The S2k-LL - Indications for the use of bone substitute materials in implant dentistry (083-009): the scientific quintessence
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RESEARCH GUIDELINE 129
Markus Tröltzsch, Peer W. Kämmerer, Andreas Pabst, Matthias Tröltzsch, Philipp Kauffmann, Eik Schiegnitz,
Phillipp Brockmeyer, Bilal Al-Nawas
The S2k-LL – Indications for the
use of bone substitute materials
in implant dentistry (083–009):
the scientific quintessence
Summary: The replacement of missing teeth after unavoidable tooth loss is a
core competence in dentistry. In addition to the obvious rehabilitation of the
masticatory function and esthetics, there are increasingly more medical con-
siderations that might warrant the replacement of missing teeth.
However, the prospective implant site is often compromised by defects of the
alveolar process which are triggered by tooth loss or which develop after
extraction. The preservation and, if necessary, the regeneration of the alveolar
process thus play a major role in daily clinical practice. Various biomaterials
are available to the dental practitioner besides autologous bone grafts. The
following questions were addressed in the guideline “Implantological indi-
cations for the use of bone substitute materials” of the DGI and DGZMK:
1. which are the indications for bone augmentation, 2. which materials are
available, 3. which techniques are recommended?
The key scientific statements of the guideline are summarized below. The lit-
erature references are therefore adapted to this format. The complete details
and background are found in the guideline.
Keywords: tooth loss; bone augmentation; jaw atrophy; bone grafts; bone
substitutes
Dental Group Practice, Maximilianstr. 5, 91522 Ansbach: Dr. Dr. Markus Tröltzsch; PD Dr. Dr. Matthias Tröltzsch
Clinic and Polyclinic for Oral and Maxillofacial Surgery – Plastic Surgery, University Medical Center Mainz: PD Dr. Dr. Peer W. Kämmerer; PD Dr. Dr. Eik Schiegnitz
Clinic for Oral and Maxillofacial Surgery, Bundeswehrzentralkrankenhaus, Rübenacherstr. 170, 56072 Koblenz: Dr. Dr. Andreas Pabst
Clinic and Polyclinic for Oral and Maxillofacial Surgery, University Hospital Munich: PD Dr. Dr. Matthias Tröltzsch
Clinic and Polyclinic for Oral and Maxillofacial Surgery, University Medical Center Göttingen: PD Dr. Dr. Philipp Kauffmann, PD Dr. Dr. Phillipp Brockmeyer
Clinic and Polyclinic for Oral and Maxillofacial Surgery – Plastic Surgery, University Medical Center Mainz: Univ.-Prof. Dr. Dr. Bilal Al-Nawas
Translation: Cristian Miron
Citation: Tröltzsch M, Kämmerer PW, Pabst A, Tröltzsch M, Kauffmann P, Schiegnitz E, Brockmeyer P, Al-Nawas B: The S2k-LL – Indications for the use of bone substitute
materials in implant dentistry (083–009): the scientific quintessence. Dtsch Zahnärztl Z Int 2021; 3: 129–139
DOI.org/10.3238/dzz-int.2021.0015
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
130 The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence
Type of Extended edentulous space,
Single-tooth gap Edentulous jaw
defect free-end gap
Dehiscence defect, Multiple dehiscence defects, Multiple dehiscence defects,
1/4
self-limiting self-limiting self-limiting
Horizontal defect, not self-limiting, Horizontal defect, not self-limiting,
2/4 augmentation required outside the augmentation required outside the Sharp-edged alveolar ridge
“skeletal envelope” “skeletal envelope”
Sharp-edged alveolar ridge
Combined defect with horizontal Combined defect with horizontal and
3/4 with vertical bone deficit
and vertical bone deficits vertical bone deficits
(Class IV according to Cawood)
Complete alveolar ridge
4/4 Continuous defect Pure vertical defect atrophy (class V and VI accord-
ing to Cawood)
Table 1 ITI classification of alveolar ridge defects according to Terheyden (Cordaro L 2014; Terheyden 2010).
Figure 1 Schematic representation of the bone shape, the soft tissue coat and an augmentation inside and outside of the soft tissue
coat. The representation applies to horizontal, vertical and combined alveolar ridge defects. The soft tissue coat (red line) describes
the natural dimension of the alveolar ridge (A). If such a defect is not augmented, the soft tissue prolapses and the bone shape is
altered (B). A distinction is made between augmentations inside (C) and outside (D) the soft tissue coat.
1. Biological basis clinical acknowledgement of this Quintessence from the guideline
problem, the evidence on this topic The following classification concern-
1.1 Defect biology remains scarce. A special emphasis ing the regeneration potential of a
For reliable and lasting implant pertaining to this topic was applied clinical situation can be derived:
placement, the alveolar process must within the framework of this guide- • procedures reconstructing defects
have sufficient dimensions. Among line. of the alveolar ridge and sinus
other factors, natural resorption, peri- The osseous regeneration of al- lifting: high biological regener-
odontitis and defects resulting from veolar process defects is even more ation capacity,
tooth extraction can be causes of difficult if an intrusion of soft tissue • lateral augmentation: medium bio-
hard and soft tissue defects of the al- has occurred. This effect can be logical regeneration capacity,
veolar process. Osteoblast activity is counteracted by performing ridge • combined lateral and vertical aug-
at its highest in the apical region dur- preservation (filling the empty al- mentation: low biological regener-
ing the first 4 weeks after tooth veolar socket with a suitable mate- ation capacity.
extraction, after which, it shifts to- rial). The ITI classification [2, 3]
ward the crestal region. In this con- exemplifies this clinical understand- 1.2 The medical history of the
text, resorption processes also take ing (Table 1, Figure 1). patient
place [1]. The biological regeneration po- The literature search revealed a pau-
It is important to note that bone tential consequently depends directly city of data addressing the question
resorption also results in soft tissue on the quantity of the delimiting of the extent to which pre-existing
reduction. In this regard, the soft tis- bone and the surrounding soft tissue. medical conditions can affect aug-
sue coat plays an important role in Defect geometries which have exten- mentation success.
the regeneration of existing bone de- sive osseous delimitation have higher There are indications for an in-
fects. Although there is widespread regeneration potential [2, 3]. creased complication rate and a lower
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence 131
Type of Origin Company Product Resorb- Area of
material able application
Allogeneic Human bone Argon Dental OsteoGraft® DBM X IM/PA/SA/GA/DS/AT
matrix OsteoGraft® CortiFlex® X IM/PA/SA/GA/DS/AT
OsteoGraft® Femur Span X IM/PA/SA/GA/DS/AT
OsteoGraft® Cortical Granula X IM/PA/SA/GA/DS/AT
OsteoGraft® Spongiosa Granula X IM/PA/SA/GA/DS/AT
OsteoGraft® J & CGrafts X IM/PA/SA/GA/DS/AT
OsteoGraft® Osillium & X IM/PA/SA/GA/DS/AT
Spongiosa Grafts
Straumann (botiss) Human-Spongiosa CHB X IM/GA/DS
Knochenring
Human-Spongiosa CHB X IM/PA/SA/GA/DS/AT
Granulat spongiös
Human-Spongiosa CHB Block X IM/GA/DS
maxgraft® cortico X IM/GA/DS
maxgraft® bonering X IM/GA/DS
maxgraft® Granulat spongiös X IM/PA/SA/GA/DS/AT
maxgraft® Granulat X IM/PA/SA/GA/DS/AT
cortico-spongiös
maxgraft® Block X IM/GA/DS
maxgraft® bonebuilder X IM/GA/DS
Zimmer Biomet Puros® Allograft Block X IM/GA/DS
Puros® Allograft Patienten X IM/GA/DS
individueller Block
Puros® Allograft Spongiosa X IM/PA/SA/GA/DS/AT
Partikel
Xenoge- Equine American Dental OsteoBiol® SP-Block X GA
neic Systems (Bone Splitting/Spread.)
Mectron BIO-GEN® Spongy IM/PA/SA/GA/DS/AT
BIO-GEN® Cortical IM/PA/SA/GA/DS/AT
BIO-GEN® Mix IM/PA/SA/GA/DS/AT
BIO-GEN® Putty AT
Porcine American Dental OsteoBiol® Gen-Os X IM/PA/SA/GA/DS
Systems
OsteoBiol® Apatos (Mix) IM/PA/SA/GA/DS/AT
OsteoBiol® mp3 X IM/PA/SA/GA/DS/AT
OsteoBiol® GTO® X IM/PA/SA/GA/DS/AT
OsteoBiol® Putty X IM/PA/GA
OsteoBiol® SP-Block X GA
(Bone Splitting/Spread.)
OsteoBiol® Bone Lamina Soft X IM/GA/DS
(Barrier)
CAMLOG MinerOss® XP X IM/PA/SA/GA/DS/AT
Champions-Implants Matri™ Bone X IM/PA/SA/GA/DS/AT
CollaWin! X IM/PA/SA/GA/DS/AT
Curasan CERASORB® Foam X IM/SA/GA/DS/AT
(Vertrieb: mds)
Dentsply Sirona Symbios® Xenograft-Granulat X IM/PA/SA/GA/DS/AT
Geistlich Biomaterials Geistlich Bio-Oss® COLLAGEN X IM/PA/SA/GA/DS/AT
Hess Medizintechnik Geistlich Bio-Oss® COLLAGEN X IM/PA/SA/GA/DS/AT
REGEDENT The Graft IM/PA/SA/GA/DS/AT
OSSIX® VOLUMAX X IM/GA/DS
OSSIX® Bone X IM/PA/SA/GA/DS/AT
Straumann (botiss) collacone® max X IM/AT
Thommen Medical The Graft IM/PA/SA/GA/DS/AT
OSSIX® Bone IM/PA/SA/GA/DS/AT
Bovine BEGO Implant BEGO OSS IM/PA/SA/GA/DS/AT
Systems
BioHorizons MinerOss®-X X IM/PA/SA/GA/DS/AT
(CAMLOG Dtl.)
Bioimplon Hypro-Oss® X IM/PA/SA/GA/DS/AT
CAMLOG MinerOss® X X IM/PA/SA/GA/DS/AT
MinerOss® X Collagen X IM/PA/SA/GA/DS/AT
Dentegris Deutschland CompactBone B X IM/PA/SA/GA/DS/AT
Geistlich Biomaterials Geistlich Bio-Oss® Spongiosa X IM/PA/SA/GA/DS/AT
Granulat
Geistlich Bio-Oss® Spongiosa X IM/SA/GA/DS
Block
Geistlich Bio-Oss® COLLAGEN X IM/PA/SA/GA/DS/AT
Geistlich Bio-OssPen® Granulat X IM/PA/SA/GA/DS/AT
Henry Schein NuOss® Granulat X IM/PA/SA/GA/DS/AT
Table 2 Overview of the marketed augmentation materials in dentistry and oral and maxillofacial surgery. Status: April 2019. From:
Yearbook of Implantology 2019, OEMUS MEDIA AG, Leipzig. Area of application: implantology (IM), periodontology (PA), sinus
floor augmentation (SA), general augmentation (GA), defect surgery (DS), alveolar treatment (AT).
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
132 The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence
Type of Resorb- Area of
material Origin Company Product able application
Hess Medizintechnik Geistlich Bio-Oss® Spongiosa X IM/PA/SA/GA/DS/AT
Granulat
Geistlich Bio-Oss® Spongiosa X IM/SA/GA/DS
Block
Geistlich Bio-Oss® COLLAGEN X IM/PA/SA/GA/DS/AT
Geistlich Bio-OssPen® Granulat X IM/PA/SA/GA/DS/AT
Nobel Biocare creos xenogain X IM/PA/SA/GA/DS/AT
OT medical BioVin® Bovine Bone X IM/PA/SA/GA/DS/AT
Septodont R.T.R. Kegel X IM/PA/SA/GA/DS/AT
Straumann (botiss) cerabone® IM/PA/SA/GA/DS/AT
Zimmer Biomet Endobon® Xenograft Granulat IM/PA/SA/GA/DS/AT
CopiOs® Xenograft Spongiosa X IM/PA/SA/GA/DS/AT
Partikel
plant-based Dentsply Sirona Frios® Algipore® X IM/PA/SA/GA/DS/AT
Symbios® Biphasisches KAM X IM/PA/SA/GA/DS/AT
Gebr. Martin/KLS Martrix X IM/PA/SA/GA/DS/AT
Martin
SIC invent SIC nature graft X IM/PA/SA/GA/DS/AT
Synthetic HA/Collagen/ ACTEON Germany BIOSTITE X IM/PA/SA/GA/DS
Glycosamino-
glycans
Sodium Argon Dental OsteoGel® Hyaluron X IM/PA/SA/GA/DS/AT
hyaluronate
BCP BEGO Implant BEGO OSS S X IM/PA/SA/GA/DS/AT
Systems
β-TCP Bicon SynthoGraft™ X IM/PA/SA/GA/DS/AT
BCP Champions-Implants Matri™ Bone X IM/PA/SA/GA/DS/AT
Kollagen CollaWin! X IM/PA/SA/GA/DS/AT
β-TCP curasan CERASORB® Classic X IM/SA/GA/DS/AT
(Vertrieb: mds)
β-TCP CERASORB® M X IM/SA/GA/DS/AT
β-TCP CERASORB® Perio X PA
β-TCP CERASORB® Plus X IM/SA/GA/DS/AT
β-TCP CERASORB® Paste X IM/PA/SA/GA/DS/AT
β-TCP CERASORB® Foam X IM/SA/GA/DS/AT
β-TCP CERASORB® Formteile X DC
HA Osbone® IM/PA/SA/GA/DS/AT
Calcium sulfate/ Demedi-Dent ethOss X IM/PA/SA/GA/DS/AT
β-TCP
BCP Dentegris Deutschland CompactBone S X IM/PA/SA/GA/DS/AT
Collagen Dentium/iCT Europe OSTEON™ IM/PA/SA/GA/DS/AT
Collagen OSTEON™ Sinus & Lifting IM/PA/SA/GA/DS/AT
Collagen OSTEON II™ IM/PA/SA/GA/DS/AT
Collagen OSTEON II™ Sinus & Lifting IM/PA/SA/GA/DS/AT
BCP Dr. Ihde Dental Nanos® X IM/PA/SA/GA/DS/AT
HA/SiO2 Hager & Meisinger NanoBone® | granulate X IM/PA/SA/GA/DS/AT
HA/SiO2 NanoBone® | block X IM/GA/DS
HA/SiO2 NanoBone® | QD X IM/PA/SA/GA/DS/AT
BCP Henry Schein BONITmatrix® X IM/PA/SA/GA/DS/AT
β-TCP K.S.I. Bauer-Schraube calc-i-oss™ X IM/PA/SA/GA/DS/AT
BCP easy-graft® X IM/PA/SA/GA/DS/AT
β-TCP LASAK PORESORB-TCP X IM/PA/SA/GA/DS/AT
HA OssaBase® -HA X IM/PA/SA/GA/DS/AT
HA/BCS MIS Implants 4MATRIX X IM/PA/SA/GA/DS/AT
Technologies
BCP 4-Bone™ X IM/PA/SA/GA/DS/AT
BCS BONDBONE® X IM/PA/SA/GA/DS/AT
BCP OT medical OToss Synthetic Bone X IM/PA/SA/GA/DS/AT
BCP OToss Synthetic Bone Inject X IM/PA/SA/GA/DS/AT
BCS REGEDENT 3D Bond X IM/PA/GA/DS/AT
HA/BCS Bond Apatite X IM/PA/GA/DS/AT
BCP OSOPIA X IM/PA/SA/GA/DS
Collagen OSSIX® Bone X IM/PA/SA/GA/DS/AT
BCP Shared Implantology SinossGraft X IM/PA/SA/GA/DS
BCP (Novadento) SinossGraft Resorb X IM/PA/SA/GA/DS
BCP SinossGraft Inject X IM/PA/SA/GA/DS
β-TCP Septodont R.T.R. Granulat X IM/PA/SA/GA/DS/AT
β-TCP R.T.R. Spritze X IM/PA/SA/GA/DS/AT
BCP Straumann Straumann® BoneCeramic X IM/PA/SA/GA/DS/AT
Continuation Table 2 Overview of the marketed augmentation materials in dentistry and oral and maxillofacial surgery. Status:
April 2019. From: Yearbook of Implantology 2019, OEMUS MEDIA AG, Leipzig. Area of application: implantology (IM), periodon-
tology (PA), sinus floor augmentation (SA), general augmentation (GA), defect surgery (DS), alveolar treatment (AT).
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence 133
Type of Resorb- Area of
material Origin Company Product able application
BCP Straumann (botiss) maxresorb® X IM/PA/SA/GA/DS/AT
BCP maxresorb® inject X IM/PA/SA/GA/DS/AT
BCP/ collacone® max X IM/AT
Collagen
β-TCP Sunstar calc-i-oss™CLASSIC X IM/PA/SA/GA/DS/AT
Deutschland
β-TCP easy-graft® CLASSIC X IM/PA/SA/GA/DS/AT
BCP easy-graft® CRYSTAL X IM/PA/SA/GA/DS/AT
β-TCP TAG Dental Sybone X IM/PA/SA/GA/DS/AT
Systems
β-TCP Thommen Medical Ceros® TCP Granulat X IM/PA/SA/GA/DS/AT
β-TCP Ceros® TCP Putty X IM/PA/SA/GA/DS/AT
BCS 3D Bond X IM/PA/GA/DS/AT
HA/BCS Bond Apatite X IM/PA/GA/DS/AT
PLA/PGA Zantomed FISIOGRAFT Granulat X IM/PA/SA/GA/DS/AT
PLA/PGA FISIOGRAFT Gel X IM/PA/SA/GA/DS/AT
PLA/PGA FISIOGRAFT Schwamm X IM/PA/SA/GA/DS/AT
HA FISIOGRAFT BONE Granular X IM/PA/SA/GA/DS/AT
HA Zimmer Biomet IngeniOs HA IM/PA/SA/GA/DS/AT
β-TCP/ IngeniOs β-TCP bioaktiv X IM/PA/SA/GA/DS/AT
Silicon
Calciumphos- Nova Bone X IM/PA/SA/GA/DS/AT
phosilicate
Autogen Autologous vital BTI PRGF® Endoret® X IM/PA/SA/GA/DS/AT
osteogenic cells Champions-Implants Smart Grinder X IM/SA/GA/DS/AT
Schlumbohm Autologer Knochen (KF T3) X IM/PA/SA/GA/DS
Continuation Table 2 Overview of the marketed augmentation materials in dentistry and oral and maxillofacial surgery. Status:
April 2019. From: Yearbook of Implantology 2019, OEMUS MEDIA AG, Leipzig. Area of application: implantology (IM), periodon-
tology (PA), sinus floor
rate of new bone formation in sis, radiation, vitamin D levels as 1.3.1 Allografts
smokers, anamnestic periodontitis well as the intake of PDE-5 in- These bone substitute materials are
and poorly controlled diabetes [4–6]. hibitors (sildenafil), selective sero- obtained from human donors. As a
Low vitamin D levels [7] and the use tonin reuptake inhibitors (SSRI) result of the multitude of existing
of PDE-5 inhibitors [8] might also and proton pump inhibitors (PPI). preparation processes, consistent
play a negative role. scientific statements, for example, re-
More consistent data exists on 1.3 The different biomaterials garding the success and complication
factors influencing implant success. In general, implants placed in the rates, are difficult to make, and the
Clinically, this data can be general- augmented area – regardless of the availability of data for certain materi-
ized to augmentations under certain augmentation material – do not have als in clinical situations is limited
circumstances. Studies associating os- a poorer long-term prognosis than [32]. Fragments of cells and DNA
teoporosis, antiresorptive therapy, implants placed in local pristine bone could be detected in various allo-
head and neck irradiation, selective [17–25] (Table 2). grafts [33–37], although their clinical
serotonin reuptake inhibitors (SSRIs) The status of autologous bone significance is controversial [38–40].
and proton pump inhibitors (PPIs) grafts as the “biological gold stan-
with higher implant failure and com- dard” can be found in some sources 1.3.2 Xenografts
plication rates exist [9–16]. in the literature [26–28]. However, Bone substitute materials in this
harvesting morbidity, resorption phe- group can be obtained, for example,
Quintessence from the guideline nomena and the required volume from cattle (bovine), pigs (porcine),
Strong contraindications against the also play a role when selecting the horses (equine), but also from corals.
use of bone substitute materials can- material [29–31]. Consequently, bone Also, in this group, not every prep-
not be found in the literature. Pa- substitute materials that are artificial aration has an equally good collec-
tients with general diseases might be in nature (alloplastic/synthetic), from tion of data. Especially for some bo-
at a higher risk for complications or a foreign species (xenogeneic) or vine products, there is a good collec-
failures. In particular, the following from human sources (allogeneic) tion of data with long observation
factors should be determined in the come into focus; they present the periods [41–44]. These materials can
medical history: main advantages of reduced perioper- be used to protect against resorption
• smoking, periodontal disease, dia- ative morbidity and higher quanti- due to their very low resorption [41,
betes, bisphosphonates, osteoporo- tative availability. 45, 46].
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134 The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence
1.3.3 Synthetic/alloplastic bone 2.2 The use of membranes/
substitute materials guided bone regeneration
Since these materials are produced (GBR) techniques for ridge
using purely artificial methods, they preservation
do not pose any problems in terms Fundamental features of membranes
of immunological or infectious re- used in GBR include the stabilization
sponses. Examples include hydroxy- of a defect’s shape, providing cell oc-
apatites, silicon-containing bioglasses, clusivity and a barrier function [61].
calcium phosphates and microporous When defects are present in the al-
composites. In direct comparison veolar wall, the use of a membrane
with xenografts, synthetic bone sub- improves the result [53, 62–65]
stitute materials appear to be equiva- (Drawing 2). In comparing various
lent at best for some indications, but types of membranes, resorbable col-
otherwise inferior [47–50]. However, lagen membranes show the most
Drawing 1 Ridge preservation with pre- these materials can be used success- favorable ratio of success to compli-
served alveolar walls, use of particulate fully for selected clinical indications cations [22].
bone substitute material without a mem- [22].
brane.
2.3 Dehiscence defects at
Quintessence from the guideline implants
The available biomaterials have dif- Osseous deficits that occur when im-
ferent properties, advantages and dis- plants are placed are referred to as de-
advantages. As a result, there is no hiscences and these are usually regen-
one “gold standard”. Moreover, it is erated with a combination of bio-
advisable to check whether sufficient materials and membranes nowadays
data is available for the material in [22, 66–68], in which, autologous, al-
question. logeneic and xenogeneic materials,
especially, demonstrate the best de-
2. Regeneration of defects fect regeneration [22]. The best results
with high biological for peri-implant augmentation per-
capacity formed simultaneously with implant
This group covers the treatment of placement can be achieved with the
defects whose regenerative capacity is simultaneous use of a resorbable col-
classified as high according to 1.1. lagen membrane [22, 69] (Drawing 3).
Characteristic to these clinical situ- Regeneration rates of up to 90 %
ations is that good osseous delim- are achievable, although it is clear
Drawing 2 Ridge preservation in par- itations exist and that the soft tissue that regenerated areas have a much
tially missing alveolar walls, use of par- coat has not yet entered into the de- better long-term prognosis than non-
ticulate bone substitute with a resorbable fect area. regenerated areas [22, 70].
collagen membrane.
2.1 Ridge preservation 2.4 Sinus lifting
The goal of ridge preservation pro- Using a variety of techniques, sinus
cedures is to attenuate post-extrac- floor elevation aims to elevate
tion resorption and preserve as much Schneider‘s membrane in order to
alveolar ridge and soft tissue volume permit augmentation in the created
as possible. The literature shows good space. There are many studies with a
prospects of success for a wide variety high level of evidence showing that it
of protocols [51–55] (Drawing 1). is irrelevant for the survival rate of
In a direct comparison, bovine the subsequently placed implants,
xenogeneic material was superior [56] whether they are placed in auto-
or equivalent [57] to allografts for logous bone, or in areas regenerated
this indication, although within the with bone substitute materials, and
allograft material group, the demin- that their success rates are com-
eralized freeze dried bone allograft parable. These results seem to be in-
(DFDBA) preparations appeared to be dependent of the used bone substi-
superior to other allogeneic prepara- tute material or technique [71–77]
tions [32, 58]. There is also data de- (Drawing 4).
Drawing 3 Dehiscence defect at the scribing the successful use of syn-
implant, regeneration with particulate thetic material [59] and platelet rich Quintessence from the guideline
bone substitute material using a resorb- fibrin (A-PRF) [60] for alveolar ridge Defects with intact bone walls can be
able collagen membrane.
preservation. regenerated with any biomaterial.
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence 135
The largest amount of data is found
for xenogeneic and allogeneic materi-
als. In cases where a bone wall is lost,
a membrane should be inserted to
act as a barrier. Overall, clinical cases
falling into this category have a
relatively high success rate.
3. Regeneration of defects
with low biological
capacity
Defects whose regenerative capacity
is classified as low according to 1.1
require significantly more technical
and surgical effort than the situations
analyzed so far. Lateral, vertical and, Drawing 4 Sinus lift with particulate Drawing 5 Lateral and vertical augmen-
especially, combined lateral and verti- bone substitute material. tation with a titanium mesh (then with
cal defects of the alveolar ridge fall additional resorbable collagen membrane
“blue line”) or as titanium-reinforced
into this group.
membrane. Fixation using screws or pins
if necessary.
3.1 Regeneration with
particulate bone substitute
material (GBR techniques)
As long as the segment to be regener-
ated does not exceed 3 mm (laterally
and/or vertically), particulate bone
substitute material in combination
with a barrier membrane can be used,
(Fig. 1, Drawings 1–7, Tab. 1 and 2: M. Tröltzsch)
analogous to the techniques pres-
ented in 2.2 and 2.3 [22] (Drawings 5
and 6).
If larger defects should be regen-
erated with the aid of particulate
bone substitute materials, specific
guided bone regeneration (GBR)
techniques such as titanium-rein-
forced membranes, individualized ti-
tanium grids, or shell techniques are
required; the bone substitute material
appears to play a subordinate role Drawing 6 Lateral and vertical augmen- Drawing 7 Lateral and vertical augmen-
compared to the barrier form [22, tation using a cortical shell technique, tation with a bone block fixed using
78–81]. In particular, the use of the filling with autologous bone chips or screws.
particulate bone substitute materials.
dimensionally stable barriers must be
emphasized, as this is the only way to
achieve similarly high levels of regen-
eration that would otherwise be pos-
sible solely with the aid of autologous Resorbable collagen membranes and ity from various harvesting sites exist.
bone blocks. In this context, CAD/ PRF can improve dehiscence rates With intraoral blocks, defects up to
CAM-produced titanium grids are of over titanium grids [85]. 5 mm can be regenerated [22, 87, 88]
particular interest, as they reduce the (Drawing 7). For larger segments,
intraoperative effort by virtue of their 3.2 Regeneration with bone from extraoral regions is recom-
preoperative preparation, and they autologous blocks and mended [22]; the iliac crest is fre-
can be customized to accurately blocks from bone quently referred to as the “gold stan-
match the existing clinical situation substitute material dard” based on the large amount of
[82–86]. Numerous extraoral and intraoral grafted osteoblasts [89, 90]. However,
The risk of wound healing dis- donor sites are available for bone some limitations of autologous
turbances with consecutive dehis- block harvesting to the experienced blocks need to be considered such as
cence and the risk of implant/graft surgeon, though it is noteworthy to long-term resorption, as well as, the
loss can only be reduced by custom- mention that evident differences possible limited quantity of the vol-
ized soft tissue management [83, 86]. with regard to the regenerative capac- ume that can be harvested and re-
© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (3)
TRÖLTZSCH, KÄMMERER, PABST ET AL.:
136 The S2k-LL – Indications for the use of bone substitute materials in implant dentistry (083–009): the scientific quintessence
moval morbidity of the graft [91–97]. to 3 mm (lateral and/or vertical), par- extraction sockets. Clin Surg 2017; 2:
As a result, the use of non-autologous ticulate bone substitute material in 1458
blocks as an alternative is being in- combination with resorbable mem- 9. Farzad P, Andersson L, Nyberg J:
vestigated and the successful appli- branes is sufficient for regeneration; Dental implant treatment in diabetic pa-
cation of xenogeneic and allogeneic on the other hand, for larger seg- tients. Implant Dent 2002; 11: 262–267
blocks have been described in the lit- ments, specialized GBR techniques 10. Heitz-Mayfield LJ: Peri-implant dis-
erature [31, 98–101]. However, direct with stable barriers or preferably eases: diagnosis and risk indicators. J Clin
Periodontol 2008; 35 (8 Suppl): 292–304
comparisons between xenogeneic autologous bone blocks is required.
[22, 102] and allogeneic block grafts 11. Gomez-de Diego R et al.: Indications
[22, 87, 103–106] have shown that and contraindications of dental implants
in medically compromised patients: up-
autologous bone blocks are inferior
date. Med Oral Patol Oral Cir Bucal
in terms of regeneration outcomes Conflicts of interest 2014; 19: e483–9
and complication rates. Moreover, or- The conflicts of interest can be found
12. Grötz CWBA-N.S.H.R. M.U.K.A.:
ganic materials and DNA residues in the detailed version of the guide- Zahnimplantate bei medikamentöser Be-
have also been detected in allogeneic line “Implantological indications for handlung mit Knochen Antiresorptiva
and xenogeneic blocks [33–37, 89, the use of bone substitute materials” (inkl. Bisphosphonate) Langversion 1.0,
107, 108] and their effects are contro- at www.online-dzz.de. 2016. AWMF Registernummer: 083–026,
2016
versially discussed [34–36, 104, 105].
Overall, the available data for xe- The full text of the guideline “Im- 13. Kandasamy B et al.: Long-term retro-
nogeneic and allogeneic bone blocks plantological indications for the use spective study based on implant success
rate in patients with risk factor: 15-year
is highly heterogeneous, partially of bone substitute materials” can be
follow-up. J Contemp Dent Pract 2018;
controversial, and generally inad- freely downloaded from the DGZMK 19: 90–93
equate. The consistency of data for (www.dgzmk.de) and AWMF (www.
14. Schimmel M et al.: Effect of ad-
alloplastic blocks must be classified as awmf.org) websites.
vanced age and/or systemic medical con-
even poorer. ditions on dental implant survival: a sys-
tematic review and meta-analysis. Clin
Quintessence from the guideline Oral Implants Res 2018; 29 (Suppl 16):
Defects up to 3 mm can be regener- 311–330
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