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Dr. Horowitz,

That laser is so amazing you could fall asleep while being treated !!

Pam W.

 
India Lecture

Hello Sir,
 
Sir it was a pleasure and priviledge to be with you , i surely take care of my photos from the case i will do from tommorow. I am back to school from tommorow with a lot of enthusiasm meeting you and other superstars of dentistry. Thank you Sir for everything. Sir you should return fast and we are eager to hear you for the second time.
 
with regards,
Dr. Akshay Melath

 
Firenze

Dear Bob,
Kudos to both you and Ziv on an outstanding meeting and venue. My family and I had a superb time in Florence, one that we will never forget. I thought that the program was terrific and that the A-V support was excellent. The arrangements by Ilana were handled in an organized fashion and of course, it was great to hear both of you present. Keep up the good work!
 
Sincerely,
 
Paul

 
Horizontal Ridge Augmentation Utilizing a Composite Graft of Demineralized Freeze Dried Allograft, Mineralized Cortital Cancellous Chips, and a Biologically Degradable Thermoplastic Carrier Combined witha Resorbable Membran

Horizontal Ridge Augmentation Utilizing
a Composite Graft of Demineralized
Freeze-Dried Allograft, Mineralized
CorticalCancellousChips,anda
BiologicallyDegradableThermoplastic
CarrierCombinedWithaResorbable
Membrane:ARetrospectiveEvaluationof
73ConsecutivelyTreatedCasesFrom
PrivatePractices

Nicholas Toscano, DDS, MS1*
Danny Holtzclaw, DDS, MS2
Ziv Mazor, DMD3
Paul Rosen, DMD, MS4
Robert Horowitz, DDS5
Michael Toffler, DDS6

Ridge deficiency is an unfortunate obstacle in the field of implant dentistry. Many techniques
are available to rebuild the deficient ridge. Some of these techniques are associated with
significant morbidity and often require a second surgical site. With the advent of guided
bone regeneration (GBR), one may now graft the deficient ridge with decreased morbidity
and without a second surgical site. The purpose of this retrospective consecutive case series
from 5 private practices is to report on the outcomes of a composite material of
demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically
degradable thermoplastic carrier (Regenaform RT) when combined with a resorbable

membrane for GBR of lateral ridge defects in human patients. The specific aim was to quantify
clinical results through direct measurement. Data were obtained from 73 consecutively treated
lateral ridge augmentations performed on 67 partial and/or completely edentate patients.
Clinical data (presurgical ridge width, ridge width at implant placement, and bone density at
implant placement) were obtained retrospectively from 5 private practices via an exhaustive
retrospective chart review, which was pooled and averaged for analysis. The average gain in
horizontal ridge width was 3.5 mm (range, 3–6 mm). The density of the bone was noted to be
type 2 to 3, with type 3 being the predominant finding. This retrospective case series from 5
clinical private practices suggests that the use of a composite material of demineralized freeze-
dried allograft, mineralized cortical cancellous chips, and a biologically degradable
thermoplastic carrier, when covered by a resorbable collagen membrane for GBR, is an
effective means of horizontal ridge augmentation.

Key Words: ridge augmentation, bone graft, particulate graft, dental implant

INTRODUCTION

Advances in surgical and im-
plant technology have enabled
dentists to meet the treatment
needs of an esthetically de-
manding patient population.
1
Historically, Albrektsson’s criteria have
served as the benchmark by which dental
implant success has been measured.2 Al-
though these criteria have remained the
gold standard, with a strict focus on
osseointegration and function, they do not
address contemporary concerns such as
esthetics or restorability secondary to im-
plant positioning. For example, implants may
be suboptimally placed because of anatomic
limitations, developmental defects, pathol-
ogy, bone resorption, and long-standing
ridge deficiencies, which when restored
may satisfy all of Albrektsson’s criteria for
success. Yet the implant may be a failure, as
seen in an undesirable esthetic outcome.
Implant malpositioning has been an
unfortunate complication of our profession.
The consequence of this can be off-axial
loading, which may result in biomechanical
problems, loosening, and/or fracturing of the
cover screw, implant, or implant collar.3,4
Implant malpositioning can adversely affect
clinical and prosthetic outcomes by creating
a suboptimal emergence profile, fracture of

the restoration, poor screw-hole positioning,
occlusal discrepancies, and compromised
esthetics and phonetics.
An ideal volume of bone is essential for
proper implant placement in the buccal/
palatal, apical/coronal, or mesial/distal di-
mension. Studies have demonstrated that
bone resorption will occur secondary to
tooth extraction5–12 (Figure 1). This tends
to occur over a 12 month period, most
notably in the first 4 months following
extraction5–11 and, depending upon location,
may range up to 5–7 mm buccolingually.8–12
In addition, 2–4 mm of vertical height loss
frequently accompanies the horizontal loss
and usually is seen when multiple adjacent
extraction sites are combined.8–12 To combat
this dimensional loss of bone volume, ridge
preservation techniques have been used to
maintain the alveolar ridge secondary to
tooth extraction.5,12–15 However, even with
current techniques, postextraction resorp-
tion may occur, mandating surgical manage-
ment of the ridge deficiency.12
Ridge splitting and expansion tech-
niques concurrent with bone grafting have
been well documented for treating hori-
zontal deficiencies. Included in these cate-
gories are ridge splitting and expansion,16,17
guided bone regeneration (GBR),18–21 dis-
traction osteogenesis,22 and block graft-

ing.23–28 The purpose of this retrospective
consecutive case series from 5 private
practices is to report on the outcomes of
a composite material of demineralized
freeze-dried allograft, mineralized cortical
cancellous chips, and a biologically degrad-
able thermoplastic carrier (Regenaform RT,
Exactech Dental Biologics, Gainesville, Fla)
when combined with a resorbable mem-
brane for GBR of lateral ridge defects in
human patients. The specific aim was to
quantify the clinical results through direct
measurement.

MATERIALS AND METHODS

Clinical data (presurgical ridge width, ridge
width at implant placement, and bone
density at implant placement) were obtained
retrospectively from 5 private practices via
an exhaustive retrospective chart review,
which was pooled and averaged for analysis.
A total of 73 consecutively treated lateral
ridge augmentations were performed on 67
partial and/or completely edentate patients
with a composite material of demineralized
freeze-dried allograft, mineralized cortical
cancellous chips, and a biologically degrad-
able thermoplastic carrier (Regenaform RT)
that was covered by a resorbable collagen
membrane (Ossix, Oropharma Inc, Langhorne,
Pa). All patients were free of systemic disease
that might compromise the results, such as
uncontrolled diabetes or thyroid disease,
osteopenia or osteoporosis, and blood dys-
crasias such as anemia, and all were smokers
of less than 1 pack of cigarettes per day. A
total of 43 augmentations were performed in
the maxilla and 40 in the mandible. Three
patients underwent bilateral grafts of the
mandible. Patients were treated under local
anesthesia using 2% lidocaine with 1:100 000
epinephrine or articaine 4% with 1:100 000
epinephrine. A beveled crestal incision was
made slightly to the palate or lingual of the
treatment site and was extended at least 1

tooth beyond in both mesial and distal
directions. After elevation of full-thickness
flaps, measurements were made near the
crest of the ridge using a UNC-15 probe to
record the preaugmentation ridge width.
Measurements were rounded up to the
nearest millimeter at pretreatment and at
posttreatment. The bone defect was decorti-
cated using a #4 round bur through the
cortical plate to enhance revascularization of
the site. The membrane (Ossix, Orapharma,
Inc, Warminster, Pa) was soaked in sterile
water or sterile saline, according to the
manufacturer’s instructions, and was trimmed
to fit the site. Further periosteal release was
performed to allow for tension-free closure of
the flap over the membrane and graft. The
thermoplastic composite graft was mixed
according to the manufacturer’s instructions
and was molded to fit the ridge defect. The
graft was covered with the pretrimmed
resorbable collagen membrane, and tension-
free closure was provided utilizing a combi-
nation of horizontal and vertical mattress
sutures (Figures 2 through 6). Patients were
placed on postoperative Motrin 800 mg 3 to 4
times daily for up to 10 days to provide both
anti-inflammatory and analgesic benefits, as
well as amoxicillin 500 mg 3 times a day or
875 mg 2 times daily for 10 days. Patients
were also instructed to use 0.12% chlorhex-
idine rinse, starting on the day after surgery,
twice daily for the first 2 weeks when the
sutures were removed, and for up to 4 weeks
if the membrane became exposed. Pa-
tients were subsequently seen at 1 month,
3 months, and 6 months after the implants
had been placed.
All cases were allowed to heal for a
minimum of 6 months before implants were
placed. At this time, a second measurement
was made following the elevation of a full-
thickness flap. Again, a UNC-15 probe was
used to record ridge width postaugmenta-
tion. This was done close to where the first
measurement was made. All clinicians noted

RESULTS

average gain in horizontal ridge width was
3.5 mm (range, 3–6 mm). The density of the
bone was noted to be type 2 to 3, with type
3 being the predominant finding. All im-
plants were successfully placed and ulti-
mately restored after an average 4 months of
healing (Figures 7 through 12).

Average presurgical ridge width was 4 mm,
and it was noted that maxillary sites tended
to have more advanced ridge defects then
mandibular sites. At stage I implant place-
ment, ridge width postaugmentation was
recorded at an average of 7.5 mm. The

470

Vol. XXXVI/No. Six/2010

DISCUSSION

The use of autogenous iliac crest block grafts
has been associated with higher rates of

Toscano et al

FIGURES 7–12. FIGURE 7. Nonrestorable tooth #7 with endodontic lesion noted. FIGURE 8. A large defect is
seen postremoval of tooth and lesion. FIGURE 9. Defect is grafted before membrane placement. FIGURE 10.
Six months postgraft with implant placed. FIGURE 11. #7 showing nonrestorable of implant placed in
grafted bone. FIGURE 12. Implant restored 8 months postgrafting.

Journal of Oral Implantology

471

Horizontal Ridge Augmentation Utilizing a Composite Graft

postoperative sequelae and morbidity,29
often requiring patient hospitalization. Al-
though iliac crest bone may present certain
advantages, such as the ability to obtain a
larger volume of graft material that would
include osteogenic material, its value has to
be questioned in light of excellent results
obtained with other graft materials and
techniques, and the significant costs and
morbidities associated with its procure-
ment.30 Autogenous block grafts from the
mandibular symphysis or ramus may be more
advantageous in that they can be procured
through an in-office, outpatient procedure.
Furthermore, intraoral autogenous grafts
have a lower rate of resorption and better
revascularization vs iliac crest grafts.31,32
Ramus and symphysial grafts have their own
sets of reported postoperative complications
such as pain, infection, edema, chin ptosis,
incision dehiscence, paresthesia, anesthesia,
and neurosensory changes.25,27,28,33,34
When GBR is compared with block grafting
techniques for ridge augmentation, little
difference is seen in the horizontal bone gain
that can be achieved. Studies by Buser have
demonstrated that using ramus and symphy-
sis blocks yielded an average ridge width gain
of 3.53 mm (range, 1–7.5 mm).35–38 More
recently, Schwartz-Arad demonstrated that
the mean ridge width increase in more than
60 onlay grafts from the symphysis and ramus
was 3.8 mm, and a mean success rate of 87.5%
was defined as sufficient bone for implant
placement.30 Additionally, Triplett (1993) re-
ported success rates for onlay grafts at 93%.36
When this is compared with the GBR literature,
bone volume gains between techniques
appear similar. Buser showed that GBR
procedures produced a horizontal ridge width
gain of 1.5–5.5 mm.18 Studies by Feulle using
GBR techniques demonstrated a mean ridge
width gain of 3.2 mm (range, 2.2–4.2 mm).43
Success rates for GBR techniques have been
similar to those of block grafts, with studies by
Tolman, Zitmann, and Nevins reporting in-

472

Vol. XXXVI/No. Six/2010

creases of 81% to 97%.39–41 A meta-analysis by
Tolman concluded that in most areas, the
success of GBR was similar to that of block
grafts, with only a slight advantage favoring
block grafting in the mandibular arch.39 A
systematic review by Aghaloo and Moy
reported findings of statistically significant
reduced implant survival rates at sites grafted
with autogenous bone block, compared with
other regenerative techniques.35 Their meta-
analysis found an implant survival rate of
74.4% for iliac crest grafts, as compared with
95.5% for GBR.
Block grafts from intraoral or extraoral
sources have the advantage of allowing
reentry slightly sooner for implant place-
ment. Pikos suggested that block grafts can
be reentered at 3–4 months in the mandible
and at 4–5 months in the maxilla.42 However,
the disadvantages of utilizing a second
surgical site, along with the increased
morbidity associated with the graft harvest,
make GBR an attractive technique for aug-
mentation of alveolar defects in preparation
for dental implant placement.
In the current study, grafting with com-
posite material of demineralized freeze-dried
allograft, mineralized cortical cancellous chips,
and a biologically degradable thermoplastic
carrier (Regenaform RT), when combined with
a resorbable membrane for GBR, resulted in
average horizontal ridge augmentation of
3.5 mm. This compares favorably with Buser’s
study of ramus and symphysial block grafts,
resulting in an average of 3.53 mm of ridge
width.37 The handling characteristic of the
composite graft, its combined osteoinductive
and osteoconductive nature, and the benefits
of avoiding a second surgical site make it
preferable over autogenous grafting tech-
niques.

CONCLUSION

This retrospective case series from 5 clinical
private practices suggests that the use of

Toscano et al

FIGURES 13–15. FIGURE 13. Deficient mandibular ridge with temporary implants placed. FIGURE 14. Ridge
grafted with tenting screws before membrane placement. FIGURE 15. Implants placed 6 months
postgrafting.

composite material of demineralized freeze-
dried allograft, mineralized cortical cancel-
lous chips, and a biologically degradable
thermoplastic carrier, when covered by a
resorbable collagen membrane for GBR, is
an effective means of achieving horizontal
ridge augmentation (Figures 13 through
15). An average of 3.5 mm of horizontal
ridge width was achieved via this technique.
Additional prospective and randomized
controlled clinical trials are needed to
determine the efficacy of this technique
and to compare it with others currently
used.

ABBREVIATION

GBR: guided bone regeneration

REFERENCES

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33. Raghoebar GM, Louwerverse C, Kalk WW, et al.
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34. Clavero J, Lundgren S. Ramus or chin grafts for
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49–70.
36. Triplett R, Schow S. Autologous bone grafts
and endosseous implants: complementary techniques.
J Oral Maxillofac Surg. 1996;54:486–494.
37. Buser D, Dula A, Hirt HP, Schenk RK. Lateral
ridge augmentation using autografts and barrier
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38. Schwartz-Arad D, Levin L, Sigal L. Surgical
success of intraoral autogenous block onlay bone
grafting for alveolar ridge augmentation. Implant Dent.
2005;14:131–138.
39. Tolman D. Reconstructive procedures with en-
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Int J Oral Maxillofac Implants. 1995;10:275–294.
40. Nevins M, Mellonig JT, Clem DS, Reiser GM, Buser
DA. Implants in regenerated bone: long-term survival. Int
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41. Zitzmann NU, Naef R, Scharer P. Resorbable
versus nonresorbable membranes in combination with
Bio-Oss for guided bone regeneration. Int J Oral
Maxillofac Implants. 1997;12:844–852.
42. Pikos MA. Mandibular block autografts for
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43. Feuille F, Knapp CI, Brunsvold MA, Mellonig JT.
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AAID Lecture Attendee

Dr. Horowitz,
   I am a young dentist that attended my first AAID meeting this past week.  I greatly enjoyed your lecture.  I am going to apply many of the concepts you presented.  I was wondering if you have advice on what text/resource would be best to have as a reference while I'm trying to determine what grafting materials to use and when.  I left the week more confused because other lecturers seemed to state that membranes aren't needed (Chanavaz), or that calcium sulfate can be used without a membrane.  I understand things are not so cut and dry, but I'd like a reference that'll help me sift through all the details.  Nonetheless, your lecture left me with the best feeling of what to do and when and why.  Thanks for you work. 


Nick Roy, DMD

 
No Pain

Dr. Horowitz,

I just want to let you know how everything is going a day after my visit to your office.Where you performed 3 extractions,bone graft,using growth material from my own blood.It seems to be working well,needed no pain medication and my swelling is down significantly. All I did was take clindamycin and ice the area.
See you next week for my check up.

C.V.

 
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