Material matters

11 November 2023

Cemal Ucer explains how to choose the right bone grafting material to achieve the best clinical outcomes for your patients.

Dental implants have become a well-established treatment for the management of complete and partial edentulism. Full arch implant-retained prostheses provide several advantages over other options, such as conventional dentures. In addition to looking and functioning like natural teeth, these prostheses are designed to be long-lasting. They’re also more comfortable and stable than conventional dentures, allowing the patient to bite and chew more naturally and to eat certain foods that can be difficult to eat with a removable alternative.

In addition, full arch rehabilitation will help to preserve the bone, while removable dentures often lead to bone resorption. After the first year of implantation, an implant should have <0.2mm annual loss of marginal bone level to be considered a success. The annual marginal bone loss for dentures varies from 0.13 +/- 0.35mm to 1.03 +/- 0.65mm.

Where bone loss has already occurred, and inadequate volume exists for implant treatment, bone augmentation may be indicated. Bone grafting is the only solution to reverse dental bone loss and is a well-accepted procedure required in one in every four dental implants placed.

There are four main types of bone grafts: guided bone regeneration (GBR), block grafting, bone expansion and distraction osteogenesis, with GBR being the most common in implant treatment.

In GBR, different materials for bone augmentation can be used. The use of autogenous bone is often considered the ‘gold standard’ in regard to grafting and is preferred in maxillofacial reconstruction.

Depending on the size of the area to be grafted, bone can be harvested from a number of different areas. Local or small bone defects will often receive grafts harvested from within the oral cavity, including the implant site, external oblique ridge, mandibular ramus, mental region, maxillary tuberosity or the anterior nasal spine region.

However, increasingly, due to the resorptive properties of the alveolus post-extraction, bone substitutes may also be used.

Allogenic bone, or allograft, is a non-living bone harvested from a cadaver which contains no organic tissue. It is processed using a freeze-dry technique to extract the water and then sterilised. Dissimilar to autogenous bone, allogenic bone cannot produce new bone on its own. It serves as a framework so that bone cells from the surrounding bone can grow to fill the defect.

Xenogenic bone, or xenograft, is derived from non-living bone of another species, usually from bovine or porcine sources. Processed at very high temperatures to avoid the possibility of immune rejection and contamination, only the mineral content of the bone is used for grafting. Xenografts are the materials most used in the dental field.

Both allogenic and xenogenic bone grafting have the advantage of not requiring a second procedure to harvest a patient’s own bone. However, bone regeneration does take longer than with autografts because they lack the same bone-forming properties.

There is also the option of alloplast or ‘synthetic bone’. This has a structure similar to natural bone, and various materials are available for grafting, the most common being tri-calcium phosphate, which shows good biocompatibility and osteoconductivity.

Different bone grafting materials can also work together. The combination of autogenous bone with deproteinised bovine bone has shown better results because of its osteogenic property.

When considering what bone graft to use, a patient’s preferences should be considered along with the usual clinical factors such as tissue viability, defect site, graft size and cost – an element that is often overlooked. Successful dental treatment does not depend solely on the provision of good dental care; it also depends on the patient’s compliance and participation in decision making. Some patients may have reservations about xenografts, for example, due to their religious or dietary beliefs.

Due to the prevalence of peri-implantitis, it is crucial to provide the most suitable bone augmenting biomaterial to accomplish the best treatment results. Indeed, peri-implantitis is considered to be the main biological cause of implant failure five years post-operatively. Review studies have estimated that peri-implantitis will affect 28 per cent to 56 per cent of patients and 12 per cent to 43 per cent of individual implant sites.

Dentists have to be right at the top of their game in the field of implantology when it comes to full-mouth rehabilitation work. Unlike simpler dental procedures, the success of such treatment largely depends on the individual dentist’s skill. Therefore, it is essential to keep your skills refreshed and also consider attending courses designed to elevate your skills. A practice can see increases in turnover and profits by offering advanced treatment options.

Training that covers full mouth rehabilitation is provided by Ucer Education. My team and I are highly skilled professionals who can guide dental practitioners through an Advanced Certificate in Full Mouth Oral Implant Rehabilitation giving them the skills to confidently practise in the area. This blended postgraduate training programme, which takes place over a period of six months, is accredited by the University of Salford and delivered at the cutting-edge facilities of the prestigious ICE Postgraduate Dental Institute.

Given the state of the nation’s oral health – around three in four adults (74 per cent) in the UK have had a tooth extracted – demand for dental implant treatments is only set to rise. Will you be ready?


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References available on request.