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. 2025 Jul 16;38(3):575–581. doi: 10.1111/jerd.70002

Effect of Cortical Block Allograft Tenting Pins for Horizontal Bone Augmentation: A Case Series

Mingxu Sun 1, Zhaozhao Chen 2, Chongxia Yue 3, Xingwang Liu 1, Hom‐Lay Wang 2,✉
PMCID: PMC13062713  PMID: 40667875

ABSTRACT

Objective

The aim of this pilot case study was to evaluate the effect of horizontal bone augmentation using cortical block allograft absorbable tenting pins (ATP) in the context of guided bone regeneration (GBR).

Clinical Considerations

Three patients requiring implant placement with simultaneous horizontal bone augmentation were treated with a total of six ATPs across four bone augmentation sites. Freeze‐dried bone allograft combined with an absorbable small intestinal submucosa membrane was used to facilitate bone augmentation. The treatment process was uneventful, with no reported instances of wound dehiscence, infection, or pin loosening. Cone‐beam computed tomography performed 5 months postoperatively showed an average horizontal bone gain of 5.24 ± 0.95 mm at the ATP sites, with an average bone resorption of 0.55 ± 0.68 mm compared to immediate postoperative measurement, resulting in a volume retention rate of 94.6%.

Conclusion

Based on the findings, GBR using ATPs is a feasible approach to achieve predictable horizontal bone gain.

Keywords: allograft block, case series, dental implants, guided bone regeneration, horizontal bone augmentation, tenting screw

1. Introduction

Horizontal alveolar ridge deficiency is a common challenge in dental implantology. Achieving predictable bone augmentation necessitates adherence to the PASS (primary wound closure, angiogenesis, space creation and maintenance, and wound stability) principle [1]. Techniques used to facilitate successful bone augmentation include guided bone regeneration (GBR), protected bone augmentation, ridge splitting, and ridge expansion, subperiosteal tunneling, and block grafting [2, 3, 4, 5, 6, 7]. When encountering moderate to large defects or defects with non‐contained morphology, most of these methods often require additional fixation devices to create and stabilize the space for regeneration. These devices include, but are not limited to, fixation pins, tenting screws, titanium reinforced membranes, and titanium mesh. However, the use of these auxiliary fixation tools typically necessitates a secondary surgery for their removal. This increases the number of surgical procedures and can result in bone and soft tissue remodeling and scar formation due to flap reflection, which is particularly disadvantageous in the esthetic zone [8, 9].

While absorbable cortical bone screws have been used in orthopedic surgical procedures, such as bunionectomies, radius/scaphoid fixation, and hand surgery [10], the report of absorbable bone pillars for auxiliary oral GBR was limited [11, 12]. Stadeker [11] reported the procedure of “Alabama Graft” in which 2‐mm diameter cortical bone pins were used in staged horizontal ridge augmentation. Subsequently, in 2014, the combination of cortical bone pins and leukocyte‐ and platelet‐rich fibrin (L‐PRF) was introduced [12]. However, narrow pins lead to issues such as limited space maintenance and easier perforation of soft tissue, which limit the use of these pins.

This study utilizes allograft blocks designed to mimic tenting screws, allowing for easy fixation of the surgical site. The designed head provides support over a larger area, enhancing the space maintenance while reducing the risk of soft tissue perforation and pin exposure (Figure 1). Additionally, the biomaterial, being absorbable allogeneic cortical bone, eliminates the need for secondary surgery for removal. The authors have termed this grafting technique absorbable tenting pin‐assisted guided bone augmentation (ATP‐GBR). This case series report aims to illustrate the approach and provide case demonstrations on ATP‐GBR for successful horizontal bone augmentation.

FIGURE 1.

FIGURE 1

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Cortical block allograft absorbable tenting pin. The length is 11.5 mm, the diameter of the head is 5 mm, and the diameter of the body is 2 mm.

2. Materials and Methods

2.1. Patients

This study adheres to the standards outlined in the Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines [13]. The protocol strictly adhered to the 1975 Declaration of Helsinki as revised in 2000 and was approved by the ethical committee of Pingdu Jianbo Dental Hospital (No. QDPD‐2024007A). Additionally, all participants provided informed consent.

Three female patients, aged 42–55 years (mean age: 48), visited a private dental hospital in Qingdao, Shandong, China, in 2024 and participated in the study. All exhibited good oral hygiene and general health, with no systemic contraindications to surgical treatment. None of the patients were smokers. Patients were selected based on the presence of an edentulous ridge with multiple missing teeth. Candidates were required to be highly motivated to undergo the implant procedure and adhere to the treatment protocol. Implant sites were chosen according to the following anatomical criteria: (1) Sites exhibiting moderate ridge deficiency requiring 3.0 to 6.0 mm of horizontal bone augmentation, with no vertical bone defects. (2) Sites suitable for simultaneous implant placement and bone augmentation. All cases were demonstrated in Figures 2, 3, 4, 5, following similar surgical procedures and post‐operative regimens as below:

FIGURE 2.

FIGURE 2

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Case 1. GBR was performed using two ATPs with simultaneous implant placement in a case necessitating horizontal bone augmentation in the posterior maxilla. (a) Flap elevation revealed a ridge with thin residual bone. (b) Three implants and two ATPs were placed. (c) The site was augmented with cortical particulate allograft. (d) An absorbable small intestinal submucosa (SIS) membrane was laid over the graft region. (e) Significant bone width gain was detected after 5 months of healing. (f) Overview of the posterior maxilla outline after 6 months of healing.

FIGURE 3.

FIGURE 3

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Case 2. GBR was performed using one ATP with simultaneous implant placement in a case necessitating horizontal bone augmentation in the posterior maxilla. (a, b) Two implants were placed with one ATP fixed at the site. (c) Significant bone width gain was detected after 5 months of healing, with a slight hump at the ATP site. (d) The bone bump was ground away. (e) Occlusal view of the left posterior maxilla after 6 months of healing.

FIGURE 4.

FIGURE 4

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Case 3. GBR was performed using two ATPs with simultaneous implant placement in a case necessitating horizontal bone augmentation in the anterior maxilla. (a) Flap elevation revealed a ridge with thin residual bone. (b, c) Four implants and two ATPs were placed. (d) The site was augmented with cortical particulate allograft. (e) An absorbable small intestinal submucosa (SIS) membrane was laid over the graft region and fixed with multiple abutments. (f) The outline of the arch profile after 6 months of healing.

FIGURE 5.

FIGURE 5

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Case 4. GBR was performed using one ATP with simultaneous implant placement in a case necessitating horizontal bone augmentation in the anterior maxilla. (a) Flap elevation revealed a ridge with thin residual bone. (b) Three implants and one ATP were placed. (c) The site was augmented with cortical particulate allograft. (d) An absorbable small intestinal submucosa (SIS) membrane was laid over the graft region and fixed with multiple abutments. (e) The outline of the arch profile after 6 months of healing.

2.2. Surgical Procedures

The surgical area was anesthetized with 2% articaine local infiltration anesthesia, and incisions were made using a 15C blade. A full‐thickness mucoperiosteal flap was elevated with a periosteum elevator, and the implants were placed in the designated sites following the operational sequence with a modified osseodensification bur (Sun Bur Kit, Xien, China). After that, implant cover screws were properly placed.

At the planned ATP sites, a 1.8 mm pilot drill was used to prepare the insertion site, generally perpendicular and parallel to the occlusal plane, with the center of the hole approximately 4 mm from the top of the alveolar ridge and at least 5 mm deep. The ATP pin was then pressed into the drilled hole using finger pressure until stable. If the bone was hard and the pin could not be positioned, the site preparation could be appropriately enlarged with the pilot drill until the ATP could reach the ideal position and remain stable.

For horizontal bone augmentation, a gap of approximately 2–4 mm was left between the ridge and the inner surface of the head of ATP. An appropriate amount of allogeneic bone graft (FDBA, Biogene, Cojoing Bio‐tech, China) material was implanted in the bone augmentation area. A suitable size of absorbable intestinal submucosa (SIS) membrane (Datsing Absorbable Collagen Membrane, Datsing Bio‐tech, China) was selected based on the bone grafting area and trimmed as necessary to ensure it could cover the entire bone grafting area. The flap was released to allow for tension‐free closure.

The flap was approximated and closed using 4‐0 nylon sutures (Weigao, China) with a horizontal mattress plus interrupted suture techniques. Postoperative care included a prescription for Amoxicillin/Clavulanic acid (875 mg/125 mg), to be taken three times a day for 1 week. Additionally, patients were advised to intermittently use ice packs on the surgical area within 2 h after surgery. Patients were also instructed to rinse with 0.2% chlorhexidine twice a day and to avoid any mechanical damage, tooth brushing, or excessive traction on the muscles in the surgical area for 4 weeks. Sutures were removed 14 days postoperatively. All patients were followed up in the fifth month.

2.3. Data Measurement

Three CBCT scans were acquired during the study: the first before bone grafting to determine the dimensions and morphology of the alveolar ridge defect (T0), the second immediately after the bone graft surgery to measure the width of the ATP graft area (T1), and the third 5 months post‐graft healing to assess the amount of bone gained (T2). The CBCT DICOM (Digital Imaging and Communications in Medicine) data from T0, T1, and T2 were imported into 3Shape software (DentalNavi, Yakebot) and were separately matched and aligned to measure the buccolingual linear bone width at six ATP sites at different time points (Figure 6).

FIGURE 6.

FIGURE 6

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Representative CBCT images and horizontal bone width measurements of pre‐ (T0), immediately after surgery (T1), and 5‐month postsurgery (T2).

During the surgical process, the occurrence of ATP fracture and its stability were assessed and recorded. Additionally, throughout suture removal and follow‐up visits, any occurrences of dehiscence, infection, or discomfort during the wound healing period were documented.

3. Results

As shown in Table 1, preoperative (T0) CBCT measurements showed an average bone width of 4.40 ± 0.85 mm, which increased to 9.64 ± 0.39 mm at 5 months postoperatively (T2). This indicates an average horizontal bone gain of 5.24 ± 0.95 mm. Compared to the immediate postoperative ridge width, a reduction of 0.55 ± 0.68 mm was observed at 5 months, resulting in a tenting screw volume maintenance rate of 94.6%.

TABLE 1.

Comparison between pre‐ (T0), immediately after surgery (T1), and 5‐month postsurgery of all three patients and six pin sites.

Bone width (mm)
PIN T0 T1 T2 T2–T0 T1–T2
1 4.59 11.16 10.06 5.47 1.1
2 4.13 10.24 9.35 5.22 0.89
3 5.05 10.36 9.06 4.01 1.3
4 5.39 10.29 9.99 4.6 0.3
5 2.97 10.06 9.8 6.83 0.26
6 4.26 9.02 9.56 5.3 −0.54
Mean ± SD 4.40 ± 0.85 10.19 ± 0.69 9.64 ± 0.39 5.24 ± 0.95 0.55 ± 0.68
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Six ATPs were implanted across four bone grafting areas in three patients. One site experienced screw fracture during implantation, which was successfully replaced with a new screw that achieved stability. Throughout the healing process, there were no instances of incision dehiscence, infection, ATP loosening, or exposure at any of the six sites, and all patients reported no discomfort.

4. Discussion

There are numerous methods for extensive horizontal bone augmentation, each with proven clinical efficacy, such as GBR with absorbable/non‐resorbable membranes, titanium mesh, and block bone grafts [14, 15]. These techniques typically require fixation with fixation pins/screws or tenting screws to create and stabilize the space. However, most of these methods necessitate a second surgery for material removal, resulting in increased surgical procedures and trauma.

In the esthetic zone, reflecting the extensive full thickness flap to remove fixed materials can lead to hard and soft tissue remodeling. This further increases the risk of subsequent bone resorption and esthetic complications, such as mucosal recession and loss of interproximal papilla [16, 17]. ATP‐GBR offers a solution by using allogeneic absorbable screws to support the bone graft space, achieving predictable osteogenic results even in extensive bone defects. Not requiring a second surgery for removal, ATP‐GBR reduces trauma and the number of surgeries. Particularly in the esthetic zone, it helps minimize post‐flap bone resorption and defect creation, reduce scar formation, and preserve the papilla, thereby enhancing esthetic outcomes [7].

Conventional GBR using absorbable membrane with bone substitutes is a commonly used technique for horizontal bone augmentation. However, in cases of extensive bone augmentation or non‐contained defects, the lack of stability in the graft area can lead to particulate bone graft migration, reducing the osteogenic effect at the alveolar crest [2]. The average bone augmentation with simultaneous implant placement has been reported as around 2.7 mm (95% CI: 2.3, 3.0) [1, 14]. When combined with fixation pins or tenting screws for space maintenance, this approach can achieve a substantial volume of augmentation. Urban proposed the sausage technique [18], which uses titanium pins to secure the native collagen membrane and compress the bone graft material crestally, creating a balloon effect. This method has demonstrated the ability to achieve approximately 5.68 mm gain in staged horizontal bone augmentation. Recently, a review article further reported that the bone augmentation effect of tenting screws ranges from 3 to 4.2 mm [19]. The use of nonresorbable membranes, such as expanded polytetrafluoroethylene (e‐PTFE), dense PTFE (d‐PTFE), Ti‐reinforced PTFE, has demonstrated an average horizontal bone augmentation of approximately 4 mm. However, this technique is highly sensitive and associated with a high exposure rate of around 38.5% [15, 20]. Similarly, the use of titanium mesh in horizontal bone regeneration results in an average ridge width gain of 3.5–6.5 mm but is accompanied by common complications such as mesh exposure (15%–36%), infection, and partial or total bone resorption [21, 22]. In terms of block graft, a retrospective study by Mertens in 2023 found that the full‐block technique increased width by 3.37 ± 0.71 mm, while the split‐block technique (cortical plate with autogenous bone chips) increased width by approximately 5.79 ± 2.2 mm [23].

In this case series, the average horizontal bone width increased by 5.24 ± 0.95 mm at ATP‐GBR sites, with all implants buccal sides having more than 2 mm of bone plate. Compared to traditional GBR using tenting screws, ATP‐GBR demonstrated an increased effect and was comparable to other techniques using titanium‐reinforced membranes, titanium mesh, or autologous block grafts, yet it was less invasive, and all cases involved simultaneous implant placement. Therefore, ATP‐GBR is a highly predictable technique for bone augmentation.

Based on authors' experience, the stability of the pins is dependent on thread engagement and taper, and different bone densities require proper management of the thread engagement. If the engagement is not suitable, it may lead to excessive insertion resistance or pin fracture. In this series, six pins were implanted, and one fractured during insertion. After enlarging the preparation site, a new ATP was successfully implanted and achieved good stability, with no loosening and no patient discomfort. This demonstrates the feasibility of ATP‐GBR fixation.

Furthermore, bone resorption during the healing period occurs with different bone augmentation methods. Caldwell reported an average bone resorption rate of 13.89% with tenting screw GBR [24]. In ATP‐GBR, the volume maintenance effect in the support area was 94.6%. However, there was a certain degree of resorption and depression in the non‐support area, especially at screw 5 (Figure 3c), as only one pin was placed, leading to more resorption in the mesial and distal bone powder areas. When the flap was reopened, the pin head was slightly prominent. Although the patient experienced no discomfort due to the abundant bone, the surgeon chose to gently grind the prominent pin head (Figure 3d). We speculate that while the ATP itself provides good support, the mesial and distal bone contour support is weaker, leading to some resorption. This suggests that we should identify appropriate sites to fix more ATP screws in the intended bone augmentation area, with the distance between pin heads preferably within 6 mm. To adequately support the stability of the alveolar crest, the pins should be placed close to the crest. In this series, they were positioned 4–5 mm below the crest, with the pin axis parallel to the occlusal plane, and the edge of the pin head located 2 mm below the crest (Figures 3b, 4c, 5c). This provided good support for the contour of the alveolar crest. These findings underline the importance of strategic placement of ATPs to maximize support and minimize resorption, thereby ensuring optimal results in horizontal bone augmentation.

The following limitations of this case series should be noted: (1) To ensure measurement consistency, this study measured the horizontal bone thickness only at the ATP sites. From CASE 1 and CASE 2 (Figures 2e, 3c), the healed bone contour at the ATP sites appears the most prominent, with slight depressions toward mesially and distally, producing a wavy or convex buccal bone contour, including measurements of non‐ATP sites could provide additional insights into the overall bone augmentation effect. (2) ATP‐GBR may not be suitable for single implant placement with simultaneous bone augmentation due to lack of space for pin insertion. However, for mild or well‐contained defects, conventional GBR is typically predictable. For moderate to severe or non‐contained defects, staged GBR using ATPs remains a viable option. 3. Future randomized clinical trials with larger sample sizes and extended follow‐up periods are necessary to further validate this treatment protocol.

5. Conclusion

ATP‐GBR is a minimally invasive and efficient method for horizontal bone augmentation, achieving favorable results with few complications. This technique shows significant potential and merits further research to fully understand its long‐term effects and benefits. Continued observation and study are necessary to validate its efficacy over extended periods.

Author Contributions

M.S., C.Y. and X.L.: involved in conception, design; preparing the cases; analysis and interpretation of case; initial and final drafting of the work; final approval of the version to be published; accountable for all aspects of the work. Z.C. and H.‐L.W.: involved in conception, design; analysis and interpretation of the case; initial and final drafting of the work; final approval of the version to be published, accountable for all aspects of the work and accountable for all aspects.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

None of the authors have any financial interests, either directly or indirectly, in the products or information enclosed in this paper except Mingxu Sun and Chongxia Yue who are the inventors of this device. During the preparation of this manuscript, the authors used ChatGPT‐4.0 to assist with grammar correction and improving readability. All content was subsequently reviewed and edited by the authors, who take full responsibility for the final version of the manuscript.

Sun M., Chen Z., Yue C., Liu X., and Wang H.‐L., “Effect of Cortical Block Allograft Tenting Pins for Horizontal Bone Augmentation: A Case Series,” Journal of Esthetic and Restorative Dentistry 38, no. 3 (2026): 575–581, 10.1111/jerd.70002.

Funding: The authors received no specific funding for this work.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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