medizintechnik GmbH, Seitingen-Oberacht, Germany). (D) Confirmation of a vertical root fracture
in the buccal aspect of the root. (E) Immediate implant (3.5 mm  13 mm Nobel Biocare Replace Select tapered TiUnite®; Nobel Biocare,
Guttenberg, Sweden) placed palatally with ideal 3D positioning. (F) Simulation of the final graft (corticocancellous bone and connective tissue
from the tuberosity area) position. (G) Postoperative clinical situation with a chairside-made resin crown provisional crown splinted to the
neighboring teeth. (H) Clinical situation at 7 days post-surgery. (I) At 6 months, the implant was restored with a titanium base zirconia abutment
and all-ceramic crown. (J) Final situation at 4-year post-treatment. (K) Clinical control at 5 and a half years showing soft tissue stabilization. (L, M)
Periapical radiograph and sagittal view of the CBCT at 6 years. (N) Facial view at 6-year follow-up
1020 ZUFÍA AND ABELLA SANS

contours in a Type III extraction socket simultaneous with the support the soft tissue healing. The provisional crown was out of
implantation. occlusion and splinted to the neighboring teeth using a palatal ortho-
dontic wire bonded with composite resin.28
At 4 months post-surgery the soft tissue appeared normal, so a
2.2.1 | Case report 2 second stage surgery was carried out to expose the implant head. The
implant was restored with a provisional screw-retained crown to pro-
A 55-year-old systemically healthy patient was referred to our surgical file the soft tissues. At 6 months, the implant was finally restored with
practice to receive treatment of a maxillary left lateral incisor. For a titanium base zirconia abutment and all-ceramic crown (Figure 3I).
months, the patient had complained of multiple debonding of the Clinical evaluation showed healthy and stable peri-implant tissues. At
ceramic crown on the tooth due to retention loss. The remaining 6-year follow-up, no significant clinical alterations regarding the level
tooth had a coronal fracture, and no ferrule effect was present of the gingival margin outline or papillae were found when comparing
(Figure 3A). Periodontal examination revealed a left lateral incisor with the treated area to the contralateral tooth (Figure 3J,K). Periapical
signs of Miller grade 2 mobility, 9 mm of probing depth, and absence radiographs and a CBCT scan showed a precise implant 3D position in
of buccal bone wall generating a functional defect that called for bone relation to the adjacent structures, horizontal and vertical bone devel-
augmentation. Periapical radiography showed that besides a root opment, and reconstruction of the bone defect with no marginal bone
canal treatment, the tooth had also received an unsuccessful surgical loss (Figure 3L,M). The patient's aesthetic and functional expectations
endodontic treatment. A small volume CBCT scan of the area of inter- were achieved with respect to the early pre-treatment condition
est confirmed the presence of an apical lesion and the total absence (Figure 3N).
of buccal bone wall (Figure 3B). The proposed treatment was a bone
and soft tissue reconstructive procedure involving an immediate
implant to improve the aesthetics and to shorten the treatment time. 2.3 | Treatment of horizontal bone defects with
The amount of basal bone was sufficient for the secure placement simultaneous implantation
of an immediate implant in the correct 3D position but without being
subjected to immediate functional loading. The hopeless tooth was When implants are placed resulting in a bone defect and leaving part
atraumatically extracted by a flapless technique under local anesthesia of the endosseous surface of the implant exposed, guided bone
using Benex extraction system (Benex; Helmut Zepf Medizintechnik regeneration is a reliable procedure for bone formation.29–33 Horizon-
GmbH, Seitingen-Oberacht, Germany) to preserve the surrounding tal bone defects are typified by reduced ridge width hindering the pri-
bone architecture and the papillae area (Figure 3C). The extracted mary stability of the implant in the prosthodontically appropriate
tooth presented a vertical root fracture and a root-end resection as a location. Autogenous bone blocks, whether alone or combined with a
result of the previous endodontic surgery (Figure 3D). A sup- bone substitute and/or collagen membranes, are the most consistent
raperiosteal tunnel was made on the buccal and palatal area of the and successful procedures for staged augmentations of large bone
recipient socket. Then, the socket wall was probed to assess the defects before implant placement.34 This clinical case describes a pro-
degree of bone damage, and as supposed no buccal bone wall was cedure that uses a tuberosity maxillary block autograft for a primary
present due to the vertical fracture on the buccal side of the root. The horizontal ridge augmentation in a previous implant failure.
tuberosity area was also evaluated on the CBCT scan in order to guar-
antee sufficient graft, while a periodontal probe was used to measure
the soft tissue thickness. 2.3.1 | Case report 3
Taking the position of the adjacent teeth as a reference, the clini-
cian immediately placed an implant (3.5 mm  13 mm Nobel Biocare A 50-year-old systematically healthy man was referred to our surgical
Replace Select tapered TiUnite®; Nobel Biocare, Guttenberg, Sweden) practice for treatment of an abscess in an implant in position 26. The
in the ideal 3D position (Figure 3E). Aware of the initial gingiva posi- patient presented a ceramic-metal implant-supported cantilever fixed
tion (baseline), the clinician inserted the implant platform 2 mm apical partial denture (FPD) from 24 to 26 with implants in position 25 and
to the buccal gingival margin. Then, the corticocancellous bone and 26 (Figure 4A). Radiographic examination showed that implant
connective tissue graft were harvested from the tuberosity area 26 presented a complete bone loss. A small volume CBCT revealed
(Figure 3F), as described in Case Report 1. The block autograft was 4 mm of marginal bone loss for implant 25 and 10 mm for implant
trimmed and inserted into the gap, filling the space between the 26 (Figure 4B,C). Both implants presented multiple sites with bleeding
implant surface and the buccal mucosa (Figure 3G–H). A partial thick- on probing. Pocket probing depth was 7 mm for implant 25 and
ness pouch was prepared in the buccal aspect close to the bony area. 12 mm for implant 26. Both implants were diagnosed with peri-
The coronal portion of the pouch was de-epithelialized in order to implantitis (inflammation in the peri-implant connective tissue and
provide enough blood supply, stabilize the graft, and advance the gin- progressive loss of supporting bone) that made their maintenance
gival margin 3 mm coronally. The initial implant stability was 20 Ncm, unfeasible.
so the immediate loading was not possible. The site was temporized After local anesthesia, the clinician removed the prosthetic
with a chairside-made resin crown to provide aesthetics and to suprastructure and implant 26 simultaneously with no need to raise a
ZUFÍA AND ABELLA SANS 1021

F I G U R E 4 Treatment of horizontal bone defects with simultaneous implantation. (A) Intraoral examination showing a severe peri-implantitis
with a complete loss of osseointegration of the implant that was in position 26. (B,C) A small volume CBCT revealing 4 mm of marginal bone loss
at implant 25 and 10 mm for implant 26. (D) Clinical situation 3 months after removal of implant 26. Note the horizontal atrophy in sites 24 and
26. (E) Measurement of the remaining bone defect after spontaneous healing. Observe that the palatal wall was partially preserved, but there was
no buccal wall. (F) Implant placement in position 26 (Nobel Replace CC PMC 4.3 mm  10 mm (Nobel Replace CC PMC 4.3 mm  10 mm) where
the need for horizontal bone regeneration is indicated. (G) Implant placement in position 24 (Nobel Replace CC PMC 3.5 mm  13 mm)
maintaining parallelism. (H) Bone block obtained from the tuberosity area of the same quadrant. (I) Block morphology modified using gouge
forceps. (J,K) Bone graft adapted to the alveolar ridge defect. (L) Bone block fixed and stabilized by using 5-mm metal pins (T-system; Curasan AG,
Kleinostheim, Germany). Particulate bone substitute (Bio-Oss®; Geistilich, Sweden) and a resorbable collagen membrane (Creos®, Nobel Biocare,
Cologne, Germany) in the palatal site of the defect. Note the perforations made in the buccal aspect of the collagen membrane to communicate
the periosteum with the autologous bone
1022 ZUFÍA AND ABELLA SANS

flap. The granulation tissue and implant 26 were removed from the 2.4 | Treatment of vertical and horizontal bone
peri-implant defect due to its clinical mobility. The FPD was kept free defects with simultaneous implantation
of occlusion and screwed on implant 25 while a spontaneous healing
and tissue closure of the affected area took place (Figure 4D). At A challenge in rehabilitating large defects is that the deficit of bone
3 months, horizontal atrophy was evident in zones 24 and 26, for dimension results in surgical interventions that are continual until a
which the treatment plan consisted of implant placement in position sufficient quantity of bone is achieved to place an implant. This is par-
24 and 26, combined with a guided bone regeneration. Implant ticularly relevant in the maxillary anterior region to accomplish an
25 was left temporarily in place to support the interim prosthesis dur- excellent aesthetic outcome.35
ing implant and bone regeneration healing.
At 3 months healing, a mucoperiostal flap was raised after clinical
and radiographic measurement of the bone defect (Figure 4E). The 2.4.1 | Case report 4
palatal cortical plate was partially preserved, but an absence of buccal
wall at position 26 meant that it had to be regenerated in order to This case involved a 46-year-old systemically healthy male complaining
place an implant in a correct 3D position. Implants in position of mild discomfort and gingival problems in the right maxillary lateral and
24 (Nobel Replace CC PMC 3.5 mm  13 mm Nobel BioCare, Kloten, central incisors. The patient had high aesthetic expectations, a 1 mm
Switzerland) and 26 (Nobel Replace CC PMC 4.3 mm  10 mm) were smile line and a thick-flat gingival biotype. Clinical inspection of the oral
placed maintaining them in parallel (Figure 4F,G). Subsequently, an cavity revealed a gingival swelling on the facial side of tooth 12, which
autogenous bone block was harvested from the maxillary tuberosity was periodontally untreated (Figure 6A,B). Examination showed slight
and was adapted to achieve intimate contact between the graft and palpation, grade III mobility, percussive discomfort with a probing depth
the bone at the recipient site and fixed tightly with 5 mm metal pins of 10-14-10 mm of the facial gingiva, and 8-9-8 mm of the palatal aspect
(T-system; Curasan AG, Kleinostheim, Germany) (Figure 4H–L). The (Figure 6C,D). The tooth also presented bleeding and suppuration at the
palatal aspect of the defect was treated with particulate bone substi- probing depth, and a 2-mm extrusion. The right central incisor showed
tute (Bio-Oss®; Geistilich, Sweden), and a resorbable collagen mem- grade I mobility and a probing depth with bleeding of 9-5-4 mm in the
brane (Creos®, Nobel Biocare, Cologne, Germany). facial aspect and 8-4-4 mm in the palatal aspect. CBCT cross-sectional
A connective tissue graft from the same donor site was images confirmed a vertical and horizontal bone defect in the maxillary
extracted to correct the gingival recession of tooth 23 (Figure 5A). lateral incisor with involvement of the distal aspect of the maxillary cen-
The flap was coronally advanced by periosteal release, adapted and tral incisor (Figure 6E). Immediate implant placement combined with
sutured to allow a tension-free primary closure at the augmented corticocancellous bone, and a soft tissue graft harvested from the maxil-
site (Figure 5B). The healing abutment was then removed, and the lary tuberosity was the suggested treatment because of the patient's
same permanent metal-ceramic FPD was placed with reduced occlu- desire both for a minimal quantity of surgical involvements and the pres-
sion to prevent loosening during the healing period (Figure 5C,D). At ervation of an aesthetic appearance during the treatment procedures.
6 months healing, a second surgical intervention was performed to The first step consisted of splinting the anterior teeth to stabilize
remove the fixation screws as well as the old implant, in position them and performing initial periodontal therapy (hygienic phase).
25, to shape the emergency profiles before placing definitive pros- Once the inflammation subsided, planning began for the extraction of
thesis (Figure 5E). After a clearly satisfactory graft integration, tooth 12 and its replacement with an immediate implant. Tooth
impressions were made to manufacture a 3-unit implant-supported 12 was carefully extracted under local anesthesia using a 2% lidocaine
interim prosthesis made of polymethylmethacrylate (PMMA) that solution with a vasoconstrictor. The extraction socket, thoroughly
would be screwed into implants 24 and 26 (Figure 5F–G). During debrided with care to avoid infection, revealed an almost complete
fabrication of the provisional by the laboratory, the patient wore no loss of the buccal plate (Figure 6F,G). Subsequently, the region of the
provisional prosthesis, so 2 healing abutments were placed to com- tuberosity was exposed, and a block graft was extracted by using a
plete the second surgical phase. Three months later, an implant- 1 cm wide flat chisel (Bontempi; Quirurgical Bontempi; Barcelona,
supported FDP was fabricated with zirconia frameworks layered Spain) and a surgical hammer according to the dimensions of the bone
with feldspathic porcelain (Figure 5H). defect (Figure 6H). A connective tissue graft was also extracted from
Follow-ups took place at 12, 36, and 60 months, when the patient the proximal palatal area for subsequent sealing of the surgical wound
reported no symptoms and expressed a high level of satisfaction with in the crestal region of the recipient area. The block autograft was
the treatment. Upon intraoral examination, the peri-implant mucosa simultaneously fixed by the implant placement (Nobel Biocare Active
was found to be firm and coral pink. No prosthetic mobility or bleed- diameter 3.5 mm and length 13 mm) with an insertion torque of
ing on probing was observed, and probing depth ranged between 35 Ncm (Figure 6I). An ideal 3D implant position was obtained
2 and 4 mm. A periapical radiograph and small volume CBCT were mesiodistally, orofacially, and coronoapically (Figure 6J). To obtain pri-
taken at 36 months (Figure 5I,J). Marginal bone levels remained stable mary stability, the recipient area was drilled 3–4 mm apically. Due to
at 60 months compared to the initial radiographic assessment the good availability of bone in the tuberous region, a second block
(Figure 5K). No complications were noted regarding the zirconia was harvested from the same region to achieve more volume in the
framework itself (Figure 5L).
ZUFÍA AND ABELLA SANS 1023

F I G U R E 5 Treatment of horizontal bone defects with simultaneous implantation. (A) The membrane was fixed by metal pins to align the
perforations exactly over the autologous bone. A connective tissue graft was harvested from the bone donor site to correct the gingival recession
of tooth 23. (B) Primary wound closure without tension. (C) Placement of the same permanent metal-ceramic FPD with reduced occlusion. (D,E)
Clinical situation 3 months after the graft and placement of the implants. (F) Reentry at 6 months showing the integration of the TAG. Removal of
both the metal pins and the old implant. (G) Aspect of the tissue with a 3-unit implant-supported interim prosthesis. (H) Three years after implant-
supported FDP placement. (I,J) Radiographic assessment of the implants at 3 years. (K,L) Clinical and radiographic control showing the
maintenance of the soft tissue at 5 years
1024 ZUFÍA AND ABELLA SANS

F I G U R E 6 Treatment of vertical and horizontal bone defects with simultaneous implantation. (A) Gingival swelling on the facial side of tooth
12. (B) Patient's smile. (C,D) Probing depth of the affected tooth. (E) CBCT cross-sectional images showing the severe periodontal bone loss with
minimal residual alveolar bone. (F) Vertical and horizontal bone defect after the maxillary lateral incisor extraction. (G) Distal attachment loss of
tooth 11. (H) Distal incision and exposure of the tuberosity region before graft harvesting. (I) Fixing the corticocancellous block graft by the
implant placement (Nobel Biocare Active 3.5 mm  13 mm). (J) Occlusal aspect of the bone block graft and the implant placed in a correct 3D
position
ZUFÍA AND ABELLA SANS 1025

F I G U R E 7 Treatment of vertical and horizontal bone defects with simultaneous implantation. (A) A second bone block fixed to the basal bone
with a 5-mm pin (T-System). (B) Placement of a porcine origin collagen membrane (Creos™ Xenoprotect; Nobel Biocare, Gothenburg, Sweden).
(C) A connective tissue graft placed in the crestal area. (D,E) Aspect of the bone 4 months post-surgery. Observe the complete integration of the
bone block in the recipient site. (F) Clinical situation 3 months after the second connective tissue graft. (G,H) Orthodontic treatment to correct
the position of tooth 11. (I,J) Three years post-treatment. (K) CBCT examination showing the reconstruction of the buccal bone after 3 years.
(L) Implant placement and tissue reconstruction at 4 months. (M) Periapical radiograph with the interim restoration before orthodontic treatment.
(N) Radiographic assessment at 3 years post-treatment
1026 ZUFÍA AND ABELLA SANS

F I G U R E 8 Graphic
description of the technique

vestibular region (Figure 7A). This second block was fixed to the basal Figure 8 illustrated the surgical technique step by step to obtain a
bone with a 5-mm pin (T-System). maxillary tuberosity block autograft.
Subsequently, a porcine origin collagen membrane (Creos™
Xenoprotect; Nobel Biocare, Gothenburg, Sweden) was placed to iso-
late the bone graft from the soft tissue. 3 | DI SCU SSION
(Figure 7B). The connective tissue graft harvested from the maxil-
lary right palatal region was inserted in the labial and coronal sides of There is a global trend toward minimally invasive health procedures
the socket to enhance the labial thickness of the soft tissue and that provide better results while fulfilling patient expectations, which
achieve primary closure for long-term maintenance and improved. includes dental implant procedures, techniques and resources. Mini-
aesthetics (Figure 7C). A cantilevered, all-ceramic (IPS e.max mally invasive procedures are possible through the synergy of treatment
Press, Ivoclar Vivadent) resin bonded fixed partial denture (RBFPD) planning, CBCT imaging, guided surgery, and updated prosthetic
provided an interim solution during the healing time. methods. A large series of animal research and human clinical studies
During the second surgical phase, at 4 months, the screw was have reported that guided bone regeneration is a successful approach
removed, and a second connective tissue graft was performed since for augmenting bone for endosseous dental implant placement.30–34 For
the first connective tissue graft was insufficient to achieve a satisfac- severely atrophic ridges, block grafting procedures are acknowledged for
tory aesthetic result (Figure 7D–F). Following that surgical phase, a their expected outcomes, especially with the utilization of autogenous
provisional crown was placed to shape the emergence profile, to bone, which is the current gold standard for its osteoconductive, osteo-
expand the peri-implant soft tissues for the final restorative stage and inductive, and osteogenic properties.36,37
to serve as an anchor for subsequent orthodontic treatment to correct Intraoral bone blocks (ramus, symphysis, and tuberosity grafts) can
the malposition of tooth 11 (Figure 7G,H). After orthodontic correc- offer surgeons with an enough autogenous intramembranous bone with
tion of tooth 11, a screw-retained zirconia frameworks layered with minimal morbidity for a successful clinical outcome. When choosing the
feldspathic porcelain over an angulated screw channel zirconia abut- optimal donor site, it is crucial to accurately assess the average quantity
ment (Nobel Biocare, Yorba Linda, CA) was delivered (Figure 7I). The and quality of bone available needed for the recipient site and the poten-
3-year follow-up demonstrated that the gingival architecture tial difficulties. However, systematic reviews have yet to find evidence
maintained the form and the definitive implant-supported crown was that one grafting method is superior to others.34
provided (Figure 7J). Radiographic assessment showed the recon- According to a radiographic evaluation of the maximum dimen-
struction of the buccal bone and revealed the stable marginal bone sions, volume, and bone quality values of different intraoral donor
level (Figure 7K–N). Peri-implant aesthetics was accomplished and sites, Ataman-Duruel et al. found that the volume and CBCT-HU of
maintained, which additionally met the patient's expectations. the maximum bone block harvesting from the symphysis was greater
ZUFÍA AND ABELLA SANS 1027

in comparison with the ramus, palatal, and tuberosity bone blocks.7 of the patient as possible source of intraoral bone block. Modern and
When harvesting the maxillary tuberosity, the clinician must consider small volume CBCT can offer in depth anatomy of the maxilla and
the low values of bone density, which may hinder bone block stability mandible that can assist in making a 3-dimensional preoperative eval-
and might tend to resorb during healing after augmentation. However, uation of the most excellent source of block graft.
to increase the density and to decrease possible resorption, Khojasteh
et al. added resorbable membranes and growth factors to a maxillary
tuberosity graft.23 The maxillary tuberosity is often small and prob- 4 | CONC LU SIONS
lematic to access, particularly in small mouth openings and/or where
there are third molars.38 All these factors may have overshadowed The use of intraoral bone block for bone augmentation has numerous
the use of a tuberosity block graft, which, among other advantages, pitfalls due to the surrounding vital anatomical structures. Surgeons
14
includes fewer complications and, due to its malleability, ease of should contemplate all factors and perform a precise CBCT assessment.
graft adaptation in the receptor bed.15 The lower density of the tuber- According to the clinical cases presented herein, tuberosity alveolar
osity block is characterized by its versatility when being adapted to bone block grafts may offer a valuable bone source for treating small
the defect in the recipient area. This is mainly achieved by using stabi- and moderate localized defects of the alveolar process around implants
lization systems such as screws, pins and even the implant itself. and teeth. The main advantage of maxillary tuberosity block autograft
The use of the maxillary tuberosity, if large enough and proper for over other intraoral donor sites is fewer postoperative complica-
a block graft, appears to be a relatively simple and helpful alternative. tions, such as nerve injury and oroantral communication. It can be
Its advantages include intraoral a corticocancellous autogenous graft used in both particulate and block form for treating localized bony
with fewer intraoperative complications, no need to restore the donor defects and for sinus augmentation procedures. However, further
site, and an excellent capability to improve localized alveolar ridge research comparing different intraoral bone block grafting sites for
defects. The maxillary tuberosity is a source of both block and particu- implant treatment would help to weigh up the benefits against the
late autogenous bone suitable for regenerating horizontal or vertical shortcomings of one graft over another.
defects of limited size. In addition, when a regeneration of the poste-
rior maxilla is required, the same surgical area also serves to harvest ACKNOWLEDG MENTS AND DISCLOS URE
donor bone, reducing costs. Hence, it is related with less morbidity The authors wish to express their gratitude to Dino Calzavara and
and reduced treatment time. However, it is noteworthy that bone Periopixel for their collaboration in the graphic part of the study, and
grafts harvested from the maxillary tuberosity have not been used to Mark Lodge for language support in revising this article. The
broadly because they are regarded as poor quality.7 Recently, da Rosa authors declare that they do not have any financial interest in the
et al. examined clinically, tomographically and histologically a case in companies whose materials are included in this article.
which block and particulate autogenous bone grafts were harvested
from the maxillary tuberosity for dental implant placement.39 In that DATA AVAILABILITY STAT EMEN T
study, advanced bone remodeling was observed during implant place- Data sharing not applicable to this article as no datasets were gener-
ment and buccal bone plate thickness was maintained. Despite the ated or analyzed during the current study. The data that support the
cancellous and thin cortical shape of the maxillary tuberosity, cancel- findings of this study are available from the corresponding author
lous bone may be condensed mechanically when graft crushing or upon reasonable request.
screwing. This procedure augments graft bone density while preserv-
ing bone volume during remodeling, even in vertical bone defects as
OR CID
shown in these clinical cases.
Francesc Abella Sans https://orcid.org/0000-0002-3500-3039
However, the maxillary tuberosity block autograft has certain lim-
itations such as difficult access due to the presence of third molars,
RE FE RE NCE S
and inadequate size of the tuberosity for restoring large defects. In
1. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for
addition, the potential occasional complications associated with tuber-
the rehabilitation of deficient edentulous ridges with oral implants.
osity harvesting are oroantral communication, bleeding (formation of Clin Oral Implants Res. 2006;17(2):136-159.
a hematoma), and tethering of the pterygoid muscles.15 Thus, it is cru- 2. Esposito M, Grusovin MG, Felice P, Karatzopoulos G,
cial to study the maxillary tuberosity in detail before harvesting. Man- Worthington HV, Coulthard P. The efficacy of horizontal and vertical
bone augmentation procedures for dental implants - a Cochrane sys-
zanera et al. showed wide variations of the maxillary tuberosity in
tematic review. Eur J Oral Implantol. 2009;2(3):167-184.
morphology (width, length, and height) and that its dimensions 3. Fu JH, Wang HL. Horizontal bone augmentation: the decision tree. Int
depend on patient age and sex.40 Likewise, Gapski et al. demonstrated J Periodontics Restorative Dent. 2011;31(4):429-436.
through histomorphometry examination that specimens obtained 4. Rabelo GD, de Paula PM, Rocha FS, Jordão Silva C, Zanetta-
Barbosa D. Retrospective study of bone grafting procedures before
from women had a statistically significant lower percentage of bone
implant placement. Implant Dent. 2010;19(4):342-350.
surface area when compared to those from men.5 In the event that a
5. Gapski R, Satheesh K, Cobb CM. Histomorphometric analysis of bone
reconstruction of localized defects of the alveolar ridge is required, density in the maxillary tuberosity of cadavers: a pilot study.
the clinician should routinely examine the maxillary tuberosity region J Periodontol. 2006;77(6):1085-1090.
1028 ZUFÍA AND ABELLA SANS

6. Sàndor GK, Nish IA, Carmichael RP. Comparison of conventional sur- 25. Touré B, Faye B, Kane AW, Lo CM, Niang B, Boucher Y. Analysis of
gery with motorized trephine in bone harvest from the anterior iliac reasons for extraction of endodontically treated teeth: a prospective
crest. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(2): study. J Endod. 2011;37(11):1512-1515.
150-155. 26. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related
7. Ataman-Duruel ET, Duruel O, Nares S, Stanford C, Tözüm T. Quantity to extraction of endodontically treated teeth. Oral Surg Oral Med Oral
and quality of intraoral autogenous block graft donor sites with cone Pathol Oral Radiol Endod. 2008;106(5):e31-e35.
beam computed tomography. Int J Oral Maxillofac Implants. 2020; 27. Olcay K, Ataoglu H, Belli S. Evaluation of related factors in the failure
35(4):782-788. of endodontically treated teeth: a cross-sectional study. J Endod.
8. Spin-Neto R, Stavropoulos A, Dias Pereira LA, et al. Fate of autolo- 2018;44(1):38-45.
gous and fresh-frozen allogeneic block bone grafts used for ridge aug- 28. Cabello G, Rioboo M, Fábrega JG. Immediate placement and restora-
mentation. A CBCT-based analysis. Clin Oral Implants Res. 2013;24(2): tion of implants in the aesthetic zone with a trimodal approach: soft
167-173. tissue alterations and its relation to gingival biotype. Clin Oral Implants
9. Zeltner M, Flückiger LB, Hämmerle CH, et al. Volumetric analysis of Res. 2013;24(10):1094-1100.
chin and mandibular retromolar region as donor sites for cortico- 29. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by
cancellous bone blocks. Clin Oral Implants Res. 2016;27(8):999-1004. guided tissue regeneration. Plast Reconstr Surg. 1988;81(5):672-676.
10. Reininger D, Cobo-Vázquez C, Rosenberg B, Lo pez-Quiles J. Alterna- 30. Dahlin C, Sennerby L, Lekholm U, Linde A, Nyman S. Generation of
tive intraoral donor sites to the chin and mandibular body-ramus. new bone around titanium implants using a membrane technique: an
J Clin Exp Dent. 2017;9(2):e1474-e1481. experimental study in rabbits. Int J Oral Maxillofac Implants. 1989;4(1):
11. Hassani A, Khojasteh A, Shamsabad AN. The anterior palate as a 19-25.
donor site in maxillofacial bone grafting: a quantitative anatomic 31. Lang NP, Hämmerle CH, Bragger U, et al. Guided tissue regeneration
study. J Oral Maxillofac Surg. 2005;63(8):1196-1200. in jawbone defects prior to implant placement. Clin Oral Implants Res.
12. Khojasteh A, Eslaminejad MB, Nazarian H, et al. Vertical bone aug- 1994;5(2):92-97.
mentation with simultaneous implant placement using particulate 32. Lazzara RJ. Immediate implant placement into extraction sites: surgi-
mineralized bone and mesenchymal stem cells: a preliminary study in cal and restorative advantages. Int J Periodontics Restorative Dent.
rabbit. J Oral Implantol. 2013;39(1):3-13. 1989;9(5):332-334.
13. Weibull L, Widmark G, Ivanoff CJ, Borg E, Rasmusson L. Morbidity 33. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around
after Chin bone harvesting - a retrospective long-term follow-up titanium dental implants in dehisced defect sites: a clinical study. Int J
study. Clin Implant Dent Relat Res. 2009;11(2):149-157. Oral Maxillofac Implants. 1992;7(2):233-245.
14. Khojasteh A, Behnia H, Shayesteh YS, Morad G, Alikhasi M. Localized 34. Jensen SS, Terheyden H. Bone augmentation procedures in localized
bone augmentation with cortical bone blocks tented over different defects in the alveolar ridge: clinical results with different bone grafts
particulate bone substitutes: a retrospective study. Int J Oral Maxil- and bone-substitute materials. Int J Oral Maxillofac Implants. 2009;24:
lofac Implants. 2012;27(6):1481-1493. 218-236.
15. Tolstunov L. Maxillary tuberosity block bone graft: innovative tech- 35. González D, Cabello G, Olmos G, Lo  pez Hernández E, Niñoles CL.
nique and case report. J Oral Maxillofac Surg. 2009;67(8):1723-1729. The three-layer technique for immediate implants on teeth without a
16. Khojasteh A, Soheilifar S, Mohajerani H, Nowzari H. The effectiveness buccal bone wall: a case report. Int J Esthet Dent. 2018;13(3):
of barrier membranes on bone regeneration in localized bony defects: a 358-376.
systematic review. Int J Oral Maxillofac Implants. 2013;28(4):1076-1089. 36. Albrektsson T, Johansson C. Osteoinduction, osteoconduction and
17. da Rosa JC, Rosa AC, da Rosa DM, Zardo CM. Immediate osseointegration. Eur Spine J. 2001;10(2):s96-s101.
Dentoalveolar restoration of compromised sockets: a novel tech- 37. Galindo-Moreno P, Avila G, Fernández-Barbero JE, et al. Clinical and
nique. Eur J Esthet Dent. 2013;8(3):432-443. histologic comparison of two different composite grafts for sinus aug-
18. da Rosa JC, Rosa AC, Fadanelli MA, Sotto-Maior BS. Immediate mentation: a pilot clinical trial. Clin Oral Implants Res. 2008;19(8):
implant placement, reconstruction of compromised sockets, and 755-759.
repair of gingival recession with a triple graft from the maxillary 38. Raghoebar GM, Meijer HJA, van Minnen B, Vissink A. Immediate
tuberosity: a variation of the immediate dentoalveolar restoration reconstruction of failed implants in the esthetic zone using a flapless
technique. J Prosthet Dent. 2014;112(4):717-722. technique and autogenous composite tuberosity graft. J Oral Maxil-
19. Tolstunov L. Management of biomechanical complication of implant- lofac Surg. 2018;76(3):528-533.
supported restoration of a patient with combination syndrome: a case 39. da Rosa JCM, Sotto-Maior BS, de Oliveira P, Rosa AC, LA VDP. Clini-
report. J Oral Maxillofac Surg. 2009;67(1):178-188. cal, tomographic, and histologic evaluation of an autogenous bone
20. Younes R, Khairallah CM. The "one piece" autologous tuberosity graft harvested from the maxillary tuberosity for guided bone regen-
graft: a contemporary concept in ridge preservation. Case Rep Dent. eration: case report with a 4-year follow-up. Int J Periodontics Restor-
2020;2020:3945076. ative Dent. 2021;41(4):e183-e190.
21. de Molon RS, de Avila ED, de Barros-Filho LA, et al. Reconstruction of 40. Manzanera E, Llorca P, Manzanera D, García-Sanz V, Sada V,
the alveolar buccal bone plate in compromised fresh socket after imme- Paredes-Gallardo V. Anatomical study of the maxillary tuberosity
diate implant placement followed by immediate provisionalization. using cone beam computed tomography. Oral Radiol. 2018;34(1):
J Esthet Restor Dent. 2015;27(3):122-135. 56-65.
22. Khojasteh A, Nazeman P, Tolstunov L. Tuberosity-alveolar block as a
donor site for localised augmentation of the maxilla: a retrospective
clinical study. Br J Oral Maxillofac Surg. 2016;54(8):950-955.
23. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and
provisionalization of maxillary anterior single implants: 1-year pro- How to cite this article: Zufía J, Abella Sans F. Applications of
spective study. Int J Oral Maxillofac Implants. 2003;18(1):31-39. maxillary tuberosity block autograft. J Esthet Restor Dent.
24. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket 2022;34(7):1015‐1028. doi:10.1111/jerd.12911
classification and repair technique. Pract Proced Aesthet Dent. 2007;
19(2):99-104.