Common Implant-Related Advanced Bone Grafting ...c3-preview.prosites.com/247660/wy/docs/my publication-2 li.pdf · Common Implant-Related Advanced Bone Grafting Complications: Classification,

Common Implant-Related Advanced BoneGrafting Complications: Classification,

Etiology, and ManagementJingjing Li, DDS,* and Hom-Lay Wang, DDS, MSD, PhD†

Bone deficiency before implantplacement can be a new chal-lenge to many clinicians. Materi-

als and techniques have been developedto overcome this deficiency and haveshown promising outcomes. However,complications associated with graftingprocedures as well as materials do occur.These complications challenge clini-cians in their ability of identifying eti-ologies and providing proper andtimely management of these problems.The purpose of this review article is toclassify these complications, identifyetiologies associated with these prob-lems, and propose a plan to managethese time-consuming and stress-inducing complications. Literaturepublications in this area over the past20 years were searched through Med-line and related articles were selectedand summarized. Implant-associatedbone grafting complications can beclassified into: socket augmentationrelated, guided bone regeneration(GBR) related, onlay grafting (autog-enous or allogenic) related, sinus liftrelated, and others. Etiologies associ-ated with above complications are of-ten categorized into: material-related,technique related, anatomical related,patient related, and others.

THE IDEAL BONE GRAFT

Although no known materialscurrently being used in bone graftingprocedures are absolutely ideal, anideal bone graft should have 2 majorcharacteristics: immunologically in-ert and physiologically stable. Im-munologically, there should be nograft rejection and no risk of diseasetransmission from the use of bonegrafting materials. Microbial contam-ination should be eliminated. Materi-als should be biocompatible, ideallyabsorbed after new bone formation,while providing scaffold for bone re-generation and affording mechanicalstability. Physiologically, an ideal bone

grafting material should provide osteo-genicity, osteoinductivity, and osteocon-ductivity for new bone formation.

SAFETY OFGRAFTING MATERIAL

Biocompatibility and absence ofcontagious substance in the graft areimportant characteristics for idealbone graft. Calcium phosphate, car-bonate, and sulfate graft materials arebasically very biocompatible withoutbeing rejected by human body. Prion,virus, and bacteria contamination ofgraft are not concerns for autogenousor alloplastic grafts. Incidence of HIVcontamination in freeze-dried bone al-

*Periodontics Resident, Department of Periodontics and OralMedicine, School of Dentistry, University of Michigan, AnnArbor, MI.†Professor and Director of Graduate Periodontics, Departmentof Periodontics and Oral Medicine, School of Dentistry,University of Michigan, Ann Arbor, MI.

ISSN 1056-6163/08/01704-389Implant DentistryVolume 17 • Number 4Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e31818c4992

Bone grafting has become an es-sential part of implant dentistry.Thanks to the advancement of graft-ing technology, areas that couldonly be managed with removabledentures or teeth-supported fixedprostheses can now be successfullytreated with implant-supported pros-thesis. Nonetheless, the complica-tions associated with bone graftingprocedures have slowly emerged tobe one of the main challenges tomany clinicians. A Medline literaturesearch of articles published from 1984to 2006 related to advanced bonegrafting complications were selectedand analyzed. To make it easier tounderstand, implant-associated bonegrafting complications were classifiedinto: socket augmentation related,guided bone regeneration related, on-lay grafting (autogenous or allo-

genic) related, sinus lift related, andothers. Etiologies associated with theabove complications were categorizedinto: material related, technique related,anatomical related, patient related, andothers. In summary, management ofgrafting complications requires properdiagnosis of all contributing etiologiesand then providing necessary treat-ments that include nonsurgical phar-macological as well as surgicalinterventions based upon their clin-ical implications. Nonetheless, pre-vention of complication is of the ut-most importance. (Implant Dent2008;17:389–401)Key Words: dental implants, bonegrafting, monocortical onlay graft,sinus augmentation, guided boneaugmentation

IMPLANT DENTISTRY / VOLUME 17, NUMBER 4 2008 389

lograft was shown to be around 1 in8,000,0001 and 1 in 2,800,000 for de-mineralized freeze-dried bone allo-graft.2 For incidence of transmissionof bovine spongiform encephalopathywith bovine xenograft, it was esti-mated to be far less than the incidenceof being hit by lightning.3 Therefore,the risk of getting disease transmissionfrom allograft and xenograft is rela-tively low as long as the disinfection/sterilization protocols when preparingthese graft materials are followed bythe suppliers. World Health Organiza-tion stated that bone is labeled as typeIV (no transmission) for proteinaceousinfectious particles (prions) diseases.All current available bone graft mate-rials are safe and reliable instead ofdisease transmission potential.

BIOLOGIC BASIS FOR BONEGRAFTING: OSTEOGENESIS,OSTEOCONDUCTION,AND OSTEOINDUCTION

Osteogenesis occurs when vital os-teoblasts and precursors are transplantedtogether with the graft. They form thecenters of bone formation during theprocess of graft integration. Autogenousiliac bone and marrow graft are exam-ples for osteogenic materials. Osteocon-duction describes a nonvital graft materialproviding scaffold for the in-growth ofosteoblasts and the precursors. Autog-enous cortical bone, allografts, allo-plasts, and xenografts are examplesfor osteoconductive materials. Os-

teoinduction is a process that newbone formation comes from the induc-tion of local undifferentiated connec-tive tissue cells or bone precursor cellsinto bone-forming osteoblasts underthe influence of the grafting material.Demineralized bone matrix or bonemorphogenic proteins are examplesof osteoinductive materials. Oftentime the healing process involves allor combination of the three mecha-nisms. The basic conditions for boneregeneration consists of the supplyof bone-forming cells, the presenceof osteoinductive stimuli, and thepresence of an osteoconductive en-vironment (Table 1).

IMPLANT-ASSOCIATED BONEGRAFTING COMPLICATIONSSocket Preservation

Socket preservation is a proceduredeveloped to preserve the alveolarbone volume by implanting graft ma-terials into the sockets after extraction.The main purpose of socket augmen-tation (a.k.a. socket preservation, ridgepreservation) after tooth extraction isto preserve the existing height andwidth of the alveolar ridge and to pro-mote new bone formation inside thesocket. Many techniques and graft ma-terials have been used and have shownpromising results.4 Complication canbe the result of surgical procedure ortreatment planning. Excessive graftmaterials should be avoided. Graft ma-terials need to be compacted slight and

allow adequate space between particlesfor revascularization and infiltration ofproteins and growth factors. Moreover,clinicians need to evaluate the augmen-tation site for flap design, especially inesthetic zone. Park and Wang intro-duced a flap design, mucogingivalpouch flap, to preserve papilla dimension,improve graft retention, and minimizemembrane exposure. Nonetheless,when the interdental distance is �6mm use of mucogingival pouch flapmay jeopardize the overall blood sup-ply of the flap due to vertical releasingincisions.5 Hence, careful treatmentplanning is needed to avoid potentialcomplication. Contamination or lossof graft materials placed into socketmay occur. The use of membrane forGBR also runs a risk of exposure andinfection. Froum et al evaluated thehealing of sockets with hydroxyapatiteand nonabsorbable anorganic bovinebone mineral covered by either ePTFEmembrane or accelular dermal matrixallograft. Without complete soft tissuecoverage over the socket, 1 of 8 sock-ets covered by accelular dermal matrixand 6 of 8 sockets covered by ePTFEshowed exposure of membranes. Thisled to premature membrane removalbecause of potential infection.6 Reduc-tion of keratinized tissue at the facialaspect with primary closure may alsobe a potential complication. However,this can be avoided by careful treat-ment planning in advance to allow thesocket to heal for 6 to 8 weeks before

Table 1. Graft Materials Used for Implant Dentistry

Graft Source Example Property

Autograft Calvarium, iliac, tibia, clavicle,scapula, mandiblesymphysis, and retromolar,maxillary tuberosity

Osteogenic OsteoinductiveOsteoconductive

Allograft Freeze-dried bone allograft(FDBA), demineralizedfreeze-dried bone allograft(DFDBA)

Puros (Zimmer Dental Inc., Carlsbad, CA),ProSpace (B. Braun Medical,Bethlehem, Pennsylvania), DBX Putty(Densply, York, PA)

Osteoinductive andOsteoconductive

Alloplast Low density hydroxyapatite(HA), beta-tricalciumphosphate, dense HA,Bioglass, polymer, calciumsulfate

Bone Ceramic (Straumann, Basel,Switzerland)

Osteoconductive

Xenograft Anorganic bovine bone,coralline HA

Bio-Oss (Osteohealth, Shirley, NY) Primary osteoconductive withsome reported minorosteoinductive property

390 COMMON IMPLANT-RELATED ADVANCED BONE GRAFTING COMPLICATIONS • LI AND WANG

grafting. Newly formed keratinizedtissue growing over the socket willthen provide necessary primary clo-sure without sacrificing the facialwidth of keratinized tissue (Table 2).

Guided Bone or Ridge Augmentation

Space provision, such as guidedtissue regeneration, was shown to beeffective in regenerating new bone onatrophied alveolar ridge, either verti-cally or horizontally, with the use of amembrane. Similar to onlay bonegraft, which also serves as a spacemaintainer, GBR may incur similarcomplications that pertain to the use ofonlay graft. In addition, GBR also in-volves the use of membrane and insome cases microscrews. Therefore,complications related to GBR maycome from membrane exposure, mi-croscrew exposure, and contamina-tion. Serious inflammatory reactionwas also reported.7 A high incidenceof flap sloughing was associated withuse of nonabsorbable membrane.8 Ex-posed membrane or fixation screw oftencauses local inflammation with de-creased bone formation.9 The signifi-cance of early membrane exposure onthe regenerative outcome has been

somewhat controversial in guided tissueregeneration and GBR procedures. Sev-eral studies have shown better responseswhen the membranes remained sub-merged than those that became exposedduring healing.10 –12 However, otherstudies failed to show such differences(Table 3).12–14

Monocortical Onlay Graft

Complications associated with theonlay graft for ridge augmentation pro-cedures mostly involve infection, inci-sion line opening, bone fracture, nervedysfunction, perforation of mucosa overthe implant, loss of portion of the bonegraft, wound dehiscence, and graft mo-bilization (Table 4).16 Incision line open-ing is the most common postoperativecomplication resulting in contaminationof graft, delayed vascularization, andloss of graft material.16,17 Wound dehis-cence was found to have the most dele-terious effect on the survival of theimplant placed at augmented sites.16 Theincidence of inadvertent perforation ofskin and/or mucosa was 5.2% for man-dibular augmentation with onlay bonegraft and the incidence for infection oc-curred in 1 of the 11 patients (9.1%)with resultant partial graft loss.18 Con-

tamination of the graft material cancome from endogenous bacteria, lack ofaseptic surgical technique, or failure ofprimary closure. Antibiotics mixed withgraft were used to prevent contamina-tion of bacteria and to improve collagenformation. However, tetracycline wasfound to chelate calcium at the graft siteand arrest bone formation. Therefore,other antibiotics, such as penicillin or clin-damycin, have been recommended.19

Sinus Lift

The sinus lift procedure is com-monly used for providing sufficientheight of bone for implant insertion bylifting Schneiderian membrane api-cally with bone grafting materials atthe posterior maxillary edentulousarea. Perforation of sinus membrane,incision line opening, sinusitis, cystformation, loss of bone graft particles,and mucosal dehiscence are complica-tions associated with sinus lift proce-dures (Table 5). Perforation of sinusmembrane can be a preexisting condi-tion or tearing during the sinus liftprocedure. This incidence of sinusmembrane perforation was about 10%to 34%.20–22 Perforation of sinus mem-brane can be managed by covering

Table 2. Common Complications Associated With Socket Augmentation Procedures

Complication Etiology Prevention Management

Sitecontamination/infection

Graft or material contamination Aseptic manipulation of graftand surgical field,complete debridement ofsocket

Complete removal of contaminatedmaterial, curettage the socket,and regraft at a later time

Loss of graft particles Primary closure not achieved Achieve tension-free primaryclosure and/or use ofmembrane

Wait and graft during implantplacement

Reduced keratinized tissue(KM)/lack of vestibulardepth

Inadequate amount of KM (�2mm); thin KM

Soft tissue graft beforesocket augmentation

Soft tissue graft, or performapically repositioned flap duringstage II surgery

Table 3. Comparison of Impact on Healing After Membrane Exposure

Author Membrane Used Result of Exposure

Machtei10 Various (meta-analysis) Poor clinical outcomesOh et al11 Two collagen membranes, Bio-Gide (Nobel Biocare,

ZÜRICH-FLUGHAFEN, Switzerland) and BioMendExtend (Zimmer dental Inc., Carlsbad, CA)

Significantly less linear bone fill and bone-implantcontact at the membrane exposure sites

Moses et al12 e-PTFE Impaired bone healingAssenza et al13 e-PTFE No adverse effectEhmke et al14 Resorbable polylactic acid membranes No impact on bone gainTal15 “Natural” crossed-linked collagen barrier Less favorable healing due to potential bacterial

infection


with an absorbable membrane. Patho-logic conditions associated with theparanasal sinuses are very commondiseases. More than 31 million peopleseek medical treatment of sinusitiseach year. The potential infection insinus area may cause severe compli-cations, such as sinusisits, orbital cel-lulitis, meningitis, osteomyelitis, andcavernous sinus thromosis. The inci-dence of acute sinusitis was reportedto be about 3%.20,22–26 Sinusitis maylead to more severe complications andwarrant more attention.27 Loss of boneparticles and sequesters are rare butpossible.28 A failure rate of 6.7% usingBranemark implants at the graftedsites was reported after a mean periodof 32 months.28 A thorough preopera-tive evaluation is important to rule outany existing pathologic conditions inthe maxillary sinus. This can certainly

reduce the risk of mucus and bacteriacontaminating the surgical field thuscompromise bone healing. Further-more, due to the proximity of the max-illary sinus to several vital structures(e.g., brain, cavernous sinus, etc),postoperative complications can be se-vere and even life threatening.29

ETIOLOGIES ASSOCIATEDWITH BONEGRAFTING COMPLICATIONSTechnique Related

Care has to be taken when har-vesting bone from the ramus with theinferior cut below the inferior alve-olar canal. The graft should not beelevated before making sure that thenerve is not attached to inside sur-face of graft. The thickness of bonegraft harvested from the ramus is not

homogenous with a thickest area of12.23 mm to a smallest area of 2.35mm.30 About 60% of the mandibularcanals were found to notch the innercortical plate of the mandible or thethird molar root surface.31 Therefore,it is advisable that during osteotomy,after initial 2 mm of penetration,great caution should be taken withthe surgical bur stopped short beforecancellous bone is encountered toprevent damaging the inferior alve-olar nerve.

The mean thickness of the lateralwall of the maxillary sinus is 0.91 �0.43 mm.32 Slow removal of the lateralcortical bone with a surgical bur dur-ing sinus lifting procedures is criticalso the sinus membrane will not beperforated. A new surgical device withpiezoelectric ultrasonic generator (Pi-ezotome, Acteon, Bordeaux, France)

Table 4. Complications Associated With Onlay Graft


Infection, membranecontamination

Microbial contamination Antibiotics coverage and asepticsurgical procedure

Remove infection source, prescribesystemic antibiotics andantimicrobial mouth rinse

Incision line opening Tension-free closure notachieved

Soft tissue graft beforeaugmentation procedure.Achieve tension-free primaryclosure

Systemic antibiotics and antisepticmouth rinse

SutureMembrane exposureWound dehiscencePerforation of mucosaBone fracture Weakened bone integrity;

inadequate bone heightand width

Familiar with local anatomy Fixation screws and plate

Nerve dysfunction Damage to surrounding nerve Palliative treatmentGraft mobilization Inadequate fixation

(insufficient screws, screwloosening).

Secure fixation screws, use �1screw, ensure no-mobility andno dead space principle

Remove and regraft at later time

Loss of graft Resorption Replace, redo surgery

Table 5. Complications Associated With Sinus Lift Procedure


Perforation of sinus membrane Surgical complication Gentle approach, familiar withlocal anatomy (e.g.,location of septum)

Seal with absorbablemembrane

Infection Graft contamination, residualpathology (e.g., sinusitis,endodontic infection)

Eliminate pathology beforesurgery

Systemic antibiotics. If infectionpersists for more than 4 wk,remove graft and re-graft atlater time

Incision line openingMucosal dehiscence

Tension-free primary closurenot achieved

Achieve tension-free primaryclosure; soft tissue graftprior to surgery

Antibiotics; resuture if needed

Sinusitis Microbial infection Know the pathology AntibioticsCyst formation Surgical removalLoss of bone graft particles Primary closure not achieved Achieve tension-free primary

closure, use of membrane.Do nothing and allow for

proper healing


recently developed, offers an alterna-tive way of safely removing hard tis-sue without damaging soft tissue andis a useful tool of performing sinus liftprocedures as well as harvesting au-togenous bone from the ramus.

Fixation of an onlay graft to therecipient site can influence the revas-cularization of a graft.33 A loose graftmay become nonunioned and encap-sulated. Fixation screws for the onlaygraft should be tightened to ensureclose adaptation. Infection is usually aconsequence of poor aseptic control ofthe surgical field. Rinse with chlo-rhexidine before surgery is a preven-tive measure to reduce the risk ofinfection. More infections were foundwith the use of nonresorbable mem-brane for GBR procedure comparedwith bioabsorbable membrane over abovine bone xenograft study.34 Selec-tion of a suitable membrane andproper timing of membrane removalmay reduce the risk of infection.Tension-free flap closure is essentialso exposure of membrane or fixationscrews can be prevented.35

Anatomy Related

Ramus. Complications associatedwith harvesting autogenous bone fromramus may involve damage to nerve,incision line opening, trismus, andfracture of mandible (Table 6). Theincidence of nerve damage resultingfrom bone harvesting from the ramusarea is far less when compared withthe mandibular symphysis.36 Buccalnerve damage from incision along theexternal oblique ridge is possible.However, reports of the incidence ofsensory nerve loss in the buccal mu-cosa were rare and oftentimes patients

did not pay attention to the change.37

On the other hand, the potential ofdamaging the inferior alveolar nerve isof a greater concern with this proce-dure. Understanding the local anatomyis very important to prevent such anevent. Some patients may experiencetrismus after the harvest procedure af-ter the harvest procedure because ofthe retraction of the masseter muscle.But the symptom is temporary.38

Moreover, other complications associ-ated with the ramus graft proceduremay include impacted third molar in-volvement and mandibular fracture,although no case reports have beenpublished.30

Mandibular symphysis. Compli-cations associated with mandibularsymphysis/chin graft include incom-plete bone regeneration, altered sensa-tion, pulp morbidity, nerve damage,vascular damage, incision line open-ing, and bone fracture (Table 7). Com-plications involving incomplete boneregeneration were found more fre-quently in older patients. However, itwas reported that the resulting profilewas not discernible.26 Altered sensationof the mandibular anterior incisors afterloss of mentalis muscle support wasalso reported. The symptom of dull-ness sensation usually went away after6 months.39 There was a higher inci-dence of pulp morbidity of mandibularanteriors reported. Possible damage topulp vasculature leads to canal oblit-eration and negative pulpal reaction.40

Incidences of nonvital teeth after ge-nioplasty or subapical osteotomy pro-cedure were also documented.41– 43

Avoidance of harvesting bone close tothe root apices, leaving about 4 to 5mm clearance, is an important preven-

tive measure. Patients have to be in-formed about possible disturbances ofthe inferior alveolar nerve function,which may last longer than 12months.44 If graft is harvested too deepinto cancellous bone, a possible dam-age to incisal branch of mandibularnerve can occur. Likewise, if a graft isharvested too distally, the mentalnerve can be damaged. A particularcomplication was also reported in-volving fracture and posterior dis-placement of the lingual cortical plateof the anterior mandible which did notoccur at the time of the surgery butduring the healing phase.45 Generally,careful measurement and planning be-fore surgery are key elements in pre-venting most of the complicationsencountered.46

Maxillary tuberosity. Attentionhas to be paid to the proximity ofanatomical structures such as maxil-lary sinus, pterygoid plates, adjacentteeth, and the greater palatine canalwhen harvesting bone from maxillarytuberosity. A possible oral-antral com-munication can occur, although rare,during bone harvesting, which can bemanaged by closure with buccal fatpad flap, antibiotics, and deconges-tants.47–48 Bleeding and tethering bythe lateral and medial pterygoid mus-cles was reported to be a potentialcomplication when the tuberosity wasfractured (Table 8).47

Patient Related

Systemic diseases affecting bonegrafting include smoking, diabetes, al-coholism, radiation, osteoporosis, andmedication.

Bisphosphonate

Bisphosphonate, an inorganic pyro-phosphate analog, has been used to treatosteoporosis or bone metastatic malig-nant diseases.49,50 Bisphosphonate in-duces osteoclastic apoptosis and reducesosteoclastic differentiation.51 With thisantiosteoclastic effect, bisphosphonateallows remodeling space to be filledand, as a consequence, reduces inci-dence of fractures and increases strengthof bone.52

However, bisphosphonate wasalso found to suppress bone turnoverand interfere with the physiological

Table 6. Complications Associated With Ramus Graft

Complication Etiology Management

Damage to nerve Damage to infra-alveolarnerve

Know the anatomy, wait, andsometimes palliative treatmentmay be needed

Incision line opening Tension-free primaryclosure not achieved

Antibiotics and in some casessoft tissue graft may be needed

Trismus Damage to masticatorymuscles

Muscle relaxation andpain management

Fracture ofmandible

Weakened bone integrity,inadequate boneheight/width

Minimize graft size, reduceocclusal force during healing


micro damage repair function of thebone.53 The accumulation of the microdamage reduces the strength of thebone to withstand traumatic insults.54

In addition, decreased vascularity inregenerative connective tissue wasalso cited as one of the untoward ef-fects of bisphosphonate.55

Bisphosphonate, when used in IVform for treating malignant bone me-tastasis, has been reported to causeosteonecrosis of the jaw.56,57 The rela-tionship between bisphosphonate useand osteonecrosis has not been identi-fied.58 Bisphosphonate-induced osteo-necrosis seems to be multifactorial.59

Patients who received IV bisphospho-nate for cancer therapy were fourtimes more susceptible to osteonecro-sis.58 Invasive dental proceduresshould be avoided due to the risk ofosteonecrosis for patients receiving IVbisphosphonate.58 Without sufficientresearch data, bone grafts and guidedregeneration should be exercisedwith extreme caution (Dental Man-agement of Patients Receiving OralBisphosphonate Therapy, ExpertPanel Recommendations, Report ofthe Council on Scientific Affairs,ADA, June 2006) as decreased vas-cularity55 and reduction in the integ-rity of the bone54 mentioned abovemay have adverse impact to thegrafted site. Although some osteone-crosis cases has been reported fororal administration of bisphospho-

nate60 – 62 the incidence is consideredto be very low among the most pre-scribed alendronates. Therefore,patients who are undergoing IVbisphosphonates are contraindicatedfor any advanced surgical procedure.These include but not limited to ex-traction, periodontal, and implantsurgery. Recently, ADA recommendedthat dentist and patients should discussthe risks, benefits and treatment alterna-tives for patients who are receivingbisphosphonate treatment before anysurgical procedure. The discussionshould be documented and patient in-formed consent should be obtained be-fore initiate of treatment.57

Smoking

Seventy five percent of the pa-tients referred to periodontists wereeither current or previous tobaccousers.59 Smoking was found to im-pair the revascularization of the bonein regenerative procedures such asbone grafting,63,64 mainly due to itseffect on vasoconstriction of the ar-tery.65,66 The subsequent decrease inblood supply further contributed tothe retardation of graft integration.67

The altered oral flora from smokingincreased the infection rate by 2 to 3times in smokers, which adverselyinfluenced the complications of peri-odontal procedures, including bonegrafting.68 Levin and Schwartz-Aradstated that nicotine, carbone monox-

ide, and hydrogen cyanide from smok-ing are possible risk factors that leadsto poor wound healing. This, in turn,may jeopardize bone grafting and im-plant placement surgeries. Patient witha history of smoking had a higher fail-ure rate of implants placed in thegrafted sinus, regardless of the amountof cigarette consumed. Smoking ad-versely affects onlay graft. Smokers had50% of complication rate in monocorti-cal onlay graft whereas only 23.1% forthe nonsmokers. However, no associa-tion was found in this article betweensinus lift operation complications andsmoking habits.69 Interestingly, maxil-lary bone was more susceptible to ad-verse reactions of tobacco,65 reaching afailure rate of 1.6 times as much com-pared with mandible undergoing thesame periodontal procedures in smok-ers.70 Moreover, tobacco usage alsowas also found to negatively affectbone grafting procedures with en-hanced bone loss 4 times as much asnonsmokers.71 Such bone loss wasmainly due to the suppression of es-trogen secondary to overexpression ofinterleukin-1, interleukin-6, and tumornecrosis factor (TNF)-�.72,73 Encour-agingly, cessation of smoking hasbeen shown to slow down the progres-sion of periodontal disease and pro-mote the healing of bone graft.71

Diabetes

Diabetes is capable of enhancingthe expression of TNF-�,74 whereasTNF-� has been attributed to the ap-optosis of osteoblast and their pre-cursors.74 This enhanced apoptosis wassuggested to be detrimental to the bonehealing process.75 Other events of cellu-lar derangements, such as decreased

Table 7. Complications Associated With Mandibular Symphysis Graft


Incomplete regeneration Reduced healing potential NoneAltered sensation Damage to neuromuscular structure NonePulp morbidity Damage to blood supply to pulp Prevented by leaving at least 4–5 mm clearance to

apices; endodontic treatmentNerve damage Damage to mental or incisal nerve Prevented by knowledge of local anatomy

(radiograph, computer tomogram)Vascular damage Damage to vasculature HemostasisIncision line opening Primary closure not achieved Achieve tension-free primary closureBone fracture Weakened bone integrity Prevented by reducing occlusal force during

healing

Table 8. Complications Associated With Maxillary Tuberosity Graft


Oral-antralcommunication

Surgical complication Closure with flap,antibiotics and decongestants

Tethering bymuscle

Damage to lateral andmedial pterygoid muscles

Pain management


production of growth factors, prolongedinfiltration of the inflammatory cells, re-duced cellular synthesis, and increasedproteolytic activities, were all thoughtto attribute to the delayed healing andfailure of bone grafts.76 It is knownthat diabetic bone disease includes os-teopenia77 and delayed bone healing.78

Furthermore, frequent nonenzymaticprotein glycation leads to the forma-tion of advanced glycation end prod-uct (AGE).79 AGE could accumulatein various tissues, including bone. Ac-cumulation of AGE in bone contrib-utes to further alveolar bone loss.80

Radiation

Mature patients undergoing headand neck radiotherapy may experienceosteopenia after one year of therapy.81

The functions of the osteoblast can beimpaired by radiation and the bonematrix subsequently decreases.82 In addi-tion, long-term vascular damage fromradiotherapy may also contribute toosteonecrosis.83 Most cases of headand neck osteoradionecrosis werefound at the mandible because of itsmore superficial location and poorblood supply.84 Fractures may occur atthe weakened areas of the bone.85

Despite the aforementioned adversefindings, one study reported an 89%survival rate of bone grafting in irra-diated osseous tissue.86 Another re-search has reported a similar rate of42% for operative complication be-tween pre- and postradiotherapy;whereas bone grafting procedures atnonradiated sites had a 28% compli-cation rate.87

Alcoholism

Alcohol use was discovered to havea negative impact on intraoral bonegrafting procedures by impairing osteo-blast proliferation and increasing oste-oclast activity.88 A recent animal studydemonstrated that alcoholic beveragescaused a significant reparative delay inthe alveolus.89 A separate study foundthat ethanol suppressed bone turnoverand encouraged bone resorption.90 Otheradverse effects on bone grafting proce-dures elicited by alcohol use could beattributed to the possible direct toxic ef-fect of ethanol on the periodontium andother tissues in the oropharynx.91,92

When a compounding factor, such as poornutrition, was added to these adverse re-actions, an even higher complication ratewas found for patients who consumedlarge amount of alcohol and underwentsurgical procedures in the mandible.93

Therefore, it was recommended that a ces-sation of ethanol consumptions should beenforced a few weeks before the invasivedental procedures in order to minimizecomplications.94

CONCLUSION

Complications associated withbone grafting are influenced by manyfactors such as different surgical tech-niques, donor and recipient site anat-omy, material property, and systemicconditions. Carefully treatment plan-ning, proper review of the patient’smedical history and habits, as well asgood surgical technique will reducecomplications during the surgicalprocedure. Understanding the anat-omy at and around donor and recip-ient sites is critical to avoid adversedamage to the vital structures. Con-tinuing improvement in manufactur-ing processes for graft materials willhelp to ensure safety and reliabilityfor higher success rates and fewercomplications.

Disclosure

The authors do not have any finan-cial interests, either directly or indi-rectly, in the products listed in the study.

ACKNOWLEDGMENTS

This article was partially supportedby the University of Michigan Peri-odontal Graduate Student ResearchFund.

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Reprint requests and correspondence to:Hom-Lay Wang, DDS, MSD, PhDDepartment of Periodontics and Oral MedicineUniversity of MichiganSchool of Dentistry1101 N. UniversityAnn Arbor, MI 48109-1078E-mail: [email protected]


Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Jingjing Li, DDS, and Hom-Lay Wang, DDS,MSD, PhD. Korrespondenz an: Hom-Lay Wang, DDS, MSD,PhD, Professor und Leiter des Graduiertenkollegs fur Orth-odontie (Professor and Director of Graduate Periodontics),Abteilung fur Orthodontie und Oralmedizin (Department ofPeriodontics and Oral Medicine), zahnmedizinische Fakultatder Universitat von Michigan (University of Michigan Schoolof Dentistry), 1101 N. University, Ann Arbor, MI 48109-1078. Telefon: 734-763-3383, Fax: 734-936-0374. eMail:[email protected] Komplikationen bei Implantatgestutzter fortschrit-tlicher Knochengewebstransplantierung: Klassifizierung, Ati-ologie and Management

ZUSAMMENFASSUNG: Die Transplantierung von Knoch-engewebe ist zu einem wesentlichen Bestandteil der Implan-tatgestutzten Zahnheilkunde geworden. Dank der Fortschrittein der Transplantierungstechnik konnen heutzutage Bereicheerfolgreich mit Implantatgestutzten Prothesen behandelt wer-den, bei denen vorher nur die Moglichkeit der Behandlungmittels herausnehmbarem Zahnersatz oder Eigenzahngestutz-ten festen Prothesen bestand. Allerdings haben sich allmahlichdie mit Transplantierungen in Verbindung stehenden Komp-likationen als zu den maßgeblichen Herausforderungen ge-horend herausgestellt, denen sich viele behandelnde Arztegegenuber sehen. Uber eine Literatursuche in Medline wur-den Artikel, die im Zeitraum von 1984 bis 2006 veroffentlichtwurden und die sich schwerpunktmaßig mit den sich ausfortschrittlicher Knochengewebstransplantierung ergebendenKomplikationen befassen, ausgewahlt und analysiert. Um dasVerstandnis zu erleichtern, wurden die mit der Transplan-tierung von Knochengewebe in Verbindung stehendenKomplikationen wie folgt eingeteilt: bei Zahnhohlenan-reicherung, bei gefuhrter Knochengewebsregeneration, beiOnlay-Transplantierung (autogen oder allogenisch), bei Sinu-sanhebungen sowie eine Gruppierung fur andere. Die mit denoben aufgefuhrten Komplikationen in Verbindung stehendenAtiologien wurden wie folgt gruppiert: in Bezug auf Material,in Bezug auf Methode, in Bezug auf Anatomie, in Bezugauf den Patienten sowie eine Gruppe fur andere. Zusam-menfassend ist festzustellen, dass die Bewaltigung vonKomplikationen bei der Transplantierung eine exakte Di-agnose aller moglichen Atiologien bedingt. Außerdem istes erforderlich, dann daraus die entsprechenden Behand-lungsmethoden abzuleiten, die sowohl nicht chirurgische,rein pharmakologische Maßnahmen mit einbezieht alsauch chirurgische Eingriffe auf Basis ihrer klinischen Imp-likationen. Nichtsdestotrotz ist die Vermeidung vonKomplikationen oberstes Ziel.

SCHLUSSELWORTER: Zahnimplantate; Knochentrans-plantierung, monokortikaler Onlay-Span, Sinusanreicherung,gefuhrte Knochengewebsanreicherung

SPANISH / ESPAÑOLAUTOR(ES): Jingjing Li, DDS, and Hom-Lay Wang DDS,MSD, PhD. Correspondencia a: Hom-Lay Wang., DDS,MSD, PhD, Professor and Director of Graduate Periodon-tics, Department of Periodontics and Oral Medicine, Univer-sity of Michigan, School of Dentistry, 1101 N. University,Ann Arbor, MI 48109-1078. Telefono: 734-763-3383, Fax:734-936-0374. Correo electronico: [email protected] comunes del injerto avanzado de huesorelacionado con implantes: clasificacion, etiología ycuidado

ABSTRACTO: El injerto de hueso se ha convertido en unaparte esencial de la odontología de implantes. Gracias a losavances en la tecnología de injertos, lugares que solamentepodrían ser tratados con dentaduras removibles o protesisfijas apoyadas en dientes ahora pueden ser tratados exi-tosamente con prostesis apoyadas por implantes. Sinembargo, las complicaciones asociadas con los procedi-mientos de injerto de hueso se han convertido lentamenteen uno de los desafíos principales para muchos clínicos. Seselecciono y analizo una busqueda de artículos publicadosen Medline entre 1984 y 2006 relacionados con las com-plicaciones del injerto avanzado de hueso. Para simplificarel entendimiento, las complicaciones del injerto de huesoasociadas con los implantes se clasificaron en: relaciona-das con el aumento de la cavidad, relacionadas con laregeneracion guiada del hueso, relacionadas con los injer-tos de onlay (autogeno o alogenico), relacionadas con laelevacion del seno y otras. Las etiologías asociadas con lascomplicaciones anteriores fueron categorizadas en: rela-cionadas con el material, relacionadas con la tecnica, rela-cionadas con la anatomía, relacionadas con el paciente yotras. En resumen, la atencion de las complicaciones de losinjertos requiere un diagnostico adecuado de todas lasetiologías contribuyentes y luego proporcionar los trata-mientos necesarios que incluyen farmacologicos sin cirugía asícomo intervenciones quirurgicas segun las consecuenciasclínicas. No obstante, la prevencion de complicaciones es desuma importancia.

PALABRAS CLAVES: implantes dentales, injerto de hueso,injerto de onlay monocorticoide, aumento del seno, aumentoguiado del hueso


PORTUGUESE / PORTUGUÊSAUTOR(ES): Jingjing Li, Cirurgiao-Dentista, and Hom-LayWang Cirurgiao-Dentista, Mestre em Odontologia, PhD.Correspondencia para: Hom-Lay Wang, DDS, MSD, PhD,Professor and Director of Graduate Periodontics, Depart-ment of Periodontics and Oral Medicine, University of Mich-igan, School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078. Telefone: 734-763-3383, Fax: 734-936-0374.e-Mail: [email protected] Comuns de Enxerto Osseo Avancado Rela-cionado a Implante: Classificacao, Etiologia & Tratamento

RESUMO: O enxerto osseo tornou-se parte essencial daodontologia de implante. Gracas ao avanco da tecnologia deenxertos, areas que so poderiam ser tratadas com dentadurasremovíveis ou proteses suportadas por dentes podem agoraser tratadas com sucesso atraves de proteses suportadas porimplantes. Nao obstante, as complicacoes associadas a pro-cedimentos de enxerto osseo emergiram lentamente para setornar um dos principais desafios de muitos clínicos. Umabusca na literatura de Medline de artigos publicados de1984 a 2006 relacionados a complicacoes de enxerto osseoavancado foi selecionada e analisada. Para facilitar mais oentendimento, as complicacoes de enxerto osseo associadoforam classificadas em: relacionadas ao aumento do alveolo,relacionadas a regeneracao guiada do osso, relacionadas aoenxerto “onlay” (autogeno ou alogenico), relacionadas a el-evacao da cavidade e outras. As etiologias associadas ascomplicacoes acima foram categorizadas em: relacionadas amaterial, relacionadas a tecnica, relacionadas a anatomia,relacionadas a paciente e outras. Em resumo, o tratamento dacomplicacao de enxerto exige diagnostico adequado de todas asetiologias contribuintes e entao o fornecimento de tratamentosnecessarios que incluem intervencoes farmacologicas bem comocirurgicas baseadas em suas implicacoes clínicas. Nao obstante,a prevencao da complicacao e de suma importancia.

PALAVRAS-CHAVE: implantes dentarios, enxerto osseo,enxerto “onlay” monocortical, aumento da cavidade, aumentoguiado do osso

RUSSIAN /��: Jingjing Li, �� , & Hom-Lay Wang, �� , �� ,�� . �� :Hom-Lay Wang., DDS., MSD, PhD., Professor and Directorof Graduate Periodontics, Dept. of Periodontics and OralMedicine, University of Michigan, School of Dentistry, 1101N. University, Ann Arbor, MI 48109-1078. ��: 734-763-3383, ��: 734-936-0374. �� : [email protected]�� - �� , �� : ��-��, ��

�� !�. �� . ��-�� , ��, �� ,��!�� , �� , ��!�� ."�� , �� , � �� -��, �� !�� . �� Medline, ��-� �� 1984 �� 2006 . ., ��!�� . #� ��-�� , � �� -�� , �� !�� : � �� !� �� -��, � �� , � �� (�� ), � �� -�� . $��, � �� , �� -�� !�� : � �� , � �� ,� �� , � �� . %�� , �� !�� -��, � �� , ��-�� , � �� . "�� , �� .

"# $�� %#��: �� ; ��; �� ;��!� �� ; �� !� ��

TURKISH / TURKCEYAZARLAR: Jingjing Li, DDS, ve Hom-Lay Wang, DDS,MSD, PhD. Yazısma icin: Hom-Lay Wang, DDS, MSD, PhD,Professor and Director of Graduate Periodontics, Depart-ment of Periodontics and Oral Medicine, University of Mich-igan, School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078 ABD. Telefon: 734-763-3383, Faks: 734-936-0374. e-posta: [email protected]ın, Implantla Iliskili Ileri Duzeyde Kemik Greft Komp-likasyonları: Sınıflama, Etyoloji ve Yonetim

OZET: Kemik greftleme, implant disciliginin temel ogeler-inden biri haline gelmistir. Greft teknolojisindeki ilerlemelersayesinde onceden ancak hareketli protezler veya dislerledesteklenen sabit protezlerle tedavi edilebilen durumlar simdiimplant ile desteklenen protezlerle basarıyla tedavi edile-


bilmektedir. Buna ragmen, kemik greftleme prosedurleri ilebaglantılı komplikasyonlar giderek klinisyenler icin ana zor-luklardan biri olarak karsımıza cıkmaktadır. Medline literaturaramasından yararlanılarak 1984 ile 2006 yılları arasında ilerikemik greftleme komplikasyonları konusunda yayınlananmakaleler secilerek analiz edildi. Anlayısı kolaylastırmakamacıyla implantla baglantılı kemik greft komplikasyonlarısu sekilde sınıflandırıldı: dis yuvası ogmantasyonu ile bag-lantılı, kılavuzlu kemik rejenerasyonu ile baglantılı, onlaygreftleme (otojen veya allojen) ile baglantılı, sinus kaldırmaile baglantılı, ve digerleri. Yukarıdaki komplikasyonlarla il-gili etyolojiler su sekilde kategorilere ayrıldı: materyalle il-

iskili, teknikle iliskili, anatomi ile iliskili, hastayla iliskili, vedigerleri. Ozet olarak, greft komplikasyonlarının yonetimi,duruma katkıda bulunan tum etyolojilerin uygun sekildeteshisine ve sonra da, gereken tedavilerin saglanmasına daya-nır. Bu tedaviler, olası klinik etkilere baglı olmak uzere,cerrahi olmadan farmakolojik tedaviden cerrahi mudahaleyekadar degismektedir. Buna ragmen, komplikasyonun olus-madan onlenmesi buyuk onem tasır.

ANAHTAR KELIMELER: dental implantlar, kemik gref-tleme, monokortikal onlay greft, sinus ogmantasyonu, kıla-vuzlu kemik ogmantasyonu

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