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. 2017 Jul-Sep;17(3):219–225. doi: 10.4103/jips.jips_19_17

Systematic analysis on the efficacy of bone enhancement methods used for success in dental implants

S Elakkiya 1,✉, A S Ramesh 1, K Prabhu 1
PMCID: PMC5601489  PMID: 28936034

Abstract

Bone grafting is beneficial in enhancing bones that are lost due to trauma or natural or pathologic process. Autogenous bone, allogenic bone, xenogeneic bone, bone substitutes, and alloplasts can also be used for this purpose. Bone quantity should be adequate for the placement of implants, which necessitate the use of bone grafts before implant placement.

Objective:

This review analyses the different bone graft materials that are used for grafting around implants and evaluate if these grafts yield successful implant osseointegration over a period of time.

Materials and Methods:

The MEDLINE–PubMed database was searched from September 2016 to 10 years previously. Several journals were hand searched and from cross-references. The primary outcome measure that was analyzed was the survival rate of dental implants in the grafted sites at 6 months–1 year, and the secondary outcomes were success rates of dental implants over a period of 3–5 years’ follow-up.

Results:

The search yielded 213 articles. Ultimately, 31 studies meeting the eligibility criteria were selected. The analysis shows that autologous bone grafts can be preferred over allografts and xenografts for grafting implant sites, which showed less complication and high success rate.

Conclusion:

Based on the available data in the current existing studies with a follow-up period of at least 3–5 years, it can be summarized that the autologous bone grafts can be preferred over allografts and xenografts for grafting implant sites since they are stable for at least 3–5 years.

Keywords: Bone grafts, bone loss, dental implants, implant success

INTRODUCTION

Most patients present after tooth loss with a wide range of bone loss, which may not accommodate a dental implant prosthesis. Bone grafting is beneficial in enhancing bones that are lost due to trauma or natural or pathologic process. Autogenous bone, allogenic bone, xenogeneic bone, bone substitutes, and alloplasts are commonly used for this purpose.[1]

The long-term success of dental implants is highly dependent upon the degree of osseointegration in sufficient and healthy bone.[2] Implants have a predictable outcome and are the advanced treatment option for edentulous patients.[3] Bone augmentation helps in providing sufficient quality and quantity of the bone in the atrophic ridges for the placement of dental implants.[4] Grafts and guided bone regeneration techniques are used to improve primary stability during implant placement in atrophic ridges.[5] Hence, a systematic analysis was performed to check the efficacy of bone enhancement methods used for success in dental implants.

MATERIALS AND METHODS

The following analysis was performed according to the guidelines and the principles of the PRISMA statement for a systematic review.

Focused question patient intervention comparison and outcome

The review is focused on: “What is the efficacy of various types of bone enhancing grafts that leads to dental implants success?”

Search strategy

The MEDLINE–PubMed database was searched from September 2016 to 10 years previously.

The following search terms were used as shown in Figure 1.

Figure 1.

Figure 1

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Keywords for article search

Study inclusion criteria

The studies were analyzed according to the following inclusion criteria:[6,7,8]

  1. All studies treated with bone grafts and implants with a follow-up of at least 1 year

  2. Patients with reduced quantity of edentulous ridges resulted due to ridge resorption, periodontal diseases, and trauma were included

  3. The following grafts were considered:[9,10,11]

    1. Autologous bone graft
    2. Allograft
    3. Composite bone grafts
    4. Xenograft.

  4. Articles related to dental implants were considered for inclusion

  5. All dental implant systems were included

  6. Only studies in the English language were included

  7. Only human studies were included.

Study exclusion criteria

The studies with following criteria were not included in the review:[12,13,14]

  1. Studies involving only implants, without any bone graft

  2. Case reports regarding patients with any syndrome or major systemic disease

  3. Studies not related to implants and bone grafts

  4. Studies not related to dentistry

  5. Studies with insufficient information

  6. Animal studies.

Data extraction

All studies which met the inclusion and exclusion criteria for review were obtained and screened independently. Relevant studies without abstract were included for full-text screening. The following data were extracted from the studies included for review:[15,16,17,18,19,20] publication, study design, number of patients, type of graft, and number of dental implants, timing of implants, follow-up time, implant survival, and implant success rate. Quality of various studies regarding bone graft, implant success, and survival were considered for quality assessment of bone graft and implant [Figures 1 and 2].

Figure 2.

Figure 2

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Search strategy

Failure of bone grafts

The most frequent complication of graft failure may be due to exposure of bone graft, not proper stabilization of the graft, and infection.[21,22,23,24,25,26] Of the complications, only graft exposure was moderately associated with bone graft failure.[27]

The factors that can increase the risk of a bone graft failure are:[28,29]

  • Periodontal disease

  • Smoking

  • Osteoporosis

  • Surgical errors

  • Systemic conditions such as uncontrolled diabetes

  • Immune system deficiencies.

The implants placed in the autologous bone grafts had a higher survival rate when compared to those placed in other graft materials. Alloplastic material had a lower resorption rate when compared to autologous material.[30] The addition of bone substitute to autogenous grafts has been found to accelerate bone formation,[27,28,29,30,31] but interestingly, in this review, majority of studies found a higher rate of graft failure in patients who received composite bone grafts [Tables 1 and 2].

Table 1.

Characteristics of 31 studies included

graphic file with name JIPS-17-219-g003.jpg

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Table 2.

Characteristics of the different bone grafts

graphic file with name JIPS-17-219-g004.jpg

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DISCUSSION

In the review of the past studies, evidence is available about the efficacy of different types of bone grafts. This review tried to systematically evaluate the current evidence and to compare the different grafts in bone enhancement as well as the success of implants placed along with the graft in long-term follow-up. In total, 31 articles could be included, from which the data were obtained. To assess the success of implant placed in different bone grafts, all the 31 articles were reviewed for the following characteristics: design of the study, number of patients per study, graft type, surgical procedure and donor site, number of dental implants, timing of implants, follow-up time, implant survival, and implant success rate.

Block graft

Out of 31 included articles, 14 studies were using block graft.[32,33,34,35,36,37,38,39,40,41,42,43,44,45] Of which, 11 studies were case reports while three were prospective. A total of 86 patients with reduced alveolar ridges were treated with block grafts. In total, 223 dental implants were placed after 3–6 months of grafting. The follow-up ranged from 1 to 5 years. The survival rates for the dental implants in grafted bone ranged from 97.3% to 100% and the mean was 98.5%.

Particulate graft

Out of 31 articles included, three studies were using particulate graft.[46,47,48] Of these, all three were case reports. A total of three patients with reduced alveolar ridges were treated with particulate graft. In total, nine dental implants were placed after 4 months of healing. The follow-up ranged from 1 to 3 years and the mean was 1.7 years.

Blood derivatives

Out of 31 articles included, three studies have used blood derivatives as grafting material.[49,50,51] A total of 15 dental implants were placed for 3 patients, of which 6 implants were placed immediately along with the graft material and 9 dental implants were placed after 2–3 months of healing. After the start of loading, the follow-up ranged from 1 to 4 years. Survival rate for the dental implants was 94.7%. The implant success rate was 93.2%.

Composite bone graft

Out of 31 articles included, seven studies have used composite bone as grafting material.[52,53,54,55] Three studies were case report while four were case series. A total of five patients were treated with three different donor materials and 21 dental implants were placed after 4–12 months of graft healing. After the start of loading, the follow-up ranged from 1.0 to 5 years. The survival rate for the dental implants in grafts was 99.3%. The implant success rate was 90.7%.

Xenograft

Out of 31 articles included, only one study used xenograft as grafting material.[30] One patient with reduced alveolar ridge was treated with bovine bone, mixed with fibrin adhesive. In total, three dental implants were placed after 6–12 months after healing of the graft material. After the start of loading, the follow-up ranged from 1 to 3 years. The survival rate for the dental implants was 85.4%. The implant success rate was 73.2%.

RESULTS

The results of the study are depicted in Chart 1.

Chart 1.

Chart 1

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Success and survival rate of implants placed in various graft materials.

The mean value of the survival and success rate of the implants on various types of grafts is charted on a graph. The blue bar signifies the survival rate and yellow bar signifies the success rate.

From the chart, we can observe that:

  • Block grafts have 98.9% survival rate and 99.05% success rate

  • Particulate grafts have 100% survival rate and 66.6% success rate

  • Blood derivatives have 97.8% survival rate and 96.6% success rate

  • Composite bone grafts have 99.6% survival rate and 66.06% success rate

  • Allografts have 90.9% survival rate and 82.8% success rate.

CONCLUSION

Based on the available data in the existing studies with a follow-up period of at least 3–5 years, it can be summarized that the autologous bone grafts can be preferred over allografts and xenografts for grafting implant sites since they are stable for at least 3–5 years.

Among the various autologous grafts reviewed, block grafts and blood derivatives had a higher percentage of success rate. Hence, by following proper diagnostic and clinic protocol for implant placement, block grafts and blood derivatives can be used for better clinical outcome and success of the implant over a long period of time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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