Clinical efficacy of grafting materials in alveolar ridge augmentation: A systematic review

https://doi.org/10.1016/j.jcms.2016.07.028Get rights and content

Abstract

Purpose

To evaluate the efficacy of grafting materials in lateral and vertical ridge augmentations.

Materials and methods

A systematic review of the literature on the clinical use of grafting materials of the years 1995 to April 2015 was conducted using electronic search of PubMed and Cochrane libraries and hand search of eight print journals. A total of 184 papers were included, comprising 6182 patients. Parameters evaluated were observation period [months], bone formation [histologic area%], defect fill [%], horizontal and vertical gain [mm], loss of augmented volume [mm], complication rate [%], and implant survival rate [%]. Results are expressed as weighted means ± SD.

Results

Results were obtained after a weighted mean observation period of 27.4 months (range 3–168 months). Bone formation in the augmented areas varied from 33.2 ± 14.9% for allogeneic grafts to 56.0 ± 25.6% for mixtures of autogenous and other grafting materials. Defect fill in dehiscence defects ranged from 51.0 ± 13.6% (synthetic) to 85.8 ± 13.4% (xenogeneic) for the different materials, with an overall weighted mean of 79.8 ± 18.7%. Weighted mean horizontal gain for all particulate grafting materials was 3.7 ± 1.2 mm, with variation between 2.2 ± 1.2 mm (synthetic) and 4.5 ± 1.0 mm (mixtures of autogenous bone with allogeneic/xenogeneic grafting material) without statistical significance. Weighted overall mean vertical gain was 3.7 ± 1.4 mm. Vertical gain was substantially higher when space-making barrier materials such as titanium meshes were used; however this was also associated with strong increase in complication rate. Block grafts achieved higher horizontal gain by approximately 1 mm. The use of block grafts achieved significantly increased vertical gain compared to particulate material only when autogenous block grafts from extraoral donor sites were used.

Conclusion

Horizontal and vertical gain by 3.7 mm on average can be achieved using particulate materials. This can be increased by using titanium meshes. Substantial vertical gains beyond this dimension require the use of extraoral bone block grafts.

Introduction

Oral rehabilitation frequently requires the repair of alveolar bone defects before prosthetic restoration can be achieved with acceptable long-term stability. The history of alveolar bone loss as well as the location and the extent of the resulting defects commonly determine the necessity and the strategy for defect repair. One of the most frequent reasons for reconstruction of the alveolar ridge is the lack of adequate bone volume for the placement of dental implants. Therefore, bone grafting procedures of the alveolar ridge are expected to provide sufficient bone height, bone width, and ridge contour for implant placement in order to provide favorable hygiene conditions for healthy periimplant tissues and satisfactory esthetics.

The use of autogenous bone grafts for ridge repair has been considered as the gold standard for obvious biological reasons (Bauer and Muschler, 2000, Reddi et al., 1987, Spin-Neto et al., 2013a). However, the surgical morbidity associated with graft procurement procedures has triggered countless attempts to avoid a second surgical site for graft procurement by using allografts, xenografts, or synthetic material to replace the lost alveolar bone. The market offers a confusing variety of commercially available grafting materials with different levels of scientific proof of their efficacy.

The ultimate goal for the use of bone grafting materials is the repair of bone to an extent that completely fills the defect and restores the former shape of the ridge. The ingrowth of bone into the grafting materials occurs through osteoconduction from the adjacent defect walls and follows the vascularization that invades the graft material. Hence, the structure and size of the graft as well as the defect geometry determine the extent of bony regeneration. As tissue ingrowth from the overlying soft tissue does not form bone in non-autogenous grafting materials (Bauer and Muschler, 2000, Merten HAG et al., 2003, Wiese and Merten, 1993, Wiltfang et al., 1997), the use of these materials is commonly combined with the use of barrier membranes that occlude the underlying defect from non-osseous tissue ingrowth, following the principles of guided bone regeneration.

The variety of grafting materials and the high number of possible combinations with membrane materials is increased by different preparations in terms of particle size and shape of the grafting materials. A systematic evaluation of this large array of variables is complicated by different defect geometries and augmentation techniques. A randomized controlled trial that could evaluate and compare such a matrix of variables in a comprehensive and systematic manner would be impossible to perform. However, countless reports of clinical and histological results from case series and cohort studies provide a large body of knowledge about the clinical performance of these materials that constitutes a kind of “community wisdom” and, if carefully reviewed, may provide valid information from which useful conclusions for clinical recommendations can be drawn. It is obvious that the validity of this compilation of results is limited by the heterogeneity of the included study designs and outcome parameters.

It was the idea of the present approach that a strict selection of studies with respect to quality of methodology, description of confounding parameters, and clear reporting of metric results would create a collection of objective data that would allow also for the application of basic statistical tests.

The aim of the present work was to assess the clinical efficacy of grafting materials in the reconstruction of the alveolar ridge through a systematic review with respect to clinically relevant parameters in different augmentation techniques and grafting materials.

Section snippets

Material and methods

This review was conducted and written with respect to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Liberati et al., 2009). The criteria of the Amstar and Glenny Scores were considered while conducting the search (Pieper et al., 2015, Zeng et al., 2015).

Results

An overview of the 184 publications included into this review is given in Fig. S1. To assess the value of the included reviews, the Amstar and Glenny scores were applied. The results can be seen in Fig. S1. The analysis considered 7473 applications of graft material in 6182 patients. The pattern of material use had changed over the observation period, with an initial preponderance for xenogeneic grafts that was more and more modified by the use of synthetic material and, even more in more

Discussion

The present review examines data from 184 studies on the use of grafting material for alveolar ridge reconstruction in conjunction with implant placement. The goal of this systematic review was to assess the clinical efficacy of grafting materials in the indication of periimplant dehiscence reconstruction on the one hand and vertical and horizontal augmentation of the alveolar ridge on the other.

The results obtained for the issue of “reconstruction of peri implant dehiscence defects” have shown

Conclusion

In conclusion, the present systematic review has shown that a satisfactory degree of defect fill in dehiscence defects of approximately 80% around implants can be achieved using grafting materials without any preference for their origin. Horizontal and vertical defects can be augmented predictably until a width/height of approximately 3.7 mm using particulate grafting material. The use of block-shaped grafts can improve the horizontal gain by approximately 1 mm, whereas significant improvement

Funding source

No external funding such as grants were used for this study.

Acknowledgment

The authors thank Ms. Susanne Ashrafi, Ms. Patricia Mathes, and Mr. Dietrich Meenen for their invaluable support in administrative and organization issues.

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    Dr. Dr. Markus Troeltzsch and Dr. Dr. Matthias Troeltzsch contributed equally to this systematic review and share first authorship.

    The publication shall be attributed to the Department for Maxillofacial Surgery, University of Goettingen, Koch Str. 40, 37075 Goettingen, Germany.

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