1

CE
Credit

IMPLANT FUNDAMENTALS
PART 1: PATIENT ASSESSMENT
AND EXTRACTION
A Peer Reviewed Publication
by Hu-Friedy
 SOLUTIONS OVERVIEW
IMPLANT FUNDAMENTALS

SCIENTIFIC REVIEWERS
Prof. Mauro Labanca Dr. Carlos Quinones

Private practice, Milan, Italy Associate Professor, Department

Consulting Professor of Anatomy, of Surgical Sciences, Division of
University of Brescia. Periodontics, University of
Puerto Rico School of Dental Medicine
Private practice, San Juan, Puerto Rico.

Dr. Lee Silverstein Dr. Jon Suzuki

Associate Clinical Professor of Professor, Department Chair, Program

Periodontics at the Georgia Health Director – Periodontology & Oral
Sciences University, Implantology Department
College of Dental Medicine Temple University Kornberg School of
Kennestone Periodontics Dentistry
Marietta, GA

Dr. István Urbán

Associate Professor, Department of

© 2019 by Hu-Friedy Mfg. Co., LLC
Periodontology,
University of Szeged, Hungary
Second Edition
Private practice, Budapest, Hungary
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or
otherwise without written permission from the publisher. [655]

Hu-Friedy Mfg. Co., LLC. Approved PACE Program

Provider for FAGD/MAGD credit. Approval does not
imply acceptance by any regulatory authority, or AGD
endorsement. The current term of approval extends
from 6/1/2019 to 5/31/2022. Provider ID# 218966

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Periodontal Biotype Grafting Concepts
page 7 page 14

ABSTRACT
In Part I of Implantology Fundamentals, participants will learn about how to best prepare
for implant placement in order to achieve long term success. Key points of discussion
include patient assessment and treatment planning as well as preservation of the implant
site through atraumatic tooth extraction. The course also covers the use of surgical
templates, grafting, and guided bone regeneration (GBR).

OBJECTIVES
At the conclusion of Part I, participants will be able to:
• List and describe the necessary steps of intraoral examination of tissue and bone
• Identify key considerations when placing implants (periodontal biotype, biologic
width, and interproximal papillae)
• Understand the use of surgical guides and how they benefit implant positioning
• Identify atraumatic extraction goals and techniques
• Understand bone augmentation and regenerative techniques
• Know bone grafting materials & concepts

COMMERCIAL DISCLAIMER
This education program is made possible through the continued support of Hu-Friedy Mfg. Co., L.L.C. The author(s)
is a Hu-Friedy employee and/or consultant for different companies and organizations within the dental industry
and received payment and/or product as compensation for the time involved in the development this course.

This course was written for dentists and dental professionals from novice to skilled.

Educational Methods: This course is a self-instructional journal and web activity.

Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must review the
material, complete the course evaluation and obtain a score of at least 70% on the examination. Upon attaining
a passing score, you will receive an emailed copy of your certificate of completion for 1 CE or you may print it
immediately. This course is provided at no charge.

Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise. Participants
must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into
their practice. Only sound evidence-based dentistry should be used in patient therapy.
 CHAPTER 1:
PATIENT ASSESSMENT AND TREATMENT PLANNING

The long-term success rates for dental implants have been well documented in the literature (Adell et al 1981;
Lekholm et al 1999; Buser et al 1997). From the first Branemark procedures completed on fully edentulous,
severely resorbed ridges (Branemark et al 1977), the indications for dental implants have expanded to include
the replacement of single teeth and partially edentulous arches (Figures 1.1 and 1.2). Recent developments in
the field have focused on the macro and microgeometry of dental implants and the use of digital diagnostics
and computer-aided surgery to aid in treatment planning, fixture placement, primary stability, and healing for
the edentulous site. As a result of these innovations,
dental professionals today can provide predictable
implant treatment for their edentulous patients.

Keys to these successes, however, are due diligence in

patient assessment and careful treatment planning.
Each patient presents a unique set of circumstances
that must be evaluated through a consistent,
systematic approach in order to determine his or her
candidacy for implant dentistry, and to permit the
involved dental professionals (e.g., general practitioner, Figure 1.1 Preoperative view of patient requiring
specialist, dental technician, supporting staff) to implant treatment on tooth #9 due to partial ankylosis
restore the patient to an optimal outcome. and root resorption.

PATIENT HISTORY AND PHYSICAL EXAMINATION

A detailed patient history should include not only dental disease but also the individual’s potential medical
problems and related medications, as multiple factors can affect one’s suitability for an implant restoration
(Ahmad 2012). Although patients with conditions such as irradiated mandibles, cardiovascular compromise,
diabetes, or advanced age were once contraindicated for implant therapy, they too can benefit from this
modality of treatment (Tanner 1997; Handelsman 1998; Weyent, Burt 1993).

The patient’s use of nicotine, alcohol, or drugs, however, can have a negative effect on vascularity at the site and
must be confidentially evaluated, discussed, and documented. The individual’s psychological mindset is a factor
to be carefully considered as well, as compliance is critical to the success of implant therapy.

All standard extraoral examinations should be performed

for the potential implant patient. The soft tissue profile
and support from the underlying alveolar bone are
critical factors that influence the design of prosthesis.
For example, if the desired final tooth position will be
facial to the residual mandibular ridge, a hybrid-type
prosthesis rather than a conventional crown and bridge
restoration may be necessary to best restore the patient
(Lazzara, Porter 2001). The status of the soft tissue in
the edentulous arch (width and thickness of the attached
gingiva) must be checked and the extension of the
Figure 1.2 Postoperative view following successful
alveolar ridge must be evaluated for its suitability as a implant restoration of tooth #9.
possible implant site.

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 The intraoral examination aids in the interdisciplinary team’s determination of which teeth can or cannot be
saved. The endodontic and restorative status of the existing teeth should be recorded as well. Evaluating the
periodontal health of the patient is mandatory and must be completed prior to placement of any dental implants.
The patient’s periodontal status also provides important information regarding his or her potential for compliance
during treatment.

MULTIDISCIPLINARY COMMUNICATION
Implant dentistry encompasses three principal stages (e.g., implant placement, abutment connection, and
restoration) and often the collaboration of multiple professionals in order to achieve the expectations of today’s
dental implant patient. This enables the pooling of experiences and expertise so that the implant placement can
be determined not by the limitations of the existing hard and soft tissue support at the edentulous or extraction
site, but rather by the desired final location as best to benefit
the patient. Thus, important throughout this process is
thorough documentation and exchange of all patient records.

ASSESSMENT OF PATIENT ANATOMY

Depending on the existing arch shape (e.g., narrow, crowded,
posterior cross bite) of the patient, orthodontics may be
necessary. Static and dynamic occlusion must be assessed
prior to treatment (Figure 1.3), as should intra-alveolar
distance and centric relations, to ensure occlusal stability
(Lazzara, Porter 2001; Ahmad 2012). Any findings of
elevated stress on the masticatory system such as bruxism
or temporomandibular disorder must be documented and
considered prior to treatment.

The location of the sinuses, the inferior dental nerve, and

the position of the mental and incisal foramina, each a vital Figure 1.3 Occlusion must be assessed prior to
treatment to ensure proper stability.
intraoral structure, must also be documented and shared
among the members of the interdisciplinary team. Adjacent
tooth roots play a similar role.

AVAILABLE BONE
Alveolar bone of sufficient dimension and quality (classified
as type I to type IV) is a prerequisite for implant placement
(Lekholm, Zarb 1985; Turkyilmaz et al 2007). (Figure 1.4).
Its insufficiency or absence will dictate the need for bone
reconstruction or augmentation prior to, or in conjunction
with, implant placement (Touati et al 2008). Type I—highly Figure 1.4 Panoramic radiographs permit
dense cortical bone—is most desired for implant placement; evaluation of patient anatomy and available
bone for implant placement.
type IV bone is often found in the posterior maxilla and is
the least dense.

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Consequently, a detailed radiographic analysis is mandatory
in each patient (Figures 1.4 and 1.5), allowing the members
of the interdisciplinary team to coordinate the necessary
implant position and angle (Lazzara, Porter 2001) in
conjunction with mounted models. The condition of the bony
ridge, any pattern of previous resorption, and the angulation
of this bone, particularly in the anterior maxilla, should be
considered during preoperative treatment planning. The
thickness of the buccal plate should be assessed as well using
the appropriate calipers and/or probes (a specialized implant
probe) (Figure 1.6).

Implants should be surrounded by 2mm of bone to prevent

undesired bone resorption and to enable correct
faciolingual implant placement and the development of Figure 1.5 Radiographic evaluation is key to
proper peri-implant soft tissues (Saadoun 2004). This can treatment planning and implant positioning.
dictate the type and size of the implants to be placed.
Fistulas and fenestrations, like vertical and/or horizontal
defects or similar pathologic conditions, must be
corrected prior to implant treatment as well, due to the
impact such defects can have on implant positioning in
a prosthetically driven approach.

Quantitatively, the available bone at the site should

have a three-dimensional configuration that permits
placement of a restoration-driven implant, be of
optimal length and diameter, and have an optimal
position and angulation (Saadoun 2004). It should also
approximate, in the buccal position, the facial bone Figure 1.6 Assessment of alveolar bone is critical
to evaluating the implant site.
level on the adjacent and contralateral teeth adjacent
to the edentulous area to support the formation of
the interproximal papillae. The faciopalatal bone dimension should permit implant placement in a position and
angulation that approaches that of a natural tooth. Furthermore, the facial contour of the restoration should
correspond to the contours of the adjacent teeth (Smukler et al 2003).

In addition to periapical and panoramic radiographs, computed tomography (CT) scans and CBCT disclose bone
dimension and the contours of the residual ridge and guide proper three-dimensional insertion of the implant
at a given edentulous site (Ascheim Dale 2001) (Figure 1.7). Cross sections of such scans are particularly useful
to the treatment team because they provide visibility of bone quantity buccolingually, and the location of vital
structures. Digital scans, in addition to providing valuable radiological diagnostics, can also be integrated for
computer-based implant planning. They permit evaluation of the site in three dimensions from its anatomical
structures and can provide information about the density of the existing bone.

Bone Measurement
Accurate, finely designed instruments,
such as bone calipers, should be used
for precise measurement of intraoral
structures.
• Bone sounding and determination
of alveolar bone dimensions
• Easily measure for implant/ Figure 1.7 Computed tomography scans and
prosthetic placement CBCT imaging also facilitate patient assessment
and treatment planning.

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 PERIODONTAL BIOTYPE
The patient’s gingival biotype is an important consideration as
well. Patients with thin, highly scalloped gingivae are prone to
gingival recession (Figure 1.8); those with thick, flat biotypes can be
predisposed to pocket formation or inflammation after implant surgery
(Figure 1.9). Defects in thin biotype patients can also be produced as a
byproduct of bone remodeling and should be accurately assessed and
surgically treated to re-establish healthy peri-implant hard and soft
tissues (Touati et al 2008).

BIOLOGIC WIDTH
Figure 1.8 Diagram of patient with
On natural teeth, the “biologic width” is the term describing the a thin periodontal biotype; less
supracrestal soft tissues (e.g., junctional epithelium and connective ideal for implant aesthetics.
tissue) that seal the oral cavity and protect against inflammation. The
dimension of the connective tissue (~1mm) around dental implants
and natural teeth is relatively constant, but the junctional epithelium
around an implant is much greater than it is around a natural tooth
(2-2.5mm vs. 1mm, respectively) (Touati et al 2008). On natural teeth,
the connective tissue is deeply inserted in the cementum through
collagen fibers, which provides high mechanical strength. Around
implants (Figure 1.10), however, the collagen fiber bundles are not
really attached but instead adhere to the transmucosal components
via glycoaminoglycosides. As a consequence, this adhesion has poor
mechanical resistance (Touati et al 2008).
Figure 1.9 Patients with a thick
Consequently, the selection of transmucosal components must biotype are less prone to gingival
be biased toward biocompatibility; if the components are not recession following implant
biocompatible, the soft tissues will migrate apically until they reach the treatment.
level of the implant. Titanium and aluminum oxide, for example, have
been shown to be biocompatible enough to allow soft tissue adherence,
(Domken et al 2003) whereas resin, gold, or porcelain at the transgingival
level does not allow soft tissue adherence and may result in gingival
recession and/or bone loss.

INTERPROXIMAL PAPILLAE
In order to achieve a natural appearance between two natural teeth, Tarnow
et al determined that a distance less than 5mm is necessary between the
contact point and the interproximal bone (Tarnow et al 1992) (Figure 1.11). Figure 1.10 The biologic width
To produce a similar aesthetic outcome for a papilla between two adjacent around an implant must be
implants, this distance must be a minimum of 3.4mm (Tarnow et al 2000). carefully observed.

These guidelines, however, must take into account the position of the crest
of bone relative to the cementoenamel junction during treatement planning.

PROSTHETICALLY DRIVEN TREATMENT PLANNING

Contemporary implant treatment is prosthetically rather than surgically
driven, as various grafting techniques are available to support implant
placement in areas where insufficient bone exists preoperatively
(Ascheim Dale 2001). Restoration-driven implant placement must guide
the harmonious peri-implant soft tissue profile with the contours of the
restoration in order to ensure compatibility with the adjacent natural teeth Figure 1.11 Diagram of contact point
(Saadoun 2004). and relationship between bone and
the interdental papilla.

7
DIAGNOSTIC WAXUP
A diagnostic waxup must be mounted on a diagnostic cast in the
dental laboratory to permit assessment of jaw relations, and to
determine if a change in occlusal position is necessary (Figure
1.12). The articulator should be positioned to establish anterior-
to-cuspid guidance with early disclusion of the posterior dentition
(“freedom in centric” as possible).

The diagnostic waxup also allows ridge morphology to be

evaluated and allows planning of the number, position, angulation, Figure 1.12 The diagnostic waxup permits
and type of implants to be placed. Augmentation procedures assessment of ridge morphology, evaluation
necessary to support this prosthetically driven placement can also of GBR needs, and implant selection.
be determined at this phase if a discrepancy is noted between the
current level of the crestal bone and the position required for the prosthetic crown.

Evaluation of the waxup enables the team to determine whether a fixed, removable, or cement-retained prosthetic
is ideal for the restoration of the patient. It also provides a template for the fabrication of provisional restorations
and a surgical guide that will determine implant positioning.

SURGICAL GUIDE
Planning and implementation of a successful implant-supported
restoration is much simpler when surgical templates or guides
are used to plan implant positions in the mouth (Figure 1.13). The
template can be converted to a drilling guide later. In the planning
phase, the guide should establish proper positioning that respects
the following requisites:

Mesio-distal plane
A distance of 1.5mm is necessary between an implant and natural Figure 1.13 An accurate surgical guide aids
the clinician in proper implant placement.
tooth; the distance should be minimally 3mm-4mm between two
adjacent implants.

Bucco-lingual plane
On both aspects a distance of 1mm (minimally) must be established.

Inciso-cervical plane
The head of the implant should be positioned apically by 3mm to the anticipated position of the gingival margin,
with no apical impingement on nearby structures.

SUMMARY
Implant therapy is an important modality for the restoration of the edentulous patient, and is ideally performed
by a cohesive team of dental professionals acting in concert to evaluate the specific medical, dental, and
physical factors of the individual patient. Meticulous assessment and diagnostics enable implant placement to be
prosthetically driven with success and predictability (Figures 1.14 and 1.15).

Figure 1.14 Pretreatment view of patient with Figure 1.15 Note natural tissue integration
failing maxillary left central incisor (tooth #9) and harmonious results achieved via
due to horizontal fracture. implant treatment at site #9.

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 REFERENCES

Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;10:387-416.

Ahmad I. Prosthodontics At A Glance. Wiley-Blackwell, 2012; pgs 104-109.

Ascheim KW, Dale BG. Esthetic Dentistry: A Clinical Approach to Techniques and Materials. Mosby; 2001.

Branemark PI, Hansson BO, Adell R, et al. Osseointegrated implants in the treatment of the edentulous jaw.
Experience from a ten-year period. Scan J Plast Reconstr Surg 1977;16(Suppl):1-132.

Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part I: 8-year
life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Impl Res 1997;8:161-172.

Domken O, Lecioux G, Repen EH. Influence of abutment surface on peri-implant soft tissue and attachment in
humans. Clin Oral Impl Res 2003;14(4):xxi.

Handelsman M. Treatment planning and surgical considerations for placement of wide body implants, Compend
Contin Educ Dent 1998;19:507.

Lazzara RJ, Porter SS. Esthetics and implant prosthetics. In: Ascheim KW, Dale BG. Esthetic Dentistry: A Clinical
Approach to Techniques and Materials. Mosby; St. Louis, 2001.

Lekholm U Gunne J, Henry P, et al. Survival of Branemark implant in partially edentulous jaws: A 10-year
prospective multicenter study. Int J Oral Maxillofac Impl 1999;14:639-645.

Lekholm U, Zarb GA. Patient selection and preparation. In: Branemark PI, Zarb GA, Albrektsson T. Tissue-
Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago, IL: Quintessence Publishing, 1985.

Saadoun AP, Le Gall MG, Touati, B. Current trends in implantology: Part II—Treatment planning, aesthetic
considerations, and tissue regeneration. Pract Proced Aesthet Dent 2004;16(10):707-714.

Smukler H, Catellucci F, Capri D. The role of the implant housing in obtaining aesthetics: Generation of peri-
implant gingivae and papillae—Part I. Pract Proced Aesthet Dent 2003;25(2):141-149.

Tanner T. Treatment planning for dental implants: Considerations, indications, and contraindications, Dent
Update 1997;24:253.

Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the
presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-996.

Tarnow DP. Cho SC, Wallace SS. The effect of inter-implant distance on the height of the inter-implant bone
crest. J Periodontol 2000;71:546-549.

Tarnow DP, Chu SJ, Kim J. Aesthetic Restorative Dentistry: Principles and Practice. Montage Media Corporation,
Mahwah, NJ. 2008.

Touati B, Etienne JM, Van Dooren E. Esthetic Integration of Digital-Ceramic Restoration. Montage Media
Corporation, Mahwah, NJ. 2008.

Turkyilmaz I, Tozum TF, Tumer C. Bone density assessments of oral implant sites using computerized
tomography. J Oral Rehabil 2007;34:267-272.

Weyant RJ, Burt BA: An assessment of survival rates and within-patient clustering of failures for endosseous oral
implants, J Dent Res 72:2, 1993.
Images presented with permission of the copyright holder and courtesy of Dr. Frank Celenza Jr., Dr. Stefano Gracis, Dr. Joseph Kan, Mr. Jason
Kim, Dr. John Kois, and Dr. Carlos R. Quinones. Special thanks to Justin Cruz, Kennesaw State University, Georgia, for assistance with the
research cited herein.

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 CHAPTER 2:
TOOTH EXTRACTION AND IMPLANT SITE PRESERVATION

For years, practitioners have endeavored to eliminate contraindications to implant placement as a means
of expanding access to care. Procedures such as sinus lifts, dental nerve repositioning, and guided bone
regeneration (GBR) have been pioneered in order to improve control of the involved treatment site(s) and
overcome limitations. These concepts have a considerable influence on treatment outcomes, particularly in
addressing alveolar bone deficiencies that come to light during treatment planning and patient examination.
Hard and soft tissue grafting at the surgical site enables functional, aesthetic implant placement, often with
optimal fixture positioning or fewer procedural steps.

Proper Use of Extraction Forceps

Reduce the risk of root tip fracturing or
crown crushing by using forceps to firmly
grasp its roots in an apical direction.
• U
 se thin, tapered beaks that penetrate
the PDL space.
• Secure multiple points of root contact
below the cervical line.
• L
 ongitudinal beak serrations provide Figure 2.1 Atraumatic tooth extraction is key to preserve
additional grip to the crown and root the alveolar bone at the implant site.
surface.

ATRAUMATIC TOOTH EXTRACTION

Tooth extraction and implant placement may be the treatment of choice for hopeless teeth, i.e., when the
periodontal involvement of the tooth or root jeopardizes an adjacent tooth or there is an infrabony defect
or caries extending apical to the osseous crest (Rosenthiel et al 2001; Genco et al 1990). Exodontia typically
involves an expansion of the alveolar bone and
severing of the periodontal ligament, as conducted
with a combination of dental elevators, periotomes,
and extraction forceps (Misch 2008) (Figures 2.1
through 2.4).

Figure 2.2 Exodontia with deference to preservation of hard

and soft tissues at the site.

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 Traditional instrumentation uses principles like simple
machines (e.g., levers, fulcrums, and wedges) to separate
the attachment apparatus and create tooth mobility
through a “prying” motion that is less desirable at the
treatment site. Implant treatment today depends on
the ability of the treatment team to ideally preserve or
supplement the extraction site for implant placement,
commonly referred to as “atraumatic extraction”, which
includes several important objectives:

Goals of Atraumatic Extraction:

Figure 2.3 A periotome is used to sever the
• Preservation of buccal bone and cortical plate periodontal ligament and facilitate extraction.
• Maintenance of the periosteal envelope and vascularity
at the site
• Generate less pressure on bony site
• Prevent root tip fractures

Advances in dental instrument design provide today’s

clinician with ideal options for achieving the goals of
atraumatic extraction. Finely tuned instrumentation, e.g.,
luxating elevators and periotomes, is key to this process,
both in the severing of the periodontal attachment and
grasping of the failing tooth below the cervical margin with
specially designed apical forceps. With the latter, a light
Figure 2.4 The thin, precision tip of a Luxating
yet constant apical pressure is applied onto the mesial and
Hybrid adapts effectively to the contours of the
distal PDL space only until the tooth is slightly elevated and tooth and root.
mobile for the proper use of atraumatic extraction forceps
(Misch 2008; Horowitz and Mazor 2010; Feck). All granulation tissue is removed using specially designed curettes
and the site is prepared for bone grafting, GBR, or implant placement according to the treatment plan.

CLASSIFICATION OF RIDGE DEFECTS

To simplify interprofessional communication regarding alveolar deficiencies, Seibert established a classification
system as such (Siebert 1983):
• Class I: Buccolingual defects yet normal apicocoronal height.
• Class II: Apicocoronal loss of tissue with a normal buccolingual ridge width.
• Class III: Combination cases involving both a vertical and horizontal deficiency.

The vertical component of bone loss is generally more challenging to manage; horizontal deficiencies are more
predictably restored (Touati et al 2008). In treating the former, the clinician must use tension-free flaps and ensure
they completely cover the regenerative materials used at the treatment site—and both addressed using GBR.

Proper Use of a Periotome or Luxating Elevator

Avoid lifting and prying with a standard elevator for a less
traumatic extraction.
• Reduce pressure on adjacent teeth during extraction.

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PRINCIPLES FOR GUIDED BONE REGENERATION
After over four decades, a significant body of scientific evidence resulted in the development of a biological
concept known as Guided Tissue Regeneration (GTR) (Quiñones et al 1996; Quiñones and Caffesse 1997). The
clinical utilization of this concept revolutionized surgical therapy in all areas of dentistry, including periodontics,
oral reconstructive surgery, and dental implantology. In the 1970s, Melcher (1976) presented the basic premises
that formed the biological basis for GTR; he suggested that each of the four tissue groups found in the
periodontium (i.e., gingival epithelium, gingival connective tissue, alveolar bone, and periodontal ligament) had
the ability to express a unique cell phenotype. Melcher further postulated that the type of healing resulting
following periodontal therapy depended on the phenotype of the cells that first re-populated the root surface,
a concept that was ultimately validated in numerous research publications that led to the various clinical
applications of GTR (Quiñones 1997). Therefore, in GTR, a barrier membrane is selectively placed during surgery
to exclude undesirable tissues and cells from the wound area and to create a space into which progenitor cells
with a regenerative potential can migrate.

The term Guided Bone Regeneration (GBR)

was introduced by Buser et al (1993) to
specifically describe those GTR procedures
Exclusion of GE/CT cells
directed towards bone regeneration. Barrier membrane
Since that date, GBR has successfully
been used clinically to facilitate bone
regeneration in extraction sites, to Migration of
progenitor cells
augment deficient alveolar ridges, and in
conjunction with dental implants (Hürzeler
and Quiñones 1991).

Clinically, GBR involves the placement of a Secluded

barrier membrane (Hürzeler and Quiñones Alveolar bone wound area

1991) (Figure 2.5) to:

1. 
Exclude undesirable gingival epithelium
and gingival connective tissues and Figure 2.5 Diagram shows placement of a barrier membrane and biological
processes at the defect site. The membrane excludes undesired gingival
cells, epithelial (GE) and connective tissue (CT) cells from the wound and
2. create a secluded wound area into establishes a protected space into which progenitor cells can migrate.
which progenitor cells from the
alveolar bone can migrate and
facilitate bone regeneration,
3. 
protect the underlying blood supply,
and
4. stabilize the wound area.

A barrier membrane is required for all four in order to promote bone regeneration. Adequate space is essential
to provide an environment for blood vessel and bone growth. A viable bone graft material is often required to
physically support the overlying membrane, thereby avoiding membrane collapse into the underlying space.
Protection of the underlying blood clot and wound stabilization, required for bone regeneration, is assured by
anchoring of the overlying membrane, which prevents micromovements from affecting the underlying space and
the ingrowth of fibrous connective tissue (Buser et al 1996; Urban et al 2009).

In patients with moderate or severe resorption, or when preoperative treatment planning reveals an alveolar
bone dimension unsuitable for implant placement at the desired location, then reconstructive surgery using GBR
principles is warranted (Fuggazatto et al 1997; Cranin et al 1999; Mayfield et al 1997; Eilan et al 2007).

12
 BONE GRAFTING MATERIALS
Numerous bone grafting materials have been utilized to augment deficient alveolar bone and support sinus lift
procedures (American Academy of Periodontology 1992).

•A  utografts – Involve the transfer of tissue from one site to a second site in the same individual (Figure 2.6).
This autogenous bone is harvested from the iliac crest or oral cavity (e.g., maxillary tuberosity, mandibular
symphysis, coronoid process) and is often considered the ‘gold standard’ in grafting because of obvious genetic
compatibility and no risk of cross contamination (Anitua 1998).
• Allografts – A graft taken from an individual of the same species as the recipient but with a different genetic
composition (e.g., freeze-dried bone; demineralized freeze-dried bone). Allografts eliminate the need for a
second donor site.
• Xenografts – Bone graft materials harvested from another species (e.g., bovine or equine bone) for their
osteoconductivity.
• Alloplasts – Synthetic bone substitutes such as porous and non-porous hydroxyapatite materials that can serve
as a scaffold for new bone formation.

The graft material one selects should be biocompatible, without provoking an immunologic response at the
treatment site. The chosen material should be readily available and easy to manipulate in the oral environment.
In each clinical application, the grafting material should be manipulated as infrequently as possible and be
maintained in a sterile environment (Anitua 1999; Anitua et al 2014).

AVERAGE AMOUNT OF BONE GRAFTING

MATERIAL REQUIRED FOR VARIOUS
PROCEDURES (ANITUA 1999)
Single Tooth 1-2mL
Two - Three Teeth 2-5mL
Sinus Lift
Unilateral 5-10mL
Bilateral 10-20mL
Severe pneumatized 20-30mL
Figure 2.6 Example of autogenous graft, harvested
with trephine burs, from the mandibular symphysis.

Graft materials essentially provide osteoblasts and newly forming bone with a scaffold to guide and support the
regenerative process. A barrier membrane should be placed over the graft site to protect the defect during healing
and promote the desired selective cell repopulation, e.g., preventing gingival epithelial and connective tissue
downgrowth and allowing the ingrowth of alveolar bone (Kay et al 1997; Quinones 1997; Anitua 1999).

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GRAFTING CONCEPTS
The dental literature contains abundant information explaining in detail the grafting procedures required to
preserve the postextraction site and ready it for implant placement, or ridge augmentation procedures. Following
here are several common examples:

Post Extraction Socket Preservation

Following atraumatic extraction of a tooth, the use of an alveolar
graft or GBR procedure is necessary to prevent the collapse of
the alveolar bone. Possessing all surrounding walls, this site has
favorable potential for regeneration (Anitua 1999).

In the post extraction socket preservation technique, full-

thickness facial and lingual crevicular incisions—including the
papillae and producing well-vascularized flaps of generous size—
are made prior to tooth removal. Mucoperiosteal reflection is
then performed down to but not beyond the vestibular level. Figure 2.7 Diagram of debridement performed
with a periodontal or surgical curette to ready
The extractions are then performed, with the clinician taking the extraction site for implant placement.
care to preserve as much of the bony socket as possible.

The site is then inspected and all follicles, cysts, or granulomas

are removed using periodontal and surgical curettes.
(Figure 2.7). At this point, it is advisable to confirm primary
flap closure will encompass the entire surgical site after
completion of the grafting procedure.

The selected graft material is then prepared for delivery.

Depending on the size of the socket, a syringe or bone scoop/
placement instrument may be used to deliver the graft
Figure 2.8 Graft material is placed into the
particulate to the site (Figure 2.8). The patient’s blood site to promote an environment suitable for
(alternately saline) may be added to the particulate to help optimal implant integration.
promote integration and contouring. The site is filled with the
particulate slurry to the level just below the highest point of
bone, and the graft is manipulated into place and covered with
a resorbable membrane (Cranin 1999). Care should be taken to
allow spacing for vascularity, angiogenesis, and cell migration.

Primary wound closure is then accomplished with an appropriate

technique (e.g., continuous box-lock) and suture material
(e.g., 4-0 dyed or undyed polyglycolic acid [PGA] sutures)
(Figure 2.9). The patient is dismissed until the usual one-week
postoperative follow-up appointment. The socket area is allowed
Figure 2.9 Closure is performed using the
to heal for a variable amount of time, typically ranging from two
operator’s technique of choice.
to six months, depending on the severity of the initial defect.

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 Particulate Bone Grafts
Many types of bone particulate can be used in support of
GBR at a future implant site. This popular approach entails
the mixing of particulate with either saline or the patient’s
own blood (Figure 2.10), placement of this “slurry”, and then
covering it with a barrier membrane to facilitate new bone
growth. Indications for particulate bone grafts include horizontal
defects, small vertical ridge defects, postextraction socket
Figure 2.10 Bone particulate harvested to support
preservation, sinus lifts, and procedures that involve grafting implant placement.
simultaneously with implant placement (Ahmad 2012).

Onlay Block Grafts

One approach for augmenting a deficient site in order to
facilitate implant placement involves autogenous bone blocks
that are affixed to residual bone via screws (Figures 2.11 and
2.12). Once removed from the symphysis or similar donor site
(i.e., obtained with the Jovanovic chisel and grasped with a
cortical bone clamp), the graft is prepared to accommodate
the residual ridge, sitting atop this bone and fixed in place with
mini screws. Block grafts are particularly valuable for making
dramatic dimensional changes in ridges of insufficient height Figure 2.11 Implant site with severe buccal resorption
(Misch et al 2014); they are similarly indicated for augmentation and adaptation of an onlay graft prior to fixation.
of ridge width.

Maxillary Sinus Augmentation

The rehabilitation of the partially or totally edentulous maxilla
with osseointegrated dental implants has often presented a
greater surgical and prosthetic challenge than that of the
similarly edentulous mandible. This is due in part to a number
of anatomical and physiologic differences between the two
arches. A main difference is the presence of enlarged or
pneumatized maxillary sinuses on the posterior areas of the
maxilla which often result in quantitative and qualitative
deficiencies of bone, thus preventing or limiting the placement Figure 2.12 Onlay block graft affixed at the treatment
of dental implants on these areas of the jaws. It is on these site to improve its potential for implant placement.
cases that a maxillary sinus augmentation procedure is
warranted (Garg and Quiñones 1997).

Sinus Lift Procedure Crestal Approach

This technique elevates the maxillary sinus floor from an
alveolar crest approach with the objective of being less
invasive and using a minimally invasive flap design. After
creating an osteotomy between teeth or along an edentulous
ridge, osteotomes, specialized instruments with round or
concave ends of varying diameters, are used to elevate the
sinus floor (Figure 2.13).

Figure 2.13 Diagram of the crestal approach used to

elevate the sinus floor for implant placement.

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Existing bone volume is augmented to prepare the hard tissues
for placement of dental implants after ossification of the sinus
graft. Steady water irrigation is important in such procedures to
prevent overheating of bone and instruments alike (Cranin 1999;
Summers 1994). The sinus lift procedure via a crestal approach
using osteotomes is mostly warranted when limited or moderate
bone atrophy of the maxillary sinus is present.

Sinus Lift Procedure Lateral Window Approach

When moderate to advanced pneumatization of the sinus is
present, and a significant amount of bone augmentation is Figure 2.14 Diagram of osteotomy utilized
required, a sinus lift procedure using a lateral window to permit lateral approach to the maxillary
sinus region.
approach is best indicated. The lateral approach to the
maxillary sinus allows the Schneiderian membrane to be
elevated with great visibility for the surgeon and augments
the vertical amount of bone within the sinus cavity
(Figure 2.14). Access to the Schneiderian membrane is made
through the lateral wall of the maxillary sinus using surgical
burs or piezo technology. The Schneiderian membrane can
then be retracted using sinus elevation instruments. Compared
to surgical curettes, sinus lift curettes have accentuated or
prominent angles to gently separate the membrane from the
bone. After successful retraction of the membrane, bone graft
material is added using a bone syringe. Implants are placed
after maturation of the bone graft (Figures 2.15 and 2.16) Figure 2.15 Radiograph of the augmented
maxillary sinus with three implants after
or, in certain circumstances, simultaneously. abutment connection.

Figure 2.16 Postoperative occlusal view of the

definitive implant restorations.

Elevate and Separate Schneiderian Membrane From Bone

Using sinus lift instruments, separate and reflect the
Schneiderian membrane from the maxillary bone, and elevate
the membrane during lateral sinus lifts for easy access.
• Delicate separation is essential to preserve the
Schneiderian membrane
• Variety of sizes and working-end angles for optimal access

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 Connective Tissue Grafts
Connective tissue grafts (e.g., harvested from
the palate or retromolar tuberosity [i.e., acellular
dermal matrix]) are often utilized in an additive
periodontal procedure such as recession coverage,
ridge augmentation, or to alter gingival biotype.
The quality of the graft tissues is important for the
long-term stability of the regenerative site; the more
fibrous the tissue, the better the long-term stability
of the soft tissues (Touati et al 2008) (Figures 2.17
through 2.20). Figure 2.17 Palatal graft site closure.

SUMMARY
Today’s bone augmentation concepts enable
clinicians to overcome many anatomical barriers
to implant placement. Regenerative procedures
such as GBR, sinus lifts, and socket preservation
improve treatment site(s) quality and allow for
predictable healing. Used in combination with
bone grafting materials, these concepts promote
osteogenesis and completion of prosthetically
driven implant placement. Figure 2.18 Preoperative facial view of implant candidate
with thin biotype.

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Figure 2.19 Connective tissue graft (CTG) is placed and

secured with chromic gut sutures.

Figure 2.20 Postoperative result of aesthetics achieved with

successful implant placement and CTG procedure.

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Images presented with permission of the copyright holder and courtesy of Dr. Eric Van Dooren, Dr. Arun Garg, and Dr. John Kois.

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