J Oral Maxillofac Surg

68:428-435, 2010

Screw “Tent-Pole” Grafting Technique for

Reconstruction of Large Vertical Alveolar
Ridge Defects Using Human Mineralized
Allograft for Implant Site Preparation
Bach Le, DDS, MD,* Michael D. Rohrer, DDS, MS,† and
Hari S. Prassad, BS, MDT‡

Purpose: The purpose of this study was to evaluate the effectiveness of using titanium screws in
combination with particulate human mineralized allograft, in a “tenting” fashion, to augment large
vertical alveolar ridge defects for implant placement.
Materials and Methods: This prospective case study evaluated augmentation in consecutive patients
with large (⬎7 mm) vertical alveolar ridge defects. Vertical ridge augmentation was performed using
mineralized allograft placed around titanium screws to tent out the soft tissue matrix. The ridges were
clinically evaluated 4 to 5 months after augmentation, and implants were placed at that time. Bone cores
were harvested from all patients for histologic evaluations.
Results: Fifteen patients were treated in this prospective case study, and the mean vertical augmenta-
tion was 9.7 mm. Two patients had wound dehiscence resulting in loss of graft and requiring secondary
grafting before implant placement. Five patients required 2-stage grafting procedures to achieve ideal
ridge height before implant placement. Clinical evaluation of the grafted sites upon re-entry revealed
uniform ridge anatomy. Histomorphometric analysis of 7 specimens revealed a mean bone content of
43%. A total of 32 implants were placed into grafted sites in 15 patients. All implants were integrated and
successfully restored. Mean follow-up was 16.8 months after implant placement.
Conclusions: Tenting of the periosteum and soft tissue matrix with titanium screws maintains space
and minimizes resorption of mineralized particulate allograft. This technique offers predictable func-
tional and esthetic reconstruction of large vertical defects without the use of autogenous bone and is
capable of osseointegration. More studies are needed to evaluate the stability of vertically grafted bone
after long-term loading.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:428-435, 2010

Bone augmentation grafting of large vertical maxillary using dental implants as “tent poles” in combination
and mandibular alveolar ridge defects is difficult. Var- with iliac crest bone grafting in the successful treat-
ious techniques have been described for the recon- ment of 64 severely resorbed mandibles, resulting in a
struction of these large vertical defects before implant mean bone height gain of 10.2 mm. The novel strat-
placement. These techniques have included autog- egy of this surgery was to allow iliac bone grafts to
enous onlay block grafts,1-4 autogenous particulate consolidate and maintain their volume with dental
grafts,5-8 distraction osteogenesis,9 and porous tita- implants that create a tenting effect.
nium mesh tray,10,11 or a combination of these.12-14 Augmentation with titanium mesh can also be suc-
Marx et al15 reported on a novel surgical approach cessful but has a high exposure rate of the mesh and

*Clinical Associate Professor, Department of Oral and Maxillofa- Address correspondence and reprint requests to Dr Le: Oral &
cial Surgery, USC School of Dentistry, Los Angeles, CA. Maxillofacial Surgery, USC School of Dentistry, 925 West 34th
†Director, Hard Tissue Research Laboratory, University of Min- Street, Los Angeles, CA 90089; e-mail: leb97201@yahoo.com
nesota, School of Dentistry, Minneapolis, MN. © 2010 American Association of Oral and Maxillofacial Surgeons
‡Research scientist, Hard Tissue Research Laboratory, University 0278-2391/10/6802-0030$36.00/0
of Minnesota, School of Dentistry, Minneapolis, MN. doi:10.1016/j.joms.2009.04.059
The authors have no financial interests in any of the products
mentioned in this article.

428
LE, ROHRER, AND PRASSAD 429

subsequent partial graft loss. Louis et al10 recently harvest autogenous bone from extraoral or intraoral
reported on 44 patients who had undergone titanium sites. The hypothesis for this case study was whether
mesh reconstruction of the maxilla or mandible using 1.5-mm screws in combination with human mineral-
iliac crest bone graft with a 52.27% exposure rate of ized bone could be used as an osteoconductive scaf-
the titanium mesh. Although these authors reported a fold to restore large vertical defects resulting in suffi-
97% overall graft success rate with this technique, cient bone quantity and quality after 4 to 5 months to
exposure of autogenous grafts to the oral environ- allow for subsequent osseointegration of endosseous
ment inevitably leads to unpredictable loss of graft implants.
volume, and it is unclear how this partial loss affected
the overall treatment plan.10 Distraction osteogenesis
Materials and Methods
can be successful in vertical augmentation, but in our
experience, it often leaves undesirable tissue scarring This prospective case study evaluated augmenta-
and usually requires secondary bone augmentation tion in 15 consecutive patients presenting with large
before implants can be placed. vertical alveolar ridge defect. Inclusion criteria for this
Block and Degen reported on the use of particulate study were partially edentulous patients seeking den-
human mineralized allograft alone to successfully aug- tal implant therapy who required more than 7 mm of
ment partially edentulous segments for implant place- vertical alveolar ridge augmentation before implant
ment through a minimally invasive tunneling tech- placement. Patients selected for this procedure also
nique.16 However, apical migration of graft material must have less than 4 mm of bone width as deter-
from the alveolar crest tends to occur with this mined by preoperative examination and CT imaging
“closed” technique. This is likely due to natural tissue studies. Before augmentation, all grafted sites were
contraction because of the inability to maintain pas- deemed inadequate because of anatomical constraints
sive space. In addition, direct visualization and cor- for placement of an implant of at least 10 mm in
rection of the defect, especially in the esthetic areas, length. Smokers, diabetic patients, and any medically
can be challenging with this tunneling technique. Le compromised patients were excluded from this se-
et al and Le and Burstein described using human ries. After prosthodontic consultation for implant res-
particulate mineralized allograft as a particulate onlay torations, patients were scheduled for bone grafting
graft to correct small volume hard tissue defects and procedures.
in combination with cortical ramus block grafts as a Vertical ridge augmentation was performed using
tenting mechanism in an open approach to treat the human mineralized allograft (Puros; Zimmer Den-
severely resorbed alveolar ridge before implant place- tal, Carlsbad, CA) placed around titanium screws to
ment.17,18 tent out the soft tissue matrix and periosteum. The
A major challenge to reconstructing large vertical ridges were clinically evaluated 4 to 5 months after
bone defects is the contraction of the “soft tissue augmentation. Panorex radiographs and computed
matrix” leading to resorption and migration of the tomography (CT) scans were taken to evaluate all
bone graft. Surgical control of the expanded soft grafted segments. Bone cores were taken using a
tissue volume prevents resorption of graft mate- trephine of all grafted segments at the time of
rial15 by maintaining a space between the perios- implant placement for histologic evaluation. Preop-
teum and bone. erative and postoperative clinical and radiographic
Alveolar ridge augmentation using autogenous comparisons were made at the time of implant
block grafts is a predictable method to augment local- placement. Panorex and periapical radiographs
ized alveolar ridge defects but can be difficult in large were taken after all implants were restored at fol-
3-dimensional defects (Figs 1A-C). Furthermore, these low-up intervals of 6 and 12 months.
large atrophic segments present a more challenging
scenario in reconstruction, as there is a limited supply SURGICAL TECHNIQUE
of intraoral donor bone. Extraoral donor sites are an A preoperative chlorhexidine rinse was given for 2
option but present an obstacle to patient treatment minutes. Surgical treatment was performed under intra-
acceptability because of increased costs and morbid- venous anesthesia, and 2% lidocaine with 1:100,000
ity. epinephrine was given as blocks and infiltrations in the
The purpose of this case study was to evaluate the maxilla and mandible. A crestal incision was made in
effectiveness of using particulate human mineralized all cases with vertical releases. Whenever possible,
allograft, in combination with titanium screws, in a available keratinized tissue was identified and in-
“tenting” fashion to augment large, localized, intraoral, cluded in the incision design. Aggressive tissue re-
vertical alveolar ridge defects for implant placement. leases were performed before screw or graft place-
This concept would make it possible to graft large, ment to ensure tension-free closure. In the anterior
3-dimensional, vertical segments without the need to maxilla, subperiosteal dissection was carried up to the
430 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

FIGURE 1. A-C, Large 3-dimensional defect of the posterior alveolar ridge after traumatic extraction and chronic infection. Note the loss of
bone attachment to the mandibular molar. D, Titanium screws placed show that 5 mm of screw threads are exposed above the ridge defect.
E-G, Clinical situation after 2 grafting procedures with screw tent-pole grafting technique using mineralized allograft. H, Dental implants
placed into grafted bone. Bone core is taken next to implant site for histologic analysis. I, Histologic analysis demonstrates good bone
formation in grafted specimen. J, K, Final restoration at 15-month follow-up shows stable bone under functional load.
Le, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge Defects. J Oral Maxillofac Surg 2010.
LE, ROHRER, AND PRASSAD 431

anterior nasal spine to obtain adequate release for grafted sites (Fig 2E). Passive primary closure over the
passive primary closure. In the posterior mandible, entire graft was obtained with interrupted 4 to 0
this often involved split thickness dissection on the resorbable chromic gut sutures.
labial for supraperiosteal advancement. Postoperatively, the patient prosthesis was adjusted
Titanium screws (1.5 mm, KLS Martin, Jacksonville, to avoid impingement on the grafted site and, when
FL) were placed in the alveolar ridge so that approx- possible, to create positive tissue architecture (Fig
imately 5 to 7 mm of screw threads were exposed 2F). All patients were placed on postoperative antibi-
(Figs 1D, 2C). Particulate mineralized allograft (can- otic treatment consisting of penicillin 500 mg ⫻ 7
cellous particles, 250 to 1,000 ␮m) was mixed with days (for penicillin-allergic patients, clindamycin 300
the patient’s blood and placed to cover the screw mg ⫻ 7 days) and a chlorhexidine mouth rinse for 1
completely (Fig 2D). The defect was overcorrected week. After 4 to 5 months, the grafted sites were
with particulate material in anticipation of future graft uncovered (Figs 1G, 2H) and the screws removed.
resorption. A resorbable membrane (OSSIX PLUS; Pre- and postoperative defects were evaluated at
OraPharma, Warminster, PA) was placed over the both the bony and soft tissue levels. Additional allo-

FIGURE 2. A, B, Large vertical alveolar defect resulting from failed orthodontic extrusion of impacted canine. Note the recession defect on
the distal of the maxillary left central incisor and resulting open bite resulting from lack of alveolar growth. C, Titanium screws are strategically
placed to tent the tissue volume. D, Human mineralized allograft (cancellous particles) placed to cover the screw heads completely. E, A
long-lasting resorbable membrane is placed over the grafted site. F-H, Clinical situation 5 months after graft procedure demonstrates excellent
3-dimensional hard tissue and soft tissue reconstruction of vertical defect, with complete coverage of screw heads with newly formed bone.
I, Final restorations on implants. J, Histomorphometric analysis demonstrates good bone integrity with trabeculae of uniform size and good
connectivity. New bone formation is quite robust surrounding particles of mineralized allograft. The lighter-stained particles are the particles
of mineralized allograft (surrounded by the darker, red staining, newly formed bone).
Le, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge Defects. J Oral Maxillofac Surg 2010.
432 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

graft material was added at the time of implant place- 4 patients with wound complete or partial wound
ment to improve the final bone and soft tissue con- dehiscence. Two of these 4 patients required a sec-
tours as necessary to affect esthetic outcome. No ond graft procedure using the same protocols with
autogenous bone was used in this prospective case screws. In 11 patients, complete coverage of the
study. screw head by bone was noted. All screws were
removed, and ridge width was clinically evaluated to
be larger than 6 mm at all sites of implant placement.
Results
A total of 32 implants were placed into the
Fifteen (2 male/13 female) consecutive patients grafted ridges at locations predetermined by the
with severe localized vertical alveolar ridge defects restoring dentists preoperatively with a surgical
underwent surgery (Table 1). The mean patient age stent. Several different implant systems were used:
was 50.06 years (range 22 to 69 yrs). Six patients had 6 BioHorizons implants (BioHorizons, Inc, Birming-
grafts placed to the mandible and nine patients had ham, AL), 15 Straumann implants (Straumann, Basel,
grafts to augment the partially edentulous maxilla. Of Switzerland), 7 AstraTech implants (AstraTech, Inc,
the 15 patients, 12 patients had 2 or more missing Waltham, MA), and 4 Zimmer implants (Zimmer Den-
teeth with severe vertical defects of the maxillary tal, Carlsbad, CA). Sixteen implants were placed in
alveolar ridge. Teeth adjacent to alveolar defects with the maxilla and 16 were placed in the mandible. A
significant root exposure resulting from loss of bone single-staged protocol was used to place 27 im-
attachment were extracted. Twelve patients under- plants. Only 5 implants required uncovering. All
went extractions of adjacent teeth to allow a more implants were allowed a waiting period of at least 3
favorable bone attachment to which to graft. Ade- months before the restoration phase. After 3 to 4
quate tension-free closure over the graft was achieved months of integration, all implants were noted to
in all patients. be integrated. All implants have been successfully
There were no postoperative wound infections. One restored in the 15 patients with a mean follow-up of
patient had complete dehiscence of the grafted site with 16.8 months (range, 4 to 38 mo) from placement.
graft and screw exposure requiring subsequent graft. Follow-up examinations have indicated stable and
Although there was complete exposure of the graft healthy peri-implant tissue and bone levels.
material, partial graft take was noted upon re-entry Bone cores were harvested from all patients for
after 4 months. Two patients had partial wound de- histologic evaluations. In addition, 7 of the grafted
hiscence and 3 patients had screw head exposure specimens underwent histomorphometric analysis.
only. Wound dehiscence and screw head exposures All cores showed good integrity with a good can-
were treated with conservative care with oral hygiene cellous bone pattern and good connectivity of the
maintenance and oral rinse during the 4-month heal- trabeculae. The new bone formation had sur-
ing period. Partial graft loss was noted on re-entry in rounded the mineralized allograft particles and had

Table 1. CHARACTERISTICS OF STUDY PATIENTS

Patient Average
No. Gender Age (yrs) Implant Site Follow-up

1 F 55 Mand L second molar, first molar, second bicuspid 13 mo

2 F 24 Max R cuspid, lateral incisor 5 mo
3 F 57 Mand L first molar and second bicuspid, L first molar 6 mo
4 F 48 Mand L first molar 12 mo
5 F 45 Max L lateral incisor 36 mo
6 F 57 Max R second molar, first molar, second bicuspid 9 mo
7 F 48 Mand R second bicuspid, first molar 16 mo
8 M 54 Max R lateral incisor, L lateral incisor 6 mo
9 F 63 Max L first bicuspid, first molar 30 mo
10 F 44 Max R cuspid, lateral incisor 11 mo
11 F 66 Mand L second molar, first molar 22 mo
12 F 22 Max L lateral incisor 4 mo
13 F 60 Mand R second bicuspid, first molar, second molar 16 mo
14 F 39 Max R central incisor, L lateral incisor 28 mo
15 M 69 Mand L second molar, first molar, second bicuspid 38 mo
Mean 50.06 16.8 mo
Abbreviations: Mand, mandibular; Max, maxillary, L, left; R, right.
Le, Rohrer, and Prassad. Screw “Tent-Pole” Grafting for Alveolar Ridge Defects. J Oral Maxillofac Surg 2010.
LE, ROHRER, AND PRASSAD 433

formed bridges resulting in a good cancellous bone ized allograft material also appeared to achieve
pattern. High-power images showed excellent inte- quicker incorporation and bridging. Marx reported
gration of new bone formation and particles of that the ideal size for capillary bud penetration is
mineralized allograft (Fig 2J). All grafted sites con- 250 ␮m.21 Large cortical size particles may make
sisted of viable bone. Histomorphometric analysis it more difficult to become incorporated into
of the 7 specimens revealed a mean bone content of the graft and could theoretically act as sequestra,
43%. Of this percent bone, the mean vital bone thereby jeopardizing the integrity of the graft.
content was 81%. In this series of patients, all implants (100%) placed
into vertically augmented sites integrated.
Discussion By appropriately placing titanium screws inter-
posed by particulate graft, it is possible to augment
Severe vertical alveolar ridge defects are usually large vertical ridge defects with no need for autog-
3-dimensional and present a difficult challenge to the enous bone. This technique involves expanding the
implant surgeon. Patients with vertical defects usually soft tissue volume and using screws as “screw tent
have concomitant horizontal defects, and these de- poles” for the surrounding particulate graft. This
fects must be fully reconstructed in all dimensions to helps prevent the soft tissues from contracting
create an esthetic and functional result. Furthermore, around the particulate graft and subsequently dis-
many vertical defects usually have loss of bone attach- placing it or causing physiologic resorption.15 This
ment to the teeth adjacent to the defect. In many soft tissue maintenance concept was confirmed by
instances, it is more beneficial to extract these teeth the clinical observation that the particulate bone
so that a healthy bone attachment level can be at- graft material resorbed no further than the level of
tained to which to graft bone. the screw heads (Figs 1G, 2H). Although longer
Autogenous bone graft has long been considered follow-up is needed to evaluate whether this is a
the gold standard for grafting severe hard tissue
permanent result, our mean follow-up of 16.8
defects. However, reconstruction of large vertical
months (range, 4 to 38 mo) demonstrates that the
defects often requires a significant amount of au-
bone height appears to be stable. Radiographs
togenous bone, including extraoral sources. Louis
taken at follow-up reveal crestal bone stability with-
et al10 reported on the use of titanium mesh for
out any evidence of peri-implant attachment loss or
reconstruction of severely atrophic maxilla or man-
inflammation with implants under functional load.
dible using iliac crest bone graft with a 97% overall
In addition to restoring the hard tissue defect, the
graft success rate, although exposure of the tita-
particulate bone preserves and augments the soft tis-
nium mesh was reported to be high (52%). The
obstacles to using iliac crest bone are obvious. In sue architecture that was lost to years of resorption.
addition to the higher resorption rate of iliac crest This allows an option for implant placement and cre-
grafts, other disadvantages include the high costs of ates a better esthetic result. Soft tissue contour typi-
hospitalization, risk of general anesthesia, and mor- cally follows underlying bony architecture. Any ridge
bidity of the procedure.1,3,8,19 augmentation through bone grafting must provide the
Conversely, the use of mineralized allograft offers foundation to reconstruct the hard tissue defects to
many advantages, including an unlimited amount of affect the soft tissue architecture.
donor bone and reduced anesthesia and operative Postoperative wound infection was not observed in
time.16,20 The procedure can be performed ideally as this patient series. Wound dehiscence occurred in 4
outpatient surgery, thereby decreasing the overall patients, resulting in partial loss of graft material. All 4
costs of the procedure. Le and Burstein reported the patients had large spans consisting of at least 2 or
successful use of mineralized allograft for the recon- more missing teeth. In 1 patient with a large vertical
struction of 10 consecutive patients with severely defect (15 mm) who was missing 2 teeth, an attempt
atrophic maxilla for implant placement.18 Le et al was made to correct this defect in 1 surgical proce-
reported on using mineralized allograft as a partic- dure. In retrospect, this could have resulted in dehis-
ulate onlay graft to augment atrophic alveolar ridge cence. Although a large dehiscence of the wound
for single implant site development.17 occurred with exposure of the screw, membrane, and
The decision to use cancellous bone versus cor- graft material in this patient, complete granulation
tical bone was anecdotal and was based on the occurred over the grafted site after removal of the
authors’ experience of seeing better incorporation exposed screw. Upon re-entry to this site for a second
and bridging of the graft material in previous histo- graft, partial graft take of the exposed site was noted.
logic evaluation and upon clinical re-entry after This suggests the biocompatibility of mineralized al-
grafting extraction socket defects. Based on the first lograft and its user-friendly status in the face of graft
author’s experience, smaller particle size mineral- exposure. Had this graft been autogenous bone, com-
434 SCREW “TENT-POLE” GRAFTING FOR ALVEOLAR RIDGE DEFECTS

plete loss of graft material would be expected with no predictable manner without the use of autologous
possibility of partial graft take. bone. The success reported is likely dependent on the
Four patients had large vertical defects (⬎10 exclusion of smokers, diabetic patients, and medically
mm) with a single missing tooth span and had compromised patients. Further research is needed to
successful correction of defect in a 1-stage grafting determine whether particle size and the use of corti-
protocol. This finding suggests that large single cal versus cancellous allograft can affect the success
missing tooth span may be corrected in a 1-stage and predictability of this procedure. Long-term fol-
surgery protocol. Four patients who developed low-up is also needed to evaluate the stability of the
wound dehiscence all had large span defects. This graft after implant loading. Our preliminary report
finding suggests that large spans (2 or more missing indicates that using this technique allowed the suc-
teeth) have a higher risk of wound dehiscence. cessful reconstruction of large defects in the patients
Correction of these defects in a 2-surgery, smaller selected.
grafting protocol (5 to 6 mm per graft) may reduce
the risk of graft dehiscence.
The overall success of this procedure can be attrib- References
uted to the meticulous reflection of tissue flaps and a 1. Misch CM: Comparison of intraoral donor sites for onlay graft-
tension-free closure. This was achieved by releasing ing prior to implant placement. Int J Oral Maxillofac Implants
the periosteal flaps from the nasal spine in addition to 12:767, 1997
2. Rasmusson L, Meredith N, Kahnberg KE, et al: Effects of barrier
scoring the periosteum in all maxillary cases. The membranes on bone resorption and implant stability in onlay
incorporation of a vertical incision in the flap is also bone grafts. An experimental study. Clin Oral Implants Res
helpful in allowing further advancement of the flap. 10:267, 1999
3. Proussaefs P, Lozada J, Rohrer MD: A clinical and histologic
In the mandible, the release of the mylohyoid muscle evaluation of a block onlay graft in conjunction with autoge-
from its attachment is critical in addition to a split- nous particulate and inorganic bovine mineral (Bio-Oss): A case
thickness flap on the labial to avoid damage to the report. Int J Periodontont Restor Dent 22:567, 2002
4. Keller EE, Tolman DE, Eckert S: Surgical-prosthodontic recon-
mental nerve. The authors have found that this step is struction of advanced maxillary bone compromise with autog-
critical in avoiding wound dehiscence and subse- enous onlay block bone grafts and osseointegrated endosseous
quent graft resorption. implants: A 12 year study of 32 consecutive patients. Int J Oral
Maxillofac Implants 14:197, 1999
In addition to allowing primary tension-free wound 5. Buser D, Dula K, Belser UC, et al: Localized ridge augmentation
closure, scoring of the periosteum promotes angio- using guided bone regeneration. II. Surgical procedure in the
genesis by creating bleeding into the graft.24 Further- mandible. Int J Periodontics Restorative Dent 15:10, 1995
6. Buser D, Dula K, Hirt HP, et al: Lateral ridge augmentation
more, creating adequate space for bone regeneration using autografts and barrier membranes: A clinical study with
by surgically expanding the soft tissue matrix with 40 partially edentulous patients. J Oral Maxillofac Surg 54:420,
tenting screws can help prevent resorption of the 1996
7. Buser D, Dula K, Hess D, et al: Localized ridge augmentation
graft material.24 The authors believe that the use of a with autografts and barrier membranes. Periodontol 2000 19:
resorbable membrane is important to the success of 151, 1999
using particulate allograft. It is unclear whether the 8. Misch CM, Misch CE: The repair of localized severe ridge
defects for implant placement using mandibular bone grafts.
use of a membrane reduces or prevents graft resorp- Implant Dent 4:261, 1995
tion. Based on a systematic review of the literature, 9. Jensen OT, Cockrell R, Kuhike L, et al: Anterior maxillary
further evidence is needed to determine whether alveolar distraction osteogenesis: A prospective 5-year clinical
study. Int J Oral Maxillofac Implants 17:52, 2002
barrier membranes prevent bone resorption in au- 10. Louis PJ, Gutta R, Said-Al-Naief N, et al: Reconstruction of the
tologous onlay bone grafts.22 Controlled clinical maxilla and mandible with particulate bone graft and titanium
trials have shown improved survival of implants mesh for implant placement. J Oral Maxillofac Surg 66:235,
2008
when a membrane was used to cover sinus window 11. Boyne PJ: Maxillofacial surgery, in Habal MB, Reddi AH (eds):
for sinus augmentation through a lateral window Bone Grafts and Bone Graft Substitutes. Philadelphia, PA, W.B.
approach.23,25-27 The increase in implant survival may Saunders, 1992, p 291
12. Thor A: Reconstruction of the anterior maxilla with platelet
be explained by the reported higher percentage of gel, autogenous bone and titanium mesh: A case report. Clin
vital bone that results when a membrane is placed Implant Dent Relat Res 4:150, 2002
over the window. Furthermore, the use of a mem- 13. Simion M, Jovanovic SA, Tinti C, et al: Long-term evaluation of
osseointegrated implants inserted at the same time or after
brane in conjunction with particulate graft is helpful vertical ridge augmentation: A retrospective study on 123 im-
in preventing graft particles from sticking to the soft plants with 1-5 year follow-up. Clin Oral Implants Res 12:35,
tissue flap on re-entry. This is especially true because 2001
14. Fugazzotto PA: Report of 302 consecutive ridge augmentation
there is aggressive undermining of the periosteum procedures: Technical considerations and clinical results. Int
and soft tissue in all grafted sites. J Oral Maxillofac Implants 13:358, 1998
In our patient series, using cancellous mineralize 15. Marx RE, Shellenberger T, Wimsatt J, et al: Severely resorbed
mandible: Predictable reconstruction with soft tissue matrix
allograft with strategically placed titanium screws has expansion (tent pole) grafts. J Oral Maxillofac Surg 60:878,
allowed us to restore large vertical bony defects in a 2002
LE, ROHRER, AND PRASSAD 435

16. Block MS, Degen M: Horizontal ridge augmentation using hu- 23. Wallace SS, Froum SJ: Effect of maxillary sinus augmentation on
man mineralized particulate bone: Preliminary results. J Oral the survival of endosseous dental implants. A systematic re-
Maxillofac Surg 62:67, 2004 view. Ann Periodontol 8:328, 2003
17. Le B, Burstein J, Sedghizadeh PP: Cortical tenting grafting 24. Wang HL, Boyapati L: “PASS” principles for predictable bone
technique in the severely atrophic alveolar ridge for implant regeneration. Implant Dent 15:8, 2006
site preparation. Implant Dent 17:140, 2008 25. Tarnow DP, Wallace SS, Froum SJ, et al: Histologic and clinical
18. Le B, Burstein J: Esthetic grafting for small volume hard and soft comparison of bilateral sinus floor elevations with and without
tissue contour defects for implant site development. Implant barrier membrane placement in 12 patients. Part 3 of an on-
Dent 17:136, 2008 going prospective study. Int J Periodontics Restorative Dent
19. James JD, Geist ET, Gross BD: Adynamic ileus as a complication
20:116, 2000
of iliac bone removal: Report of two cases. J Oral Surg 39:289,
26. Tawil G, Mawla M: Sinus floor elevation using a bovine bone
1981
20. Doblin JM, Salkin LM, Mellado JR, et al: A histologic evaluation mineral (Bio-Oss) with or without the concomitant use of a
of localized ridge augmentation utilizing DFDBA in combina- bilayered collagen barrier (bio-Gide): A clinical report of im-
tion with e-PTFE membranes and stainless steel bone pins in mediate and delayed implant placement. Int J Oral Maxillofac
humans. Int J Periodontics Restorative Dent 16:120, 1996 Implants 16:713, 2001
21. Marx RE: Bone and bone grafting. Oral Maxillofac Surg Clin 27. Froum SJ, Tarnow DP, Wallace SS, et al: Sinus floor elevation
North Am 19:455, 2007 using anorganic bovine bone matrix (OsteoGraf/N) with and
22. Gielkens PF, Bos RR, Raghoebar GM, et al: Is there evidence without autogenous bone: A clinical, histologic, radio-
that barrier membranes prevent bone resorption in autologous graphic, and histomorphometric analysis–Part 2 of an ongo-
bone grafts during the healing period? A systematic review. Int ing prospective study. Int J Periodontics Restorative Dent
J Oral Maxillofac Implants 22:390, 2007 8:529, 1998