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Oral Maxillofac Surg8:428-435, 2010

Screw “Tent-Pole” Grafting Technique forReconstruction of Large Vertical AlveolarRidge Defects Using Human Mineralized

Allograft for Implant Site PreparationBach Le, DDS, MD,* Michael D. Rohrer, DDS, MS,† and

Hari S. Prassad, BS, MDT‡

Purpose: The purpose of this study was to evaluate the effectiveness of using titanium screws incombination with particulate human mineralized allograft, in a “tenting” fashion, to augment largevertical alveolar ridge defects for implant placement.

Materials and Methods: This prospective case study evaluated augmentation in consecutive patientswith large (�7 mm) vertical alveolar ridge defects. Vertical ridge augmentation was performed usingmineralized allograft placed around titanium screws to tent out the soft tissue matrix. The ridges wereclinically evaluated 4 to 5 months after augmentation, and implants were placed at that time. Bone coreswere harvested from all patients for histologic evaluations.

Results: Fifteen patients were treated in this prospective case study, and the mean vertical augmenta-tion was 9.7 mm. Two patients had wound dehiscence resulting in loss of graft and requiring secondarygrafting before implant placement. Five patients required 2-stage grafting procedures to achieve idealridge height before implant placement. Clinical evaluation of the grafted sites upon re-entry revealeduniform ridge anatomy. Histomorphometric analysis of 7 specimens revealed a mean bone content of43%. A total of 32 implants were placed into grafted sites in 15 patients. All implants were integrated andsuccessfully restored. Mean follow-up was 16.8 months after implant placement.

Conclusions: Tenting of the periosteum and soft tissue matrix with titanium screws maintains spaceand minimizes resorption of mineralized particulate allograft. This technique offers predictable func-tional and esthetic reconstruction of large vertical defects without the use of autogenous bone and iscapable of osseointegration. More studies are needed to evaluate the stability of vertically grafted boneafter long-term loading.© 2010 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 68:428-435, 2010

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one augmentation grafting of large vertical maxillarynd mandibular alveolar ridge defects is difficult. Var-ous techniques have been described for the recon-truction of these large vertical defects before implantlacement. These techniques have included autog-nous onlay block grafts,1-4 autogenous particulaterafts,5-8 distraction osteogenesis,9 and porous tita-ium mesh tray,10,11 or a combination of these.12-14

arx et al15 reported on a novel surgical approach

*Clinical Associate Professor, Department of Oral and Maxillofa-

ial Surgery, USC School of Dentistry, Los Angeles, CA.

†Director, Hard Tissue Research Laboratory, University of Min-

esota, School of Dentistry, Minneapolis, MN.

‡Research scientist, Hard Tissue Research Laboratory, University

f Minnesota, School of Dentistry, Minneapolis, MN.

The authors have no financial interests in any of the products

entioned in this article.

428

sing dental implants as “tent poles” in combinationith iliac crest bone grafting in the successful treat-ent of 64 severely resorbed mandibles, resulting in aean bone height gain of 10.2 mm. The novel strat-

gy of this surgery was to allow iliac bone grafts toonsolidate and maintain their volume with dentalmplants that create a tenting effect.

Augmentation with titanium mesh can also be suc-essful but has a high exposure rate of the mesh and

Address correspondence and reprint requests to Dr Le: Oral &

axillofacial Surgery, USC School of Dentistry, 925 West 34th

treet, Los Angeles, CA 90089; e-mail: leb97201@yahoo.com

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6802-0030$36.00/0

oi:10.1016/j.joms.2009.04.059

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LE, ROHRER, AND PRASSAD 429

ubsequent partial graft loss. Louis et al10 recentlyeported on 44 patients who had undergone titaniumesh reconstruction of the maxilla or mandible using

liac crest bone graft with a 52.27% exposure rate ofhe titanium mesh. Although these authors reported a7% overall graft success rate with this technique,xposure of autogenous grafts to the oral environ-ent inevitably leads to unpredictable loss of graft

olume, and it is unclear how this partial loss affectedhe overall treatment plan.10 Distraction osteogenesisan be successful in vertical augmentation, but in ourxperience, it often leaves undesirable tissue scarringnd usually requires secondary bone augmentationefore implants can be placed.Block and Degen reported on the use of particulate

uman mineralized allograft alone to successfully aug-ent partially edentulous segments for implant place-ent through a minimally invasive tunneling tech-

ique.16 However, apical migration of graft materialrom the alveolar crest tends to occur with thisclosed” technique. This is likely due to natural tissueontraction because of the inability to maintain pas-ive space. In addition, direct visualization and cor-ection of the defect, especially in the esthetic areas,an be challenging with this tunneling technique. Let al and Le and Burstein described using humanarticulate mineralized allograft as a particulate onlayraft to correct small volume hard tissue defects andn combination with cortical ramus block grafts as aenting mechanism in an open approach to treat theeverely resorbed alveolar ridge before implant place-ent.17,18

A major challenge to reconstructing large verticalone defects is the contraction of the “soft tissueatrix” leading to resorption and migration of the

one graft. Surgical control of the expanded softissue volume prevents resorption of graft mate-ial15 by maintaining a space between the perios-eum and bone.

Alveolar ridge augmentation using autogenouslock grafts is a predictable method to augment local-

zed alveolar ridge defects but can be difficult in large-dimensional defects (Figs 1A-C). Furthermore, these

arge atrophic segments present a more challengingcenario in reconstruction, as there is a limited supplyf intraoral donor bone. Extraoral donor sites are anption but present an obstacle to patient treatmentcceptability because of increased costs and morbid-ty.

The purpose of this case study was to evaluate theffectiveness of using particulate human mineralizedllograft, in combination with titanium screws, in atenting” fashion to augment large, localized, intraoral,ertical alveolar ridge defects for implant placement.his concept would make it possible to graft large,

-dimensional, vertical segments without the need to m

arvest autogenous bone from extraoral or intraoralites. The hypothesis for this case study was whether.5-mm screws in combination with human mineral-

zed bone could be used as an osteoconductive scaf-old to restore large vertical defects resulting in suffi-ient bone quantity and quality after 4 to 5 months tollow for subsequent osseointegration of endosseousmplants.

aterials and Methods

This prospective case study evaluated augmenta-ion in 15 consecutive patients presenting with largeertical alveolar ridge defect. Inclusion criteria for thistudy were partially edentulous patients seeking den-al implant therapy who required more than 7 mm ofertical alveolar ridge augmentation before implantlacement. Patients selected for this procedure alsoust have less than 4 mm of bone width as deter-ined by preoperative examination and CT imaging

tudies. Before augmentation, all grafted sites wereeemed inadequate because of anatomical constraintsor placement of an implant of at least 10 mm inength. Smokers, diabetic patients, and any medicallyompromised patients were excluded from this se-ies. After prosthodontic consultation for implant res-orations, patients were scheduled for bone graftingrocedures.Vertical ridge augmentation was performed using

uman mineralized allograft (Puros; Zimmer Den-al, Carlsbad, CA) placed around titanium screws toent out the soft tissue matrix and periosteum. Theidges were clinically evaluated 4 to 5 months afterugmentation. Panorex radiographs and computedomography (CT) scans were taken to evaluate allrafted segments. Bone cores were taken using arephine of all grafted segments at the time ofmplant placement for histologic evaluation. Preop-rative and postoperative clinical and radiographicomparisons were made at the time of implantlacement. Panorex and periapical radiographsere taken after all implants were restored at fol-

ow-up intervals of 6 and 12 months.

SURGICAL TECHNIQUE

A preoperative chlorhexidine rinse was given for 2inutes. Surgical treatment was performed under intra-

enous anesthesia, and 2% lidocaine with 1:100,000pinephrine was given as blocks and infiltrations in theaxilla and mandible. A crestal incision was made in

ll cases with vertical releases. Whenever possible,vailable keratinized tissue was identified and in-luded in the incision design. Aggressive tissue re-eases were performed before screw or graft place-

ent to ensure tension-free closure. In the anterior

axilla, subperiosteal dissection was carried up to the

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430 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

IGURE 1. A-C, Large 3-dimensional defect of the posterior alveolar ridge after traumatic extraction and chronic infection. Note the loss ofone attachment to the mandibular molar. D, Titanium screws placed show that 5 mm of screw threads are exposed above the ridge defect.-G, Clinical situation after 2 grafting procedures with screw tent-pole grafting technique using mineralized allograft. H, Dental implantslaced into grafted bone. Bone core is taken next to implant site for histologic analysis. I, Histologic analysis demonstrates good boneormation in grafted specimen. J, K, Final restoration at 15-month follow-up shows stable bone under functional load.

e, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge Defects. J Oral Maxillofac Surg 2010.

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LE, ROHRER, AND PRASSAD 431

nterior nasal spine to obtain adequate release forassive primary closure. In the posterior mandible,his often involved split thickness dissection on theabial for supraperiosteal advancement.

Titanium screws (1.5 mm, KLS Martin, Jacksonville,L) were placed in the alveolar ridge so that approx-mately 5 to 7 mm of screw threads were exposedFigs 1D, 2C). Particulate mineralized allograft (can-ellous particles, 250 to 1,000 �m) was mixed withhe patient’s blood and placed to cover the screwompletely (Fig 2D). The defect was overcorrectedith particulate material in anticipation of future graft

esorption. A resorbable membrane (OSSIX PLUS;raPharma, Warminster, PA) was placed over the

IGURE 2. A, B, Large vertical alveolar defect resulting from failehe distal of the maxillary left central incisor and resulting open bitelaced to tent the tissue volume. D, Human mineralized allograft

ong-lasting resorbable membrane is placed over the grafted site. F--dimensional hard tissue and soft tissue reconstruction of vertical d

, Final restorations on implants. J, Histomorphometric analysis demonnectivity. New bone formation is quite robust surrounding partif mineralized allograft (surrounded by the darker, red staining, n

e, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge

rafted sites (Fig 2E). Passive primary closure over thentire graft was obtained with interrupted 4 to 0esorbable chromic gut sutures.

Postoperatively, the patient prosthesis was adjustedo avoid impingement on the grafted site and, whenossible, to create positive tissue architecture (FigF). All patients were placed on postoperative antibi-tic treatment consisting of penicillin 500 mg � 7ays (for penicillin-allergic patients, clindamycin 300g � 7 days) and a chlorhexidine mouth rinse for 1eek. After 4 to 5 months, the grafted sites werencovered (Figs 1G, 2H) and the screws removed.Pre- and postoperative defects were evaluated at

oth the bony and soft tissue levels. Additional allo-

dontic extrusion of impacted canine. Note the recession defect ong from lack of alveolar growth. C, Titanium screws are strategicallyllous particles) placed to cover the screw heads completely. E, Aical situation 5 months after graft procedure demonstrates excellentwith complete coverage of screw heads with newly formed bone.tes good bone integrity with trabeculae of uniform size and goodmineralized allograft. The lighter-stained particles are the particlesrmed bone).

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432 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

raft material was added at the time of implant place-ent to improve the final bone and soft tissue con-

ours as necessary to affect esthetic outcome. Noutogenous bone was used in this prospective casetudy.

esults

Fifteen (2 male/13 female) consecutive patientsith severe localized vertical alveolar ridge defectsnderwent surgery (Table 1). The mean patient ageas 50.06 years (range 22 to 69 yrs). Six patients had

rafts placed to the mandible and nine patients hadrafts to augment the partially edentulous maxilla. Ofhe 15 patients, 12 patients had 2 or more missingeeth with severe vertical defects of the maxillarylveolar ridge. Teeth adjacent to alveolar defects withignificant root exposure resulting from loss of bonettachment were extracted. Twelve patients under-ent extractions of adjacent teeth to allow a more

avorable bone attachment to which to graft. Ade-uate tension-free closure over the graft was achieved

n all patients.There were no postoperative wound infections. One

atient had complete dehiscence of the grafted site withraft and screw exposure requiring subsequent graft.lthough there was complete exposure of the graftaterial, partial graft take was noted upon re-entry

fter 4 months. Two patients had partial wound de-iscence and 3 patients had screw head exposurenly. Wound dehiscence and screw head exposuresere treated with conservative care with oral hygieneaintenance and oral rinse during the 4-month heal-

ng period. Partial graft loss was noted on re-entry in

Table 1. CHARACTERISTICS OF STUDY PATIENTS

PatientNo. Gender Age (yrs)

1 F 55 Mand L2 F 24 Max R c3 F 57 Mand L4 F 48 Mand L5 F 45 Max L la6 F 57 Max R s7 F 48 Mand R8 M 54 Max R la9 F 63 Max L fi

10 F 44 Max R c11 F 66 Mand L12 F 22 Max L la13 F 60 Mand R14 F 39 Max R c15 M 69 Mand L

Mean 50.06

bbreviations: Mand, mandibular; Max, maxillary, L, left; R

e, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge

patients with wound complete or partial woundehiscence. Two of these 4 patients required a sec-nd graft procedure using the same protocols withcrews. In 11 patients, complete coverage of thecrew head by bone was noted. All screws wereemoved, and ridge width was clinically evaluated toe larger than 6 mm at all sites of implant placement.A total of 32 implants were placed into the

rafted ridges at locations predetermined by theestoring dentists preoperatively with a surgicaltent. Several different implant systems were used:

BioHorizons implants (BioHorizons, Inc, Birming-am, AL), 15 Straumann implants (Straumann, Basel,witzerland), 7 AstraTech implants (AstraTech, Inc,altham, MA), and 4 Zimmer implants (Zimmer Den-

al, Carlsbad, CA). Sixteen implants were placed inhe maxilla and 16 were placed in the mandible. Aingle-staged protocol was used to place 27 im-lants. Only 5 implants required uncovering. All

mplants were allowed a waiting period of at least 3onths before the restoration phase. After 3 to 4onths of integration, all implants were noted to

e integrated. All implants have been successfullyestored in the 15 patients with a mean follow-up of6.8 months (range, 4 to 38 mo) from placement.ollow-up examinations have indicated stable andealthy peri-implant tissue and bone levels.Bone cores were harvested from all patients for

istologic evaluations. In addition, 7 of the graftedpecimens underwent histomorphometric analysis.ll cores showed good integrity with a good can-ellous bone pattern and good connectivity of therabeculae. The new bone formation had sur-ounded the mineralized allograft particles and had

Implant SiteAverage

Follow-up

molar, first molar, second bicuspid 13 molateral incisor 5 moolar and second bicuspid, L first molar 6 moolar 12 moncisor 36 momolar, first molar, second bicuspid 9 mo

d bicuspid, first molar 16 moncisor, L lateral incisor 6 mouspid, first molar 30 molateral incisor 11 momolar, first molar 22 mo

ncisor 4 mod bicuspid, first molar, second molar 16 moincisor, L lateral incisor 28 momolar, first molar, second bicuspid 38 mo

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LE, ROHRER, AND PRASSAD 433

ormed bridges resulting in a good cancellous boneattern. High-power images showed excellent inte-ration of new bone formation and particles ofineralized allograft (Fig 2J). All grafted sites con-

isted of viable bone. Histomorphometric analysisf the 7 specimens revealed a mean bone content of3%. Of this percent bone, the mean vital boneontent was 81%.

iscussion

Severe vertical alveolar ridge defects are usually-dimensional and present a difficult challenge to the

mplant surgeon. Patients with vertical defects usuallyave concomitant horizontal defects, and these de-ects must be fully reconstructed in all dimensions toreate an esthetic and functional result. Furthermore,any vertical defects usually have loss of bone attach-ent to the teeth adjacent to the defect. In many

nstances, it is more beneficial to extract these teetho that a healthy bone attachment level can be at-ained to which to graft bone.

Autogenous bone graft has long been consideredhe gold standard for grafting severe hard tissueefects. However, reconstruction of large verticalefects often requires a significant amount of au-ogenous bone, including extraoral sources. Louist al10 reported on the use of titanium mesh foreconstruction of severely atrophic maxilla or man-ible using iliac crest bone graft with a 97% overallraft success rate, although exposure of the tita-ium mesh was reported to be high (52%). Thebstacles to using iliac crest bone are obvious. Inddition to the higher resorption rate of iliac crestrafts, other disadvantages include the high costs ofospitalization, risk of general anesthesia, and mor-idity of the procedure.1,3,8,19

Conversely, the use of mineralized allograft offersany advantages, including an unlimited amount of

onor bone and reduced anesthesia and operativeime.16,20 The procedure can be performed ideally asutpatient surgery, thereby decreasing the overallosts of the procedure. Le and Burstein reported theuccessful use of mineralized allograft for the recon-truction of 10 consecutive patients with severelytrophic maxilla for implant placement.18 Le et aleported on using mineralized allograft as a partic-late onlay graft to augment atrophic alveolar ridgeor single implant site development.17

The decision to use cancellous bone versus cor-ical bone was anecdotal and was based on theuthors’ experience of seeing better incorporationnd bridging of the graft material in previous histo-ogic evaluation and upon clinical re-entry afterrafting extraction socket defects. Based on the first

uthor’s experience, smaller particle size mineral- e

zed allograft material also appeared to achieveuicker incorporation and bridging. Marx reportedhat the ideal size for capillary bud penetration is50 �m.21 Large cortical size particles may make

t more difficult to become incorporated intohe graft and could theoretically act as sequestra,hereby jeopardizing the integrity of the graft.

In this series of patients, all implants (100%) placednto vertically augmented sites integrated.

By appropriately placing titanium screws inter-osed by particulate graft, it is possible to augment

arge vertical ridge defects with no need for autog-nous bone. This technique involves expanding theoft tissue volume and using screws as “screw tentoles” for the surrounding particulate graft. Thiselps prevent the soft tissues from contractinground the particulate graft and subsequently dis-lacing it or causing physiologic resorption.15 Thisoft tissue maintenance concept was confirmed byhe clinical observation that the particulate boneraft material resorbed no further than the level ofhe screw heads (Figs 1G, 2H). Although longerollow-up is needed to evaluate whether this is aermanent result, our mean follow-up of 16.8onths (range, 4 to 38 mo) demonstrates that the

one height appears to be stable. Radiographsaken at follow-up reveal crestal bone stability with-ut any evidence of peri-implant attachment loss or

nflammation with implants under functional load.In addition to restoring the hard tissue defect, the

articulate bone preserves and augments the soft tis-ue architecture that was lost to years of resorption.his allows an option for implant placement and cre-tes a better esthetic result. Soft tissue contour typi-ally follows underlying bony architecture. Any ridgeugmentation through bone grafting must provide theoundation to reconstruct the hard tissue defects toffect the soft tissue architecture.

Postoperative wound infection was not observed inhis patient series. Wound dehiscence occurred in 4atients, resulting in partial loss of graft material. All 4atients had large spans consisting of at least 2 orore missing teeth. In 1 patient with a large vertical

efect (15 mm) who was missing 2 teeth, an attemptas made to correct this defect in 1 surgical proce-ure. In retrospect, this could have resulted in dehis-ence. Although a large dehiscence of the woundccurred with exposure of the screw, membrane, andraft material in this patient, complete granulationccurred over the grafted site after removal of thexposed screw. Upon re-entry to this site for a secondraft, partial graft take of the exposed site was noted.his suggests the biocompatibility of mineralized al-

ograft and its user-friendly status in the face of graft

xposure. Had this graft been autogenous bone, com-

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434 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

lete loss of graft material would be expected with noossibility of partial graft take.Four patients had large vertical defects (�10m) with a single missing tooth span and had

uccessful correction of defect in a 1-stage graftingrotocol. This finding suggests that large singleissing tooth span may be corrected in a 1-stage

urgery protocol. Four patients who developedound dehiscence all had large span defects. Thisnding suggests that large spans (2 or more missingeeth) have a higher risk of wound dehiscence.orrection of these defects in a 2-surgery, smallerrafting protocol (5 to 6 mm per graft) may reducehe risk of graft dehiscence.

The overall success of this procedure can be attrib-ted to the meticulous reflection of tissue flaps and aension-free closure. This was achieved by releasinghe periosteal flaps from the nasal spine in addition tocoring the periosteum in all maxillary cases. Thencorporation of a vertical incision in the flap is alsoelpful in allowing further advancement of the flap.n the mandible, the release of the mylohyoid musclerom its attachment is critical in addition to a split-hickness flap on the labial to avoid damage to theental nerve. The authors have found that this step is

ritical in avoiding wound dehiscence and subse-uent graft resorption.In addition to allowing primary tension-free wound

losure, scoring of the periosteum promotes angio-enesis by creating bleeding into the graft.24 Further-ore, creating adequate space for bone regeneration

y surgically expanding the soft tissue matrix withenting screws can help prevent resorption of theraft material.24 The authors believe that the use of aesorbable membrane is important to the success ofsing particulate allograft. It is unclear whether these of a membrane reduces or prevents graft resorp-ion. Based on a systematic review of the literature,urther evidence is needed to determine whetherarrier membranes prevent bone resorption in au-ologous onlay bone grafts.22 Controlled clinicalrials have shown improved survival of implantshen a membrane was used to cover sinus window

or sinus augmentation through a lateral windowpproach.23,25-27 The increase in implant survival maye explained by the reported higher percentage ofital bone that results when a membrane is placedver the window. Furthermore, the use of a mem-rane in conjunction with particulate graft is helpful

n preventing graft particles from sticking to the softissue flap on re-entry. This is especially true becausehere is aggressive undermining of the periosteumnd soft tissue in all grafted sites.

In our patient series, using cancellous mineralizellograft with strategically placed titanium screws has

llowed us to restore large vertical bony defects in a

redictable manner without the use of autologousone. The success reported is likely dependent on thexclusion of smokers, diabetic patients, and medicallyompromised patients. Further research is needed toetermine whether particle size and the use of corti-al versus cancellous allograft can affect the successnd predictability of this procedure. Long-term fol-ow-up is also needed to evaluate the stability of theraft after implant loading. Our preliminary reportndicates that using this technique allowed the suc-essful reconstruction of large defects in the patientselected.

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