20 Years of Guided Bone Regeneration in Implant Dentistry

Second Edition

Library of Congress Cataloging-in-Publication Data

20 years of guided bone regeneration in implant dentistry / edited by Daniel Buser. — 2nd ed.

p. ; cm.

Rev. ed. of: Guided bone regeneration in implant dentistry / edited by Daniel Buser, Christer Dahlin, Robert K. Schenk. c1994.

Includes bibliographical references and index.

ISBN 978-0-86715-401-6 (hardcover) | ISBN 978-0-86715-996-7 (eBook)

1. Endosseous dental implants. 2. Guided bone regeneration. I. Buser, Daniel. II. Guided bone regeneration in implant dentistry. III. Title: Twenty years of guided bone regeneration in implant dentistry. IV. Title: Guided bone regeneration in implant dentistry.

[DNLM: 1. Guided Tissue Regeneration, Periodontal. 2. Bone Regeneration. 3. Dental Implantation, Endosseous—methods. WU 240 Z999 2009]

RK667.I45G84 2009

617.6’92—dc22

2009024243

©2009 Quintessence Publishing Co, Inc

Quintessence Publishing Co Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Kathryn Funk
Design: Gina Ruffolo
Production: Angelina Sanchez

Printed in Singapore

Contents

Dedication

Foreword

Preface

Contributors

1 Guided Bone Regeneration over the Past 20 Years

Daniel Buser

2 Biologic Basis of Bone Regeneration

Dieter D. Bosshardt and Robert K. Schenk

3 Properties of Barrier Membranes

Michael M. Bornstein, Thomas von Arx, and Dieter D. Bosshardt

4 Bone Grafts and Bone Substitute Materials

Simon Storgård Jensen, Dieter D. Bosshardt, and Daniel Buser

5 Intraoral Bone Harvesting

Thomas von Arx

6 Implant Placement with Simultaneous Guided Bone Regeneration: Selection of Biomaterials and Surgical Principles

Daniel Buser

7 Implant Placement in Postextraction Sites

Daniel Buser and Stephen T. Chen

8 Guided Bone Regeneration and Autogenous Block Grafts for Horizontal Ridge Augmentation: A Staged Approach

Thomas von Arx and Daniel Buser

9 Guided Bone Regeneration for Vertical Ridge Augmentation: Past, Present, and Future

Massimo Simion and Isabella Rocchietta

Index

To the pioneers of guided bone regeneration

L. A. Hurley
C. A. L. Bassett
P. J. Boyne
T. P. Rüedi
T. Karring
S. Nyman
C. Dahlin
R. K. Schenk

Foreword

To be provided with the opportunity to write a foreword for a significant new textbook represents both a true honor and privilege, but certainly also a genuine responsibility toward the authors. The work at hand not only represents a definite landmark in clinical dentistry but also has been carefully edited and in part written by my close friend of many years. The text comprehensively surveys 20 years of a fundamental and ever-growing field in implant dentistry and defines the current state of the art in guided bone regeneration. At the end of the first decade of the new millennium, guided bone regeneration and peri-implant contour augmentation are well established and inseparably connected to successful clinical implant dentistry. In fact, the knowledge of what techniques, procedures, and associated biomaterials are available today, linked to indispensable scientific documentation, provide the clinician with the basis for appropriate clinical decision making and—according to the practitioner’s education and competence—subsequent treatment. In this context, the SAC concept, which objectively differentiates between straightforward (S), advanced (A), and complex (C) clinical situations, has particular importance and therefore has been strongly promoted by the author. Furthermore, as the title of this textbook suggests, guided bone regeneration, although an independent discipline, is strongly and primarily connected to implant dentistry, which now promotes prosthetically driven implant placement, rather than the antiquated bone-driven approach. The authors, all of them highly qualified and considered experts in the field, guarantee both the impressive quality of this work and its completeness in covering all the various aspects involved. Oral surgeons, periodontists, prosthodontists, general practitioners, and dental students are certain to find information that is relevant to their unique goals and perspectives. This textbook is destined to quickly reach the level of a true standard and long-standing reference.

Urs C. Belser, DDS, PROF DR MED DENT

Professor

Department of Prosthodontics

School of Dental Medicine

University of Geneva

Geneva, Switzerland

Preface

The use of barrier membranes for the regeneration of bone defects has significantly changed implant dentistry in the past 20 years. This principle, often called guided bone regeneration (GBR or GBR technique), was first described in 1959 by Hurley and colleagues for experimental spinal fusion treatment. In the 1960s, the research teams of Bassett and Boyne tested microporous cellulose acetate laboratory filters (Millipore) for the healing of cortical defects in long bones and for osseous facial reconstruction, respectively. The authors used these filters to establish a suitable environment for osteogenesis by excluding fibrous connective tissue cells from bone defects. However, these pioneering studies did not immediately lead to a broad clinical application of barrier membranes in patients. The clinical potential of the membrane technique was not recognized until the early 1980s, when the research team of Karring and Nyman systematically examined barrier membranes in various experimental and clinical studies for periodontal regeneration. A few years later, barrier membrane techniques were tested in experimental studies on bone regeneration. Based on promising results in these studies, clinical testing of membranes began in implant patients in the late 1980s.

In 1994, after 5 years of intensive experimental and clinical work, the first edition of this textbook, Guided Bone Regeneration in Implant Dentistry, was published and generated a high level of interest among those in the field of implant dentistry. Since that time, the GBR technique has continued to evolve, necessitating an updated analysis of its scientific basis and clinical applications. The result is in your hands—the second edition of the GBR book, 20 Years of Guided Bone Regeneration in Implant Dentistry.

This book is again written for the clinician with interest and experience in implant dentistry. The first four chapters focus on the basic science of GBR in implant dentistry. These chapters help the reader to understand the biologic and biomaterial background of this well-documented and well-established surgical technique in implant dentistry—essential knowledge for the use of barrier membranes in patients. As an introduction to the topic of the book, chapter 1 discusses the development of the GBR technique over the past 20 years. In this chapter, the four factors important for a successful regenerative outcome are described. Chapter 2 covers the biologic basis of bone regeneration and pre-sents a scientific update on bone formation and remodeling. It features excellent histologic images obtained using undecalcified sections over the course of more than 30 years of experimental orthopedic research. Chapter 3 describes the characteristics, advantages, and disadvantages of nonresorbable and bioresorbable barrier membranes used in implant dentistry. Chapter 4 contains information about the various types of bone grafts and bone substitutes routinely used in combination with barrier membranes. These bone fillers not only provide support and thus help prevent membrane collapse but also influence new bone formation and bone remodeling in the defect area. The various characteristics of bone fillers, such as their osteogenetic and osteoconductive potential and substitution rates, are presented based on various experimental studies.

Chapters 5 through 9 focus on the clinical applications of GBR. Each chapter presents specific indications and describes the criteria for patient selection, the step-by-step surgical procedure, and aspects of postoperative treatment. Emphasis is placed on incision technique, flap design, the handling and placement of barrier membranes, the combination of membranes with autogenous bone grafts and low-substitution bone fillers, and approaches to wound closure. These five clinical chapters reflect the immense progress of GBR in the past 10 to 15 years and the current clinical status of GBR in implant dentistry.

As editor, I cordially thank all the authors and coauthors for the great amount of time and effort they contributed to the realization of this textbook. It has been a very intensive but satisfying experience to collaborate with colleagues of such quality. I also thank Ms Jeannie Wurz for her excellent work in editing and checking all manuscripts prior to submission to the publisher. Last but not least, I thank the staff of Quintessence Publishing for their excellent collaboration in completing this book and again providing superb quality in their work and printing.

Contributors

Michael M. Bornstein, DR MED DENT

Assistant Professor and Head

Section of Dental Radiology and Stomatology

Department of Oral Surgery and Stomatology

University of Bern

Bern, Switzerland

Dieter D. Bosshardt, PHD, DR SC NAT

Senior Scientist and Head Laboratory of Oral Histology

School of Dental Medicine

University of Bern

Bern, Switzerland

Daniel Buser, DDS, PROF DR MED DENT

Professor and Chairman

Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Bern, Switzerland

Stephen T. Chen, BDS, MDSC, PHD

Senior Fellow in Periodontics

School of Dental Science

University of Melbourne

Victoria, Australia

Simon Storgård Jensen, DDS

Consulting Oral and Maxillofacial Surgeon

Department of Oral and Maxillofacial Surgery

Copenhagen University Hospital

Glostrup, Denmark

Research Fellow

Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Bern, Switzerland

Isabella Rocchietta, DDS

Research Fellow

Department of Periodontology

School of Dentistry

University of Milan

Milan, Italy

Robert K. Schenk, MD, PROF DR MED

Professor Emeritus of Anatomy

Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Bern, Switzerland

Massimo Simion, MD, DDS

Professor and Chairman

Department of Periodontology

School of Dentistry

University of Milan

Milan, Italy

Thomas von Arx, DDS, PROF DR MED DENT

Associate Professor

Department of Oral Surgery and Stomatology

School of Dental Medicine

University of Bern

Bern, Switzerland

Based on fundamental experimental studies performed by the research teams of Per-Ingvar Brånemark from the University of Gothenburg (Sweden) and André Schroeder from the University of Bern (Switzerland), the use of dental implants has become a scientifically accepted treatment for the replacement of lost or missing teeth in fully and partially edentulous patients. In landmark papers published in the late 1960s and 1970s, both research teams described the phenomenon of osseointegrated titanium implants.1–3 An osseointegrated implant is characterized by direct apposition of living bone to the titanium surface.4,5

Several prerequisites have been defined for achieving osseointegration of titanium implants with high predictability.1,2 Some of these have been revised over the past 30 years; others are still considered important. To achieve osseointegration, the implant must be inserted with a low-trauma surgical technique to avoid overheating of the bone during preparation of a precise recipient site, and the implant should be placed with sufficient primary stability.6 When these clinical guidelines are followed, successful osseointegration will predictably occur for nonsubmerged titanium implants (single-stage procedure) as well as for submerged titanium implants (two-stage procedure), as demonstrated in comparative, experimental studies.7,8

When clinical testing of osseointegrated implants first began, the majority of treated patients were fully edentulous. Promising results were reported in various retrospective studies.9–13 Encouraged by these good treatment outcomes, clinicians started to utilize osseointegrated implants in partially edentulous patients, and the first reports of promising short-term results were published in the late 1980s and early 1990s.14–18 As a consequence, single-tooth gaps and distal-extension situations have become more and more common indications for implant therapy in daily practice, and today these applications dominate in many clinical centers.19

One of the most important prerequisites for achieving and maintaining successful osseointegration is the presence of a sufficient volume of healthy bone at the recipient site. This includes not only bone of sufficient height to allow the insertion of an implant of appropriate length but also a ridge of sufficient crest width. Clinical studies have shown that implants placed in a site with a missing buccal bone wall have a greater rate of soft tissue complications20 and/or a compromised long-term prognosis.21,22 To avoid increased rates of implant complications and failures, these studies suggested that sites with inadequate bone volume either should be considered local contraindications to implant placement or should be locally augmented with an appropriate surgical procedure to regenerate the bone and allow implant placement.

In the 1980s and early 1990s, several attempts were made to develop new surgical techniques to augment bony defects in the alveolar ridge to overcome these local contraindications to implant-borne prostheses. The proposed techniques included vertical ridge augmentation with autogenous bone grafts from the iliac crest in extremely atrophic mandibles or maxillae,23,24 sinus floor elevation procedures in partially or fully edentulous maxillae,25–27 the application of autogenous onlay grafts for lateral ridge augmentation,28–30 or split-crest techniques, such as alveolar extension plasty.31–33

During the same period, in addition to these new surgical techniques, the concept of guided bone regeneration (GBR) utilizing barrier membranes was introduced. Based on case reports and short-term clinical studies, various authors reported first results with this membrane technique for the regeneration of localized bone defects in implant patients.34–39

This textbook provides an update on the biologic basis of the GBR technique and its clinical applications, predominantly in partially edentulous patients. Clinical experience with GBR in implant patients now spans 20 years. These 20 years can be divided into a development phase and a phase of routine application.

  Development Phase

The utilization of barrier membranes for implant patients was certainly triggered by the clinical application of barrier membranes for periodontal regeneration, called guided tissue regeneration (GTR). GTR was first developed in the early 1980s by Nyman et al.40,41 The initial studies were made with Millipore filters (Millipore), which had already been used in the late 1950s and 1960s for the regeneration of bone defects in experimental studies.42–44 However, these studies had no impact on the development of new surgical techniques to regenerate localized defects in the jaws because the potential of this membrane application probably was not recognized.

The articles by Nyman et al40,41 in the field of GTR, both of which demonstrated successful treatment outcomes of GTR procedures, created a great deal of interest and led to much research activity in the mid- to late 1980s.45–48 These studies were performed with expanded polytetrafluoroethylene (ePTFE), which is a bioinert membrane and became the standard membrane for GTR and GBR procedures during the development phase of both techniques. The use of ePTFE membranes for bone regeneration was initiated in the mid-1980s by the group led by Nyman and Dahlin, who performed a series of experimental studies.49–51 These studies confirmed the concept that the application of an ePTFE membrane creates a physical barrier that separates the tissues and cells that could potentially participate in the wound healing events. The barrier membrane creates a secluded space and facilitates the proliferation of angiogenic and osteogenic cells from the marrow space into that defect without interference by fibroblasts. These events were nicely demonstrated by Schenk et al52 in a landmark experimental study in foxhounds. The current understanding of wound healing events in membrane-protected bone defects are presented in chapter 2.

The utilization of ePTFE membranes for GBR procedures in patients started in the late 1980s. The main objective was to regenerate peri-implant bone defects in implant sites with local bone deficiencies. The GBR technique has been used with a simultaneous or a staged approach.35 Implant placement with simultaneous GBR was predominantly used for immediate implant placement in postextraction sites to regenerate peri-implant bone defects34,37 or for implants with crestal dehiscence defects.39 The staged approach was used in clinical situations with healed implant sites but an insufficient crest width. The membrane technique was utilized to enlarge the crest width with a first surgery, and implant placement took place in a second surgical procedure performed after 6 to 9 months of healing.36

Early on, several complications were noted with both approaches, and modifications of the surgical techniques were proposed to improve the predictability for successful treatment outcomes. One frequently seen complication was the collapse of ePTFE membranes, which reduced the volume of the regenerated tissue underneath the membrane. In addition, some of the regenerated sites demonstrated insufficient bone formation and the formation of a periosteum-like tissue underneath the membrane.36,39 Therefore, bone fillers such as autografts or allografts were recommended by various groups, not only to support the membrane and eliminate membrane collapse but also to enhance new bone formation through the osteogenic potential of autogenous bone grafts.53–55 The combination of ePTFE membranes and autogenous bone grafts provided good clinical outcomes with both approaches (Figs 1-1 and 1-2).

In the mid-1990s, several expert meetings took place to discuss the potential and limitations of the GBR technique used in daily practice at that time. These meetings clearly showed that an improvement of the GBR technique was necessary to allow its widespread use in implant dentistry. The experts agreed that the GBR technique—based on the utilization of ePTFE membranes in combination with bone grafts or bone substitutes—had the following weaknesses: (1) a significant rate of membrane exposures arising from soft tissue dehiscences, often leading to local infection underneath the membrane and subsequently to a compromised treatment outcome of the GBR procedure56–59; (2) difficult handling of the membrane during surgery because of its hydrophobic properties, requiring stabilization of the membrane with miniscrews and tacks54,60; and (3) the need for a second surgical procedure to remove the bioinert, nonresorbable membrane.

During these meetings, the participants defined objectives to improve the predictability and attractiveness of GBR procedures in implant patients for both the patient and the clinician ( Box 1-1). It was clear to the participants at these expert meetings that these objectives could only be achieved with the utilization of a bioresorbable membrane. This trend was again initiated in the field of GTR, with the introduction of the first bioresorbable membranes in the early 1990s.61,62 Subsequently, numerous studies in animals examined different bioresorbable membranes for GBR procedures as well.63–74 In general, two different groups of bioresorbable membranes were evaluated: (1) polymeric membranes made of polylactic or polyglycolic acid and (2) collagen membranes produced from various animal sources.75 The characteristics of different barrier membranes used for GBR procedures are discussed in detail in chapter 3.

Compared with the selection of an appropriate barrier membrane, the selection of appropriate bone fillers to support membranes is at least as important for the treatment outcome. The various bone grafts and bone substitutes that can be used as bone fillers underneath membranes are discussed in detail in chapter 4.

  Routine Application

Parallel to these experimental studies, clinicians started to use bioresorbable membranes in patients. The first published clinical reports were predominantly studies with collagen membranes.76–81 Today, collagen membranes are routinely used in daily practice for GBR procedures.

In the past 10 years, the GBR technique has become the standard of care for the regeneration of localized bone defects in implant patients. A systematic review by Aghaloo and Moy82 demonstrated that implants placed with the GBR procedure have favorable survival rates and that the GBR procedure is the only well-documented surgical technique among various surgical techniques used for localized ridge augmentation. The only other scientifically well-documented surgical technique at present is sinus grafting (sinus floor elevation). Today, clinicians performing GBR procedures are in the favorable situation of selecting their surgical approach and biomaterials from a variety of options. The chosen GBR procedure should always attempt to fulfill the primary and secondary objectives in a given clinical situation ( Box 1-2).

The primary objectives of a GBR procedure are the achievement of successful bone regeneration in the defect area with high predictability and a low risk of complications. The secondary objectives are to obtain a successful outcome with the least number of surgical interventions, a low morbidity for the patient, and a shortened healing period. As already discussed, these secondary objectives have been very important in the past 10 to 15 years because clinicians around the globe have tried to improve these clinical aspects in an attempt to make GBR procedures less stressful and/or more attractive for patients in daily practice. These secondary objectives should not compromise the primary objectives of GBR procedures, however. In other words, a therapeutic approach that promises a low number of surgical procedures, a low morbidity for the patient, or a short treatment time should neither reduce the predict-ability of successful treatment outcomes nor increase the risk of complications. Therefore, all aspects are important, but the primary objectives have a clear priority.

The anticipated treatment outcome is influenced by four factors that have recently been described in detail by Buser and Chen83 for implant placement in postextraction sites (Fig 1-3). These factors are valid for GBR procedures in general. The key factor is the clinician, who makes all decisions based on a proper assessment of the clinical situation. The clinician evaluates the patient, selects appropriate biomaterials, and decides on the most suitable treatment approach to provide the anticipated treatment outcome.

A comprehensive analysis of the patient enables the clinician to determine whether the situation can be classified as low, medium, or high risk. In addition to determin-ing if the patient has a smoking habit, the clinician should evaluate medical, dental, and anatomical risk factors in detail, in particular the morphology of the bone defect to be regenerated. The defect morphology plays an important role in the selection of the appropriate surgical technique and particularly in determining whether a simul-taneous or a staged approach is more appropriate. These aspects are discussed in detail in chapter 6.

  Conclusion

Over the past 20 years, significant progress has been made in developing GBR procedures in implant dentistry. GBR has become a standard of care for the regeneration of localized bone defects in the alveolar ridge of potential implant patients. This progress has been an important contributing factor in the rapid expansion of implant therapy in the past 10 to 15 years.

The recommended step-by-step procedures in various clinical situations are presented in chapters 6 through 9. The reader of this textbook will quickly realize that the recommended surgical techniques are rather conservative. This conservative approach offers the best level of predictability in attaining a successful treatment outcome with a low risk of complications. Hence, this conservative approach offers the best chance to be a successful clinician who is able to satisfy patients’ high expectations.

  References

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52. Schenk RK, Buser D, Hardwick WR, Dahlin C. Healing pattern of bone regeneration in membrane-protected defects: A histologic study in the canine mandible. Int J Oral Maxillofac Implants 1994;9: 13–29.

53. Nevins M, Mellonig JT. Enhancement of the damaged edentulous ridge to receive dental implants: A combination of allograft and the Gore-Tex membrane. Int J Periodontics Restorative Dent 1992;12: 97–111.

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For both the esthetic outcome and long-term success, a sufficient amount of living bone is required to place an endosseous dental implant in jawbone. In about 50% of implant sites, however, there is a need for a procedure that predictably generates enough bone volume for the placement of a dental implant. There are several options for the enhancement of bone formation, including (1) osteoinduction by bone grafts or growth factors; (2) osteoconduction by bone grafts or substitute materials that serve as a scaffold for new bone formation; (3) transfer of stem cells or progenitor cells that differentiate into osteoblasts; (4) distraction osteogenesis; and (5) guided bone regeneration (GBR) using barrier membranes. Regardless of the method used, there is always an underlying basic mechanism of bone healing.

Bone reveals a unique potential for regeneration, which is probably best illustrated by fracture repair. Bone is able to heal fractures or local defects with regenerated tissue, or regenerate, of equally high structural organization without leaving a scar. The mechanism of this healing pattern is often considered to be a recapitulation of embryonic osteogenesis and growth. Because bone has a unique spontaneous healing capacity, the trick in reconstructive surgery is to harness this great regenerative potential to enhance bone formation for clinical applications. Thus, adequate bone augmentation or treatment of any bone defect requires a profound understanding of bone development and morphogenesis at the cellular and molecular levels. This chapter will summarize the development, structure, function, biochemistry, and cell biology of bone to provide the biologic basis for discussion of the GBR healing pattern.

  Development and Structure of Bone

Functions

Bone is certainly a high achievement in the evolution of supporting tissues. However, it has functions that go beyond mere body support. Functions of bone include (1) mechanical body support, motion, and locomotion; (2) support of teeth for biting and crushing of food; (3) support and protection of the brain, spinal cord, and internal organs; (4) housing of bone marrow, which is the source of hematopoietic cells; and (5) calcium homeostasis.

It is probably because these functions are of vital importance that bone possesses an exceptional capacity for self-healing, repair, and regeneration.

Skeletogenesis