IMPLANT DENTISTRY / VOLUME 21, NUMBER 3 2012 175

Horizontal and Vertical Ridge

Augmentation in Localized Alveolar
Deficient Sites: A Retrospective
Case Series
Susanna Annibali, MD, DDS,* Isabella Bignozzi, DDS, PhD,† Gilberto Sammartino, MD, DDS,‡
Gerardo La Monaca, DDS, PhD,§ and Maria Paola Cristalli, DDS, PhDk

he rehabilitation of partial and Purpose: This study reviews the 4.48%, and 90.42% 6 11.93% for

T total edentulism using dental

implants is a modality of treat-
ment that has predictable long-term
clinical outcomes of ridge augmen-
tations performed via horizontal- or
vertical-guided bone regeneration
h-GBR, edentulous ridge expansion,
and v-GBR, respectively; a limited
amount of marginal bone level was
clinical outcomes.1–4 Nevertheless, (h-GBR, v-GBR) or edentulous ridge reported for all three groups, while
a poor bone volume following clinical
expansion. a large amount of horizontal bone
situations such as long-time edentu-
lism, dental trauma, periodontal break- Materials and Methods: The resorption was detected.
down, and untreated chronic infections degree of defect correction, the mar- Conclusions: All surgical tech-
can prevent appropriate implant place- ginal bone level, and the horizontal niques considered in this study are
ment in a prosthetically guided posi- stability of the augmented bone predictable procedures, and the pro-
tion. Several techniques have been (five patients) were examined with posed survey template measurement
proposed to recreate adequate bone a new proposed rigid resin survey system showed to be a reliable
volume and morphology at alveolar template. method of evaluating horizontal bone
edentulous deficient ridges. Results: Thirty ridge defects stability of the augmented ridges.
It has been demonstrated that onlay ranging from 1 to 8 mm were (Implant Dent 2012;21:175–185)
bone graft harvesting from intraoral or corrected, and 56 implants were Key Words: dental implants, ridge
extraoral sites is a predictable proce- positioned. The percentages of augmentation, guided bone regen-
dure,5–8 although few data are available
alveolar defect correction were eration, ridge expansion, split crest,
regarding the long-term dimensional
stability of grafted bone.9 Furthermore, 91.85% 6 22.30%, 97.13% 6 bone stability
this technique is associated with

significant morbidity and requires a sec- intermaxillary relationships14 or for

*Associate Professor of Oral Surgery, Department of Oral and ond surgical site. the reconstruction of maxillary and
Maxillofacial Sciences, “Sapienza” University of Rome, Rome, Italy.
†Lecturer, Department of Oral and Maxillofacial Sciences, Distraction osteogenesis allows for mandibular wide defects after onco-
“Sapienza” University of Rome, Rome, Italy.
‡Associate Professor of Oral Surgery, Department of Oral and
Maxillofacial Sciences, University of Naples Federico II, Naples, Italy.
a natural formation of bone and soft logic surgery.15 These techniques have
§Lecturer, Department of Oral and Maxillofacial Sciences, “Sapienza” tissues between the basal and the dis- extremely limited clinical applications,
University of Rome, Rome, Italy.
kAssistant Professor of Oral Surgery, Department of Oral and tracted segments with restricted morbid- are highly sensitive to the skill of the
Maxillofacial Sciences, “Sapienza” University of Rome, Rome, Italy.
ity and operating time.10 Nevertheless, operator, require general anesthesia,
Reprint requests and correspondence to: Susanna a poor control of the trajectory of dis- and imply a relevant postoperative
Annibali MD, DDS, Department of Oral and
Maxillofacial Sciences, “Sapienza” University of Rome, traction in the planes of space11,12 as well morbidity.16,17
6, Caserta St., 00161 Rome, Italy, Phone: +39 06 as considerable long-term bone resorp- Guided bone regeneration (GBR) is
49976651, Fax: +39 06 44230811, E-mail: susanna.
annibali@uniroma1.it tion have been reported.13 a well-documented surgical procedure
The Le Fort I osteotomy with that was designed to provide atrophic
ISSN 1056-6163/12/02103-175
Implant Dentistry interpositional or revascularized bone alveolar ridge augmentation and correct
Volume 21  Number 3
Copyright © 2012 by Lippincott Williams & Wilkins grafts is recommended in the presence development of deficient implant
DOI: 10.1097/ID.0b013e31824ee3e9 of severe atrophy and unfavorable sites.18–20 The rationale underlying the
176 HORIZONTAL AND VERTICAL RIDGE AUGMENTATION  ANNIBALI ET AL

Edentulous ridge expansion (ERE)

aims to correct horizontal ridge defi-
ciencies using a high-precision sagittal
osteotomy and a controlled greenstick
fracture that moves the buccal bone
plate laterally. The result is the creation
of a wider bony bed for simultaneous
ideal implant placement,26–29 increas-
ing the amount of well-keratinized
Fig. 1. Cortical bone drilled to expose marrow spaces: (A) vertical defect, (B) horizontal defect.
gingiva and restoring both the muco-
gingival line and the fornix depth at
the expanded site.30 Ridge expansion
is a suitable technique for correcting
areas of great bone deficiency with lim-
ited morbidity.26–29
Nevertheless, most studies that
have focused on implants placed in
regenerated bone have only considered
the implant survival rate and, if avail-
able, the clinical success rate, with no
evaluations of the amount of augmented
bone and its stability.9 Augmented bone
Fig. 2. Bone particles positioned to cover the exposed implant surfaces: (A) vertical defect, stability has been evaluated in only a few
(B) horizontal defect. studies by the vertical measurement of
marginal bone level (MBL) using peri-
apical radiographs. Measurements of
regenerated ridge stability are difficult
to obtain unless reentry surgery28,31 or
follow-up CT scans are made, proce-
dures that are both associated with great
biologic and economic impact for
patients.
This study assessed retrospectively
the clinical results of GBR and ERE
Fig. 3. Expanded polytetrafluoroethylene (e-PTFE) titanium-reinforced membrane secured to
techniques considering the following
the bone surface with titanium fixation screws: (A) vertical defect (Gore-Tex membrane), (B) parameters for each procedure: success
horizontal defect (Citoplast membrane). rate of the augmentation technique,
survival and success rates of the
implants, and stability of the augmented
bone.

MATERIALS AND METHODS

Patient Selection
All patients who were consecu-
tively treated with bone augmentation
procedures according to GBR or ERE
surgical protocols between May 2006
and January 2009 at the Oral Surgery
Operative Unit of Sapienza–University
Fig. 4. Surgical reentry: the implants completely surrounded by new-formed bone: (A) of Rome meeting the following inclu-
regenerated bone in the vertical defect site, (B) regenerated bone in the horizontal defect site.
sion criteria were selected:
 Patient treated with horizontal
GBR (h-GBR), ERE, or vertical
GBR protocol lies in the prevention of evidence for the effectiveness and pre- GBR (v-GBR) for localized
undesirable, nonosteogenic cells from dictability of GBR in promoting vertical edentulous ridge bone defects.
growing into the bony defect by provid- and lateral bone augmentation of ridge  Availability of complete clini-
ing a mechanical barrier. There is strong deficiencies.21–25 cal records, including clinical

Fig. 5. Buccal bone displaced facially.
Fig. 6. Implant placement in a prosthetically guided position.
Fig. 7. Survey template evaluation of the long-term horizontal bone stability.
photographs, diagnostic casts,
wax-up, radiographic/surgical
templates, panoramic radio-
graphs and (CT) DentaScan, as
needed, and periapical radio-
graphs and clinical parameters
taken at each follow-up recall.
Exclusion criteria to treatment at
the time of recruitment were impaired
systemic conditions, smoking habit of
more than 10 cigarettes per day,32 full
IMPLANT DENTISTRY / VOLUME 21, NUMBER 3 2012
mouth plaque score, and full mouth
bleeding score of .25%.
All subjects provided written in-
formed consent to undergo the augmen-
tation surgical procedure and, if possible,
simultaneous implant insertion.
Clinical Procedures
For all patients, the prosthetically
ideal positions of the fixtures was
identified by means of a radiographic
177
surgical template, according to a pre-
viously described procedure.33
Surgical technique selection was
made in accordance with the therapeu-
tically oriented defect classification pre-
sented by Tinti and Parma-Benfenati.34
During GBR technique,21 the bony
defects around implants were evaluated
clinically by using a 15-mm periodontal
probe (XP23/UNC15, Hu-Friedy, Chi-
cago, IL) for vertical defects and two
perpendicularly crossed periodontal
probes for horizontal defects. Cortical
bone was drilled with a 0.5- to 0.8-
mm round surgical bur to expose the
marrow spaces and to increase bleeding
(Fig. 1, A and B).
Either titanium-reinforced ex-
panded polytetrafluoroethylene (Gore-
Tex TR6Y or TR9W, W.L. Gore,
Flagstaff, AZ; Citoplast Ti25OXL,
Osteogenics Biomedical, Inc. Lubbock,
TX) or resorbable membranes (Bio-
Gide, Geistlich Pharmaceutical,
Wolhusen, Switzerland) were used
depending on the defect morphology.
The exposed implant threads were
covered with autogenous bone chips
which had been harvested using
a grafter (Safescraper TWIST, Meta,
C.G.M. S.p.a., Reggio Emilia, Italy)
peripherally within the same surgical
site. The autograft was enhanced with
a second layer of demineralized freeze-
dried bone allograft (DFDBA; Tutogen
Medical, Neunkirchen am. Brand, Ger-
many) or Bio-Oss (Geistlich Pharmaceu-
tical) to achieve the desired amount and
shape of bone graft and to overcontour
the desired final anatomy18,35 (Fig. 2, A
and B). The membrane was secured to
the bone surface with titanium fixation
screws (Fig. 3, A and B). A tension-free
primary closure was achieved and sta-
bilized with a double suture line (W.L.
Gore). A checkup radiograph was then
taken (T0).
Reentry surgery was performed after
6 to 9 months of submerged membrane
healing (Fig. 4, A and B). A clinical eval-
uation of ridge size was performed, in the
same manner as in the first-stage surgery,
to recalculate the bone dimension.
At provisional restoration screwing
(T1), a checkup periapical radiograph
was taken using the long-cone parallel
technique. After 3 months, a cement-
fused porcelain-to-metal final restoration
178 HORIZONTAL AND VERTICAL RIDGE AUGMENTATION  ANNIBALI ET AL

Table 1. Characteristics of Patients and Clinical Results in Group A (Horizontal-GBR)

Patient Augmentation Implant Implant Manufacturer, h-Defect Bone Gain

No. Site Site Type, and Dimension Regeneration Materials (mm) (mm)
1A 1A-1 1.3 S & M, Pilot, 3.8 3 13 AP + Bio-Oss + Gore-Tex NRM 1.5 1
2A 2A-4 4.6 S & M, Pilot, 6.7 3 10.5 AP + Bio-Oss + Gore-Tex NRM 2 2
3A 3A-4 4.5 TBR, 4 3 13 AP + Bio-Gide Res M 2 2
4.6 5 3 10 2 2
4.7 5 3 10 2 2
4A§ 4A-1 1.4k Nobel Speedy, 4310 AP + DFDBA + Gore-Tex NRM¶ 8 8
1.6k 538 8.5 8
4A-2 2.4k Nobel Speedy, 4310 AP + DFDBA + Gore-Tex NRM 8 8
2.6k 538 8.5 8
5A 5A-4 4.1 Nobel Straight, 3.5 3 13 AP + Bio-Oss + Bio-Gide ResM 1 1
6A 6A-3 3.1 Nobel Straight, 3.5 3 13 AP + Gore-Tex NRM 1 1
7A 7A-2 2.5 S & M, Pilot, 3.8 3 13 AP + Bio-Oss + Gore-Tex NRM 4 4
2.7 6.7 3 13 8 7
8A 8A-3/4 3.1 S & M, Pilot, 3.4 3 13 AP + Bio-Oss + Gore-Tex NRM 2 2
4.1 3.4 3 13 2 2
9A# 9A-1 1.4 S & M, Pilot, 3.8 3 13 AP + Bio-Oss + DFDBA + Gore-Tex NRM 3 3
1.6 5.7 3 13 3 3
1.7 5.7 3 13 3.5 3
9A-2 2.4k S & M, Pilot, 3.8 3 13 AP + Bio-Oss + DFDBA + Gore-Tex NRM** 3 3
2.6k 5.7 3 13 3 3
2.7k 5.7 3 13 4 3
Total 11
Mean 6 SD 3.80 6 2.64 3.61 6 2.51
Range 1–8.5 1–8
* Provisional crown delivery.
† Final crown delivery.
‡ Last available follow-up.
§ Patient 4A corresponds to patient 2C in Table 3.
k Implants placed via a staged approach.
¶ Membrane exposure 1 month after surgery.
# Patient 9A corresponds to patient 5C in Table 3.
** Membrane exposure 2 months after surgery.
AP indicates autogenous particulate; DFDBA, demineralized freeze-dried bone allograft; Res M, resorbable membrane; NRM, nonresorbable membrane; S & M, Sweden & Martina; h-defect, horizontal
defect; MBL, marginal bone level; M, mesial; D, distal; BBR, buccal bone resorption; NR, not recorded.

was delivered and a standardized periap-
ical radiograph, using a Rinn film holder
(Dentsply Rinn, Elgen, IL) customized
by polymerizing polyvinylsiloxane onto
the occlusal surfaces of the final restora-
tion, was taken (T2).
During ERE technique,26 the buc-
cal bone was displaced facially includ-
ing at least 3 mm of cortical bone and
1.5 mm of spongy bone (Fig. 5), while
a cortical bone plate at least 1-mm thick
was left intact at the oral side. The top of
the ridge was measured before and after
expansion to quantify the reached bone
gain with a 15-mm periodontal probe.
The implants were placed according to
the prosthetic need (Fig. 6). In case of
crestal lack of soft tissues, a lyophilized
equine collagen coat (Gingistat, Gaba
Vebas, San Giuliano Milanese, Italy)
was laid to support secondary intention
healing. Interrupted 4-0 and 5-0 Gore-
Tex sutures were placed to fit the flaps
around healing abutment. A checkup
radiograph was taken (T0).
A further checkup periapical radio-
graph was taken using the long-cone
parallel technique at provisional resto-
ration screwing (T1). After 3 months,
a cement-fused porcelain-to-metal final
restoration was delivered and a stan-
dardized periapical radiograph was
taken at this stage (T2).
All patients were included in a
quarterly professional oral hygiene
recall plan.
Clinical and Radiographic Follow-Up
The degree of defect correction
(expressed as a percentage) was eval-
uated at reentry surgery for GBR and
after ridge expansion and implant
placement for ERE, using a 15-mm
periodontal probe. A complete defect
fill (DF) was defined as full coverage
of the implant surface until the top of
the shoulder with a bone width of
at least 1 mm all around the implants36
placed according to the restorative
plan.
Implant success was evaluated
according to Albrektsson et al37 criteria,
updated and integrated by Misch et al.38
The long-term vertical dimensional sta-
bility of the augmented bone was eval-
uated using radiographic examinations.
The radiographs made at provi-
sional restoration delivery (T1 ¼ pre-
loading MBL), at final restoration
delivery (T2), and at the last available
radiographic follow-up (T3) were ana-
lyzed to evaluate the MBL around
implants. Radiographs were digitalized
by taking a photograph (Fine Pix S
5500, Fuji Photo Film, Tokyo, Japan)
of the film superimposed on a millimeter
grid from a standard position and at
magnification of 1:1. The distance from
the reference point, established at the
outer edge of the implant shoulder, to
the most coronal bone to implant con-
tact on the mesial and distal aspects of
each implant was assessed using Image
Analysis Software (Graphisoft Archi-
CAD 11).
 IMPLANT DENTISTRY / VOLUME 21, NUMBER 3 2012 179

Table 1. (Continued)
Mean BBR Mean BBR
on Site Basis on Site Basis
T1* MBL (mm) T2† MBL (mm) T3‡ MBL (mm)
at 6 Months at 12 Months
M D M D M D T3 (Month) (mm) (mm)
1.2 1.5 1.7 1.9 1.9 2.8 22 NR NR
2.9 3 3.8 3.2 4 3.2 25 NR NR
3.1 2.8 3.3 3 3.9 3 38 NR NR
2.5 2.5 2.7 2.6 2.7 2.9
2.5 1.9 2.5 2.1 2.5 2.4
2 2 2.4 2.6 3.5 3.2 13 NR NR
2.9 2.2 3.5 2.3 3.7 2.6
2.6 2.3 2.6 2.4 2.6 2.6 13 NR NR
1.9 1.8 2.3 2.3 2.4 2.4
2.3 2.5 2.3 2.7 2.2 2.6 12 0 0.23
1.8 2 2 2 3.5 2.9 32 NR NR
1.7 1.5 1.7 1.6 1.7 2.2 25 NR NR
2.6 2.5 2.8 2.9 3.1 2.9
3.1 3.4 3.9 4.2 4.7 5 27 NR NR
4 3.9 4.6 4.1 5 4.4
2.3 2.8 2.6 3.1 2.6 3.1 12 1.7 1.96
2 1.5 2 1.6 2 1.6 3.03 3.46
1.9 1.8 1.9 2 1.9 2 0.6 1.66
1.5 1.9 1.8 2.2 1.8 2.2 12 1.36 1.9
2.1 2.5 2.2 2.7 2.2 2.7 1.33 2.26
2.1 2.9 2.1 3.5 2.1 3.5 1.23 3.23

2.28 6 0.7 2.34 6 0.63 2.60 6 0.79 2.61 6 0.71 2.67 6 1.10 2.86 6 0.75 20.61 6 9.82 1.32 6 0.94 2.10 6 1.07
1.2–4 1.5–3.9 1.7–4.6 1.6–4.2 1.7–5 1.6–4.4 12–38 0–3.03 0.23–3.46

A pilot feasibility study for survey-
ing long-term horizontal stability of the
augmented ridge was carried out on five
of the patients who received their final
restoration at the starting point of the
current study (patients 5A, 9A, 2B, 3C,
and 5C), using a rigid resin customized
template and an endodontic instrument.
The survey template was manufactured
on the basis of the final restoration and
provided with several holes at points
chosen for dimensional evaluation.
After application of topical anesthetic
(EMLA cream; AstraZeneca Spa,
Basiglio, Milan, Italy), the endodontic
instrument (40 K-file, Dentsply
Maillefer, Ballaigues, Switzerland)
was thrust through the template holes
into the mucosa, perpendicular to bone
plate, so that it came into contact with it
(Fig. 7). The part of the K-file that
entered the template hole was measured
at final crown delivery (T2), at 6-month
follow-up (T2a), and at final follow-up
(T3) using a CCD laser micrometer
(Keyence, Osaka, Japan) to evaluate
horizontal bone remodeling of the
regenerated bone. All measurements
were collected on the same clinical ses-
sion independently by two trained
examiners who were different from
the surgeons and who were blinded to
the treatment allocation of the subjects
(ie, h-GBR, ERE, or v-GBR).
Statistical Analysis
The variables of interest were the
success of augmentation procedures,
with the complication rate being used
as a statistical unit of analysis of the
augmentation procedure in itself, and
the percentage of defect correction,
with survival and success rates of
implants and marginal stability over
time of the augmented bone with the
single implant as references. In partic-
ular, the percentage of clinically evalu-
ated DF at each implant site was plotted
on a box plot, and mean and SD values
were calculated for groups A (h-GBR),
B (ERE), and C (v-GBR). One-way
analysis of variance (ANOVA) (P ,
0.01) was used to identify significant
differences among the three treatment
groups for the variable DF.
Changes in the radiographic verti-
cal MBL over the time interval T2 (final
crown delivery) to T3 (last available ra-
diographic follow-up after final crown
delivery; T2–T3) were obtained as dif-
ferences of paired mesial (M) and distal
(D) values for each implant between the
two follow-up time points. These val-
ues are presented as mean 6 SD values.
One-way ANOVA (P , 0.01) was used
to identify significant differences
among groups A, B, and C for this vari-
able. When statistical significance was
identified among serial means by
ANOVA, Bonferroni post hoc testing
(P , 0.05) was carried out to determine
which of the paired means showed a sta-
tistically significant difference.
Finally, to test the reproducibility
of the method used to assess horizontal
180 HORIZONTAL AND VERTICAL RIDGE AUGMENTATION  ANNIBALI ET AL

Table 2. Characteristics of Patients and Clinical Results in Group B (Edentulous Ridge Expansion)

Augmentation Implant Manufacturer,

Patient No. Site Implant Site Type, and Dimension h-Defect (mm) Bone Gain (mm)
1B 1B-4 4.6 S & M, Pilot, 5.7 3 10.5 5 5
4.7 5.7 3 10.5 5 5
2B 2B-4 4.6 Nobel Speedy, 6310 5 5
4.7 6 3 10 5.5 5
3B 3B-4 4.6 S & M, Pilot, 3.8 3 13 4.5 3.8
4B 4B-1 1.5 S & M, Pilot, 4.7 3 10.5 5 4.7
1.7 6.7 3 10.5 7 6.7
4B-2 2.5 S & M, Pilot, 4.7 3 10.5 5 4.7
2.7 6.7 3 10.5 7 6.7
4B-3 3.5 S & M, Pilot, 4.7 3 10.5 3 3
3.7 5.7 3 10.5 3 3
4B-4 4.5 S & M, Pilot, 4.7 3 10.5 2 2
4.7 5.7 3 10.5 3 3
5B 5B-1 1.5 S & M, Pilot, 5.7 3 10.5 5.5 5
5B-2 2.5 S & M, Pilot, 5.7 3 10.5 5.5 5.5
5B-3 3.4 S & M, Pilot, 3.8 3 13 4 4
3.5 3.8 3 10.5 5 5
5B-4 4.4 S & M, Pilot, 3.8 3 13 4 4
4.5 5.7 3 10.5 4 4
Total 11
Mean 6 SD 4.63 6 1.30 4.45 61.19
Range 2–7 2–6.7
S & M indicates Sweden & Martina; h-defect, horizontal defect; MBL, marginal bone level; M, mesial; D, distal; h-RR, horizontal ridge resorption; NR, not recorded.

Table 3. Characteristics of Patients and Clinical Results in Group C (Vertical GBR)

Augmentation Implant Implant Manufacturer, v-Defect Bone Gain

Patient No. Site Site Type, and Dimension Regeneration Materials (mm) (mm)
1C 1C-3 3.6 S & M, Pilot 5.7 3 10.5 AP + Bio-Oss + Gore-Tex NRM 4 3
3.7 5.7 3 10.5 5 5
2C* 2C-3 3.6 Nobel Straight, 5 3 10 AP + DFDBA + Gore-Tex NRM 4.5 4
3.7 5 3 10 5 5
2C-4 4.6 Nobel Straight, 5310 AP + DFDBA + Gore-Tex NRM 3.5 3
4.7 5 3 10 3 3
3C 3C-3 3.5 S & M, Pilot, 3.8 3 10.5 AP + Bio-Oss + Gore-Tex NRM 6 6
3.7 5.7 3 10.5 6.5 5
4C 4C-3 3.6 S & M, Pilot, 3.8 3 10.5 AP + Bio-Oss + Gore-Tex NRM 3 3
3.7 4.7 3 13 2 1.5
4C-4 4.5 S & M, Pilot 3.8 3 10.5 AP + Bio-Oss + Gore-Tex NRM 5.5 4
4.6 3.8 3 13 5.5 4
5C† 5C-3 3.5 S & M, Pilot, 3.8 3 13 AP + DFDBA + Gore-Tex NRM 4 4
3.7 5.7 3 10.5 4 4
5C-4 4.5 S & M, Pilot, 3.8 3 10.5 AP + DFDBA + Gore-Tex NRM 4 4
4.7 5.7 3 8.5 3 3
Total 8
Mean 6 SD 4.28 6 1.23 3.84 6 1.09
Range 2–6.5 1.5–6
* Patient 2C corresponds to patient 4A in Table 1.
† Patient 5C corresponds to patient 9A in Table 1.
AP indicates autogenous particulate; DFDBA, demineralized freeze-dried bone allograft; NRM, nonresorbable membrane; S & M, Sweden & Martina; v-defect, vertical defect; MBL, marginal bone level; M,
mesial; D, distal; h-RR, horizontal ridge resorption; NR, not recorded.
 IMPLANT DENTISTRY / VOLUME 21, NUMBER 3 2012 181

Table 2. (Continued)
Mean h-RR Mean h-RR
on Site on Site
T1 MBL (mm) T2MBL (mm) T3MBL (mm)
Basis at 6 Basis at 12
M D M D M D T3 (Month) Months (mm) Months (mm)
1.9 2.8 2.8 3.2 4.3 3.7 6 NR NR
1.7 2 2.4 2.3 3.0 3.5
2.4 2.5 2.5 2.8 3.6 2.9 6 0.43 0.48
1.9 1.6 1.9 1.6 2 1.7 0.2 0.22
2 2 2.2 2 3.1 3.2 12 NR NR
1.9 1.6 2.3 2.3 3.1 2.7 14 NR NR
3 2.9 3.2 3.4 3.7 3.8
3.2 3.3 3.8 3.5 3.8 3.5 14 NR NR
3.9 4.8 4.3 4.9 4.8 4.9
1.8 1.8 2.4 2.3 2.4 2.3 14 NR NR
1.8 1 2 1 2 1
1.9 1.9 2.4 2.2 2.4 2.8 14 NR NR
1.5 1.7 1.5 1.7 1.9 1.7
3.2 2.3 3.4 2.6 3.7 3.3 14 NR NR
2.1 2.3 2.5 2.5 2.9 3.3 14 NR NR
1.6 2.2 2 2.7 2.9 2.7 14 NR NR
2.8 2.3 3 2.7 3.4 2.7
2.3 2.9 2.6 3.1 3.6 3.3 14 NR NR
3.8 3 4.1 3.2 4.1 3.5

2.35 6 0.74 2.36 6 0.82 2.70 6 0.76 2.63 6 0.84 3.19 6 0.81 2.97 6 0.88 12.21 6 3.32 0.31 6 0.16 0.35 60.18
1.5–3.9 1–4.8 1.5–4.1 1–4.9 1.9–4.8 1–4.9 6–14 0.2–0.43 0.22–0.48

Table 3. (Continued)
Mean h-RR Mean h-RR
on Site on Site
T1 MBL (mm) T2 MBL (mm) T3 MBL (mm)
Basis at 6 Basis at 12
M D M D M D T3 (Month) Month (mm) Month (mm)
2.5 1.5 2.6 1.8 3.1 2 14 NR NR
1.2 1.2 1.4 1.2 1.4 1.5
2.5 2.9 2.7 3.5 2.7 3.5 13 NR NR
1.5 1.3 1.7 1.6 2.4 2.1
2.6 2.9 2.8 3.2 3.7 3.4 13 NR NR
2.8 1.4 2.8 1.6 2.8 1.8
1.9 1.9 2.5 2.2 2.7 3.1 12 0.13 0.5
3.2 2.2 3.6 2.2 5.4 4.9 0.8 3.32
2.3 1.8 2.9 2.6 3 2.7 12 NR NR
1.8 2.9 1.8 2.9 2.8 3.1
1.8 1.8 1.8 1.8 5.8 5.8 12 NR NR
1.6 1.2 1.7 1.2 5.7 5.2
1.2 1.9 1.7 2.8 1.7 2.8 12 0.5 1.83
2.2 1.6 2.4 1.8 2.4 1.8 0.83 3.23
2.3 2.9 2.9 3.3 3.1 3.3 12 0.7 2.36
2.5 2.5 3 3.1 3.4 3.1 0.73 2.73

2.11 6 0.57 1.99 6 0.64 2.39 6 0.62 2.30 6 0.76 3.25 6 1.30 3.13 6 1.25 12.5 6 0.73 0.61 6 0.26 2.32
1.2–3.2 1.2–2.9 1.4–3.6 1.2–3.5 1.4–5.8 1.5–5.8 12–14 0.13–0.83 0.5–3.32
182 HORIZONTAL AND VERTICAL RIDGE AUGMENTATION
bone remodeling of the augmented
ridge using the survey template, the
consistency between the two examiner
evaluations was calculated as the per-
centage of values that were identical or
affected by a negligible difference (de-
fined as ,0.1 mm). Pearson correlation
analysis was used to determine the
interobserver agreement.
RESULTS
Seventeen patients treated between
May 2006 and January 2009 with
h-GBR (group A), ERE (group B),
and v-GBR (group C) fulfilled the study
inclusion criteria: 30 ridge defects rang-
ing 1 to 8 mm (4.22 6 1.90 mm) were
corrected and 56 implants were posi-
tioned in the augmented bone. Of the
22 horizontal defects, 11 were treated
with h-GBR (group A) and 11 were
treated with ERE (group B: 5 in the
maxilla and 6 in the mandible); all ver-
tical deficiencies (n ¼ 8) were in the
mandible and were treated with
v-GBR (group C).
The alveolar ridge defect was
3.80 6 2.64 mm (range, 1–8 mm) in
group A, 4.63 6 1.30 mm (range, 2–7
mm) in group B, and 4.28 6 1.23
(range, 2–6.5 mm) in group C.
Twenty-one implants (13 in the maxilla
and 8 in the mandible) were placed in
bone augmented with h-GBR, 19
implants (7 in the maxilla and 12 in
the mandible) were placed in the ridge
split with ERE, and 16 implants in man-
dibles augmented with v-GBR.
Surgeons were able to place one to
three implants with a simultaneous
approach (ie, at the same time as bone
regeneration), according to the original
treatment plan, in all augmentation sites
except three (patient 4A, augmentation
sites 4A-1 and 4A-2, implants 4A-14,
4A-16, 4A-24, and 4A-26; patient 9A,
augmentation site 9A-2, implants 9A-
24, 9A-26, and 9A-27). In these three
exceptions, the severity of the defects
and the lack of primary stability neces-
sitated both h-GBR and a sinus lift
procedure followed by delayed implant
placement.
The subjects’ characteristics and
clinical results are summarized in
Tables 1 (group A), 2 (group B), and 3
(group C). All the augmentation
 ANNIBALI ET AL
procedures were successful,24 and the
bone gain achieved at each implant site
was 3.61 6 2.51 mm (range, 1–8 mm)
with h-GBR, 4.45 6 1.19 mm (range,
2–6.7 mm) with ERE, and 3.84 6 1.09
(range, 1.5–6 mm) with v-GBR. No sta-
tistically significant differences were
identified by ANOVA (P , 0.01) for
this parameter. A complete DF was
obtained in 71.42%, 63.15%, and
56.25% of implant sites for groups A,
B, and C, respectively.
Two h-GBR sites (4A-1 and 9A-2)
met with early membrane exposure
between 1 and 2 months after surgery.
These patients received systemic anti-
biotic therapy (1 g amoxicillin clavula-
nate twice a day for 6 days) and reentry
surgery. The membrane was removed
and after irrigation with sterile saline
and tetracycline solution (Minocin,
Teofarma, Pavia, Italy), the flap was
closed and the graft was allowed to heal
for an additional period ranging from 3
(4A-1) to 8 months (9A-2).
One v-GBR site (1C-3) had late
membrane exposure at 4 months after
the augmentation procedure. The mem-
brane was removed and a covering tissue
that was not completely organized was
found. Nevertheless, because the required
amount of defect filling was achieved,
healing abutment connection was carried
out. In this case, follow-up radiographs
showed stable MBL after loading, despite
the reported complication (Table 3).
Finally, another v-GBR site (4C-4)
developed an abscess without mem-
brane exposure 6 months after surgery.
The same protocol of reentry surgery as
other sites with complications (sys-
temic antibiotic therapy, membrane re-
moval, sterile saline, and tetracycline
irrigation) was applied, and the healing
abutments were screwed to the
implants.
The complication rate for augmen-
tation procedures was 18% in group A
and 25% in group C. No complications
were reported in group B. The follow-
up period after implant final prosthetic
loading was 20.61 6 9.82 months in
group A, 12.21 6 3.32 months in group
B, and 12.5 6 0.73 months in group C.
The overall implant survival rate was
100% in all three groups, while the suc-
cess rate was 100% only for group A. In
group B, the success rate was 94.7%,
due to one implant (1B-46) that
exhibited a critical MBL of 1.5 mm at
6 months of follow-up37,38 (Table 2).
In group C, a success rate of
81.25% was found: the two implants
(4C-45 and 4C-46) present at augmen-
tation site 4C-4 that developed an
abscess 12 months after loading, al-
though still in place, exhibited an MBL
of 1.8 mm (M) and 2.7 mm (D), with an
apparent lack of integration between
the implant and the newly regenerated
bone (Table 3).
Preloading MBLs of 2.28 6
0.7 mm (M) and 2.34 6 0.63 mm (D),
2.35 6 0.74 mm (M) and 2.36 6 0.82
mm (D), and 2.11 6 0.57 mm (M) and
1.99 6 0.64 mm (D) were found for
groups A, B, and C, respectively, at
provisional crown delivery, probably
due in part to incomplete DF and in
part to reestablishment of the biologic
width after healing abutment connec-
tion39,40; this variable did not differ sig-
nificantly among the groups (ANOVA,
P , 0.01).
The change in MBL (M and D)
over the T2–T3 time period (T2–T3
MBL; ie, the marginal bone resorption
after definitive prosthetic loading) was
0.25 6 0.41 mm (M) and 0.24 6 0.32
mm (D) for group A, 0.49 6 0.44 mm
(M) and 0.34 6 0.39 mm (D) for group
B, and 0.86 6 1.32 mm (M) and 0.83 6
1.40 mm (D) for group C. The T2–T3
MBL data differed significantly
(ANOVA, P , 0.01) among the three
groups. Serial means were subjected to
multiple comparisons with Bonferroni
correction (P , 0.05), which revealed
that they only differed significantly
between groups A and C.
The survey template evaluation
revealed a poor predictability affecting
the long-term horizontal bone stability
of the regenerated bone (Tables 1–3)
specially for h-GBR technique. The
interexaminer variability in the evalua-
tion of horizontal bone remodeling
using the survey template appeared
negligible, with 168 (96.55%) reeval-
uated values being identical or differing
by ,0.05 mm and 174 (100%) differing
by #0.1 mm. Pearson correlation
analysis was used to check the inter-
examiner reproducibility, revealing
a covariance of 1.5022 with a correla-
tion index of 0.9998, indicating a good

reliability of the survey template mea-
suring system.
DISCUSSION
The overall implant survival and
success rates in this study were 100%
and 91.98%, respectively, and are con-
sistent with published results of
implants placed in horizontally or ver-
tically augmented ridges by GBR or
ERE techniques, respectively.9,19,20,24
Studies on h-GBR and v-GBR have
found implant survival rates from
96.9% to 100%,41 with rates ranging
from 86.2% to 100% reported for ERE
procedures9,24; both sets of findings are
consistent with those of implants placed
in pristine sites.
Comparison of clinical outcomes
appears to be difficult because of the
high degree of heterogeneity that exists
among the published data regarding
study design, procedures, timing, mate-
rials, evaluated outcomes and chosen
units of statistical analysis, and range of
follow-up periods.24 In many articles,
different surgical techniques or regen-
erative materials were used without
separating the survival rate of implants
on the basis of procedure,22,42 and the
success rate of implants analyzed
according to well-established criteria
is often lacking.
For lateral augmentations, most
studies present a staged approach,31,43,44
while only dehiscences, fenestrations,
or postextraction defects seem to be
treated by simultaneous h-GBR.45,46
In this study, a simultaneous
approach, with implant placement con-
ducted at the regeneration time point,
was used in all the three procedures,
even in the presence of no-space-giving
defects,34 the only exceptions being
cases (augmentation sites 4A-1, 4A-2,
and 9A-2) where h-GBR in combina-
tion with lateral window sinus lift
were performed to correct sites that
exhibited both horizontal and vertical
deficiencies, in the presence of a good
implant–crown ratio but without reli-
ability for adequate primary stability.
The reported complication rates for
GBR (18.2% for h-GBR and 25% for
v-GBR) appear to be acceptable in
comparison with data presented in the
literature, which in fact are highly
dissimilar and disagree among
IMPLANT DENTISTRY / VOLUME 21, NUMBER 3 2012
themselves, ranging from 2.5%47 to
13%31 and up to 64%48 for h-GBR
and from 8%49 to 19%22 and up to
45%23 for v-GBR. The most common
complication that other authors have
encountered with ERE, buccal bone
plate fracture, was not found within
the current retrospective case series.
It is noteworthy that universally
accepted ridge augmentation success
criteria are lacking, and this is an
obstacle for comparing different trials
and surgical techniques. Moreover, in
most studies, there is a lack of data
regarding the initial defect size and
shape, the postoperative degree of
defect reduction, and the stability over
time of the augmented bone.41
The success rate for augmentation
procedures was 100% in this study,
based on the possibility of implant
placement in a ideal position, driven
by the restorative plan, the osseointe-
gration of implants in regenerated
and pristine bone, and the mainte-
nance of function for at least 6 months
after loading.24 Of course, this is
a somewhat permissive criterion that
could also judge as successful a regen-
erative procedure with incomplete DF
or showing a large amount of bone re-
sorption over time. Of course, the de-
gree of DF and the long-term stability
of augmented bone could be important
variables that will reflect the success
of the augmentation procedure and
confirm the importance of correction
even in localized, moderate deficien-
cies to provide long-term implant
success.
In the current study, the initial
mean defect size and the degree of
defect correction did not differ signifi-
cantly among the groups (ANOVA,
P , 0.01), indicating that the three sur-
gical techniques have a comparable
clinical effectiveness.
Moreover, the mean pre- and post-
loading MBL values collected at T1, T2,
and T3 appeared to be in agreement
with previously reported clinical
data.20,22,42,45,50 Marginally statistically
significant differences were noticed
only regarding postloading (T2–T3)
MBL among the three treatment groups
(ANOVA, P , 0.01), in particular be-
tween groups A and C (Bonferroni post
hoc test, P , 0.01).
183
Nevertheless, radiographic evalua-
tion of MBL presents a relevant limita-
tion, being able to monitor only bone-
to-implant contact variations along the
vertical dimension of the mesial and
distal sides of implants and being un-
able to show any dimensional variation
of the buccal bone surface. Chiapasco
et al evaluated the amount of horizontal
bone remodeling that occurred after h-
GBR31 and ERE28 using a surgical cal-
iper during reentry surgery and after
prosthetic loading through the mucosa,
trying to repeat measurements in the
same position using a resin stent. Those
authors reported measurements as abso-
lute width variations of the ridge at dif-
ferent time points, because the caliper
does not permit the distinction between
buccal bone remodeling and lingual or
palatal bone remodeling and introduces
a small but unavoidable methodologi-
cal limitation because measurements
made during surgery were compared
with those made without reopening of
the sites. Conversely, neither open flap
measurements nor CT can be consid-
ered feasible routine methods of moni-
toring bone stability over time because
of their unreasonable economical and
biological costs.
In this study, a pilot feasibility
investigation was conducted to evaluate
an experimental device aimed to mea-
sure horizontal bone remodeling at
augmented sites after definitive pros-
thetic loading. Although these data,
obtained only for five patients, cannot
be considered as significant clinical
findings, a good reproducibility of the
applied measurement system was
reported, indicating the customized sur-
vey template as a reliable method for
evaluating the postloading horizontal
stability of augmented ridges.
CONCLUSIONS
Survival and success rates of
implants placed in bone augmented
using the GBR and ERE techniques
appeared to be similar to those of
implants placed in pristine sites.
Membrane exposure could adversely
affect the degree of defect correction
obtained with GBR, while an excel-
lent degree of defect correction
and lower complication rate were
184 HORIZONTAL AND VERTICAL RIDGE AUGMENTATION
reported for ERE. The tested survey
template, showing good reproduc-
ibility of the measurements, may be
considered a reliable method to eval-
uate long-term horizontal stability of
regenerated bone.
DISCLOSURE
The authors claim to have no finan-
cial interest in any company or any of the
products mentioned in this article.
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