J Oral Maxillofac Surg 65:2039-2046, 2007

Maxillary Alveolar Ridge Reconstruction With Nonvascularized Autogenous Block Bone: Clinical Results
Antonio Barone, DDS, PhD,* and Ugo Covani, MD, DDS
Purpose: The purposes of this study were to evaluate the clinical success of bone reconstruction of the

severely atrophic maxilla using autogenous bone harvested from the anterosuperior edge of iliac wing and to analyze the clinical success and the marginal bone level of dental implants placed 4 to 5 months after bone grafting and before prosthetic rehabilitation. Patients and Methods: Fifty-six patients (18 men, 38 women) aged 27 to 63 years were included in the study and required treatment for maxillary atrophy. All patients selected were scheduled for onlay bone graft and titanium implants in a 2-stage procedure. The dental implants were inserted 4 to 5 months after grafting. Results: No major complications were observed from the donor sites. A total of 129 onlay bone grafts were used to augment 56 severely resorbed maxillas. Three out of 129 bone grafts had to be removed because of early exposure occurring with bone grafts placed to increase the vertical dimension of the alveolar ridge. One hundred sixty-two implants were placed in the area of bone augmentation. Seven implants failed to integrate and were successfully re-placed without any need for additional bone grafting. The clinical measurements for bone resorption around implants revealed a mean bone loss of 0.05 mm ( 0.2); the marginal bone level evaluated with periapical radiographies was 0.3 mm ( 0.4) at implant placement and 0.1 mm ( 0.3) 6 months after placement. Conclusion: The success rate of the block grafts was very good. The clinical and radiographic bone observations showed a very low rate of resorption after bone graft and implant placement. Therefore, on the basis of this preliminary study, iliac bone grafts (from the anterosuperior edge of the iliac wing) can be considered a promising treatment for severe maxillary atrophy. 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:2039-2046, 2007 Implant-supported rehabilitation of the edentulous ridge require adequate volume and integrity of the alveolar bone. Loss of teeth leads to a pattern of bone resorption that can contribute to severe jaw atrophy and eventually to an unfavorable maxillomandibular relationship.1,2 Reconstruction of severely resorbed jaws requires different surgical procedures depending on the severity of the bone atrophy. These procedures often involve the use of bone substitutes or the harvesting of autogenous bone from a donor site. Autogenous bone is believed to be the most effective bone graft material and is still regarded as the gold standard for augmentation procedures because of its osteogenic potential. However, this graft has a limited availability; furthermore, the surgical harvesting procedures might cause additional morbidity.3-5 To minimize these risks, bone substitute materials such as synthetic scaffolds may be used to provide alternatives to autogenous bone to improve bone volume.6 Although excellent clinical and histologic outcomes have been reported,7,8 some types of bone defects cannot be repaired with biomaterials because of local mechanical instability and defect size. Therefore, in cases where large amounts of bone are required, autogenous bone is considered the rst choice and can be harvested from sites such as the iliac crest, tibia, skull, or mandible.9-12 The onlay/ inlay bone grafting techniques have been used in situations with a normal or acceptable maxillomandibular relationship.

Received from the Department of Oral Pathology and Oral Medicine, Nanoword Institute, School of Dental Medicine, University of Genova, Italy. *Assistant Professor. Associate Professor. Address correspondence and reprint requests to Dr Barone: Piazza Diaz 10, 55041 Camaiore (Lu), Italy; e-mail: barosurg@ libero.it
2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6510-0023$32.00/0 doi:10.1016/j.joms.2007.05.017

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2040 Some authors have reported the treatment of patients showing severe maxillary atrophy with using onlay bone grafts in combination with simultaneous insertion of endosteal implants. The survival rate of the implants after 3 years was 75%. It was concluded that, in spite of the high implant failure rate, onlay bone grafting to the maxilla was a valuable method in cases of severe maxillary atrophy.13 The onlay block grafts, when compared with particulate bone marrow, have shown reduced osteogenic activity and slow revascularization.14,15 Revascularization is the key factor for successful incorporation and remodeling of the bone graft. The revascularization process is dependent on the vascular supply in the host area, and surgery should always be carried out as carefully as possible to preserve the supply of blood vessels.16-18 Several studies have shown that intramembranous bone graft (calvaria and mandible), when compared with endochondral bone grafts (iliac crest), may have minimal resorption and better incorporation at the donor site.19,20 More recently, some other authors21 have conrmed that bone resorption of the calvarial bone grafts was signicantly less than that seen with iliac bone grafts. All these considerations could suggest that embryologic origins were responsible for differences in resorption patterns; however, it should be taken into account that the microarchitectural features (cortical/cancellous ratio) represent the main determinant in the volume maintenance of bone grafts in the craniofacial skeleton.22,23 The purposes of this study were as follows: 1) to evaluate the clinical success of bone reconstruction of severely atrophic maxillas using autogenous block bone before dental implant placement; and 2) to analyze the clinical success and the marginal bone loss of dental implants placed 4 to 5 months after bone grafting and before prosthetic rehabilitation.

MAXILLARY ALVEOLAR RIDGE RECONSTRUCTION

eases; diabetes; pulmonary, renal, or cardiovascular diseases; blood diseases; malignant neoplasias; hepatitis; drug abuse; chemotherapy or radiotherapy. In addition, patients smoking more than 10 cigarettes per day were excluded from the study; patients smoking fewer than 10 cigarettes per day were requested to stop smoking before and after surgery, although their compliance could not be controlled. Each case was accurately evaluated examining diagnostic casts to assess the interarch relationship; moreover, panoramic radiographs and computed tomography were taken. Following these analyses, all patients, when partially edentulous, underwent any dental treatment necessary to provide an oral environment more favorable to wound healing. All patients received and signed a consent form. Thirty-eight patients were fully edentulous and were treated with onlay bone grafts in the anterior maxilla and maxillary sinus augmentation in the posterior area. The remaining 18 patients were partially edentulous and were treated with onlay bone grafts in the atrophic area. All patients included in this study had an atrophic area with bone thickness ranging from 2 to 3 mm.
SURGERY

Patients and Methods

PATIENT POPULATION

Fifty-six patients (18 men, 38 women) aged 27 to 63 years were included in the study. All patients selected for this study required bone augmentation procedures because of severe alveolar ridge atrophy and were scheduled for onlay bone graft and titanium implants in a 2-stage procedure. The inclusion criteria were as follows: the need for alveolar ridge reconstruction and implant placement in a 2-stage procedure; presence of severe maxillary bone atrophy; and presence of healthy systemic conditions without any disease that would contraindicate surgery under general anesthesia. Patients were not admitted to the study if any of the following criteria were present: immune system dis-

In all patients, surgery was performed under general anesthesia. One hour before surgery, 2 g of ceftriaxone and 8 mg dexamethasone were administered intravenously. The iliac bone was exposed and autogenous grafts were harvested with a slow-speed oscillating saw. Only the anterosuperior edge of iliac wing was harvested, keeping a safe distance of 2 cm from the anterosuperior iliac spine (Fig 1). After osteotomy, the corticocancellous bone blocks were harvested using chisels (Fig 2). A second team of surgeons performed the augmentation of the atrophic maxilla. A crestal incision (at the top of the edentulous alveolar crest) and 2 vertical releasing incisions were performed; subsequently a full-thickness ap was raised and the palatal ap was held with a 3-0 suture. The recipient site was then recontoured to improve graft adaptation, if needed, and was perforated with a ssure bur to induce bleeding and promote the revascularization of the graft. The harvested corticocancellous blocks were adapted to the atrophic maxilla and attached to the residual ridge with self-tapping screws (Cizeta, Milano, Italy) until the head reached the surface of the bone graft (Fig 3). Any sharp angles in the block grafts were smoothed to avoid perforation of the overlaying ap. An additional mixture of corticocancellous porcine bone particle and collagen (Osteobiol; Tecnoss, Coazze, Italy) was placed at the periphery of the block grafts. Periosteal fenestration was performed at

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2041 The following postoperative regimen was prescribed: ceftriaxone (2 gr/day) for 5 days after surgery; dexamethasone (4 mg/day) for 2 additional days; and chlorhexidine mouthwash twice daily for 21 days. Provisional rehabilitations were made using removable prostheses which were placed 30 days after surgical procedure. A bone graft was dened successful according to the following criteria: absence of graft exposure and postoperative infection; incorporation of the graft with the recipient site; absence of bone radiolucency; bleeding from the bone graft after removing stabilization screws; and possibility for implant placement.

FIGURE 1. Schematic drawing of the harvesting from the iliac crest. A, Frontal view; B, Sagittal view of the iliac wing. The green line shows the osteotomy contour. Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

DENTAL IMPLANT TREATMENT

the base of buccal ap to obtain a tension-free adaptation of the wound margins. The ap was sutured with a resorbable suture that was removed after 2 weeks.

The implant phase was begun 4 to 5 months after consolidation of the grafted sites. An alveolar crest incision was made and mucoperiosteal aps were elevated to expose the sites for implant placement. The xation screws were removed and the implant sites were prepared. Double acid-etched screw type implants (3I, Implant Innovations, West Palm Beach, FL) were placed using a surgical guide. All of the implants in this study were

FIGURE 2. Principles of harvesting corticocancellous bone from the iliac wing: A, Osteotomy; B, donor site after bone harvesting; C, corticocancellous block. Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

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MAXILLARY ALVEOLAR RIDGE RECONSTRUCTION

FIGURE 3. Monolateral augmentation of an atrophic maxilla. A, Preoperative panoramic radiograph; B, horizontal onlay augmentation; C, panoramic radiograph 4 months after augmentation. Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

inserted at the alveolar crest level and showed good primary stability. The aps were subsequently closed with silk sutures. The successive stage of surgical procedures was performed 6 months after implant placement for all experimental sites. At this stage the clinical distance between the neck of the implants (which were placed at the crestal level) and surrounding crestal bone was measured at 4 sites (buccal, palatal, mesial, and distal) for each implant to evaluate any rate, if present, of bone resorption around the implants.
RADIOGRAPHIC EVALUATION

mediately after implant placement was considered the baseline for further measurements (Fig 4). Radiographic measurements of each implant were calculated per patient by averaging the clinical parameter for the implants per patient because the intrasubject variation was much lower than the intersubject variation. Subsequently, the means and medians were calculated per patient. The comparison between baseline and 6-month data was performed with the Student t test for paired data (the results were considered statistically signicant at the level P .05).

Routine panoramic radiographs were taken for all clinical postgrafting procedures (before implant placement). Moreover, to quantify the bone level changes around implants inserted in grafted sites, the periapical radiographs were evaluated immediately and 6 months after implant placement (before prosthetic rehabilitation). The distance from the implant shoulder and the rst bone-implant contact (DIB) mesially and distally to the implant was measured using periapical radiographs taken in a standardized manner.24,25 All measurements were taken by 1 examiner (A.B.). The bone level measurements performed im-

Results
No major complications were observed from the donor sites. One patient out of 56 required drainage for a small hematoma. Six patients were still experiencing pain 1 week after graft harvesting. Two weeks later, none of the patients had referred pain or difculties during walking. A total of 129 onlay bone grafts were used to augment 56 severely resorbed maxillas. Thirty-seven out of 129 onlay bone grafts were scheduled for vertical alveolar ridge augmentation and the remaining 92 for horizontal alveolar ridge augmentation (Table 1). The exposure of the onlay

BARONE AND COVANI

2043 soft tissues closure over the graft. No further infection or dehiscence was observed. Subsequently, 6 months after placement the implants showed evident marginal bone resorption. All the observed complications were associated with onlay bone grafts placed to increase the vertical dimension of the alveolar ridges (Table 2). During the re-entry procedures for implant placement all the bone grafts were successfully incorporated and xed at the recipient site. The xation screws were removed and bleeding from the bone graft was observed, indicating revascularization of the grafted bone. Only 5 xation screws out of 215 used for bone block stabilization on recipient sites showed a marginal bone resorption between 1.5 and 2 mm around the head. The mixture of corticocancellous porcine bone particle and collagen placed at the periphery and over the grafts appeared well integrated with the recipient sites. One hundred sixty-two implants ranging in length from 10 to 15 mm were placed in the area of bone augmentation. All implants were inserted with satisfactory primary stability. The complete rehabilitation of the totally edentulous patients required implants placed in augmented maxillary sinuses and were not included in this study. Six months after implant placement, 7 implants failed to integrate and no signs of infection were noted during the healing period. The failed implants were successfully re-placed at the time of exposure without any need for additional bone grafting. The remaining 155 implants were successful according to the criteria of success26 and were fully surrounded by bone. The clinical measurements for bone resorption around implants showed a mean marginal bone loss of 0.05 mm ( 0.2). Moreover, the mean marginal bone level value, measured by periapical radiograph, was 0.3 mm ( 0.4) at implant placement and 0.1 mm ( 0.3) 6 months after placement. The reduction of the marginal bone level value from baseline to the 6-month evaluation could reect differences in mineralization of the grafted bone, which within 6 months showed an increase in mineralization and incorporation at the recipient site (Table 3).

FIGURE 4. Periapical radiographic evaluation: A, at implant placement and B, 6 months after placement. Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

bone graft was observed in 3 patients who received a full maxillary reconstruction. Each patient showed the exposure of 1 block occurring 3 to 5 weeks after grafting. The exposed part of the blocks graft appeared necrotic (given the discoloration and soft consistency when examined with the explorer) and was removed using a diamond bur under water cooling. Despite any treatments, all the block grafts showing an early exposure had to be completely removed because of infection. In another clinical case where signs of exposure appeared 3 months after grafting, a surgical procedure was performed to remove the surgical xation screws and to place implants. A successful treatment of the exposure was observed with a

Table 1. CLINICAL CHARACTERISTICS OF 56 PATIENTS WHO UNDERWENT MAXILLARY RECONSTRUCTION USING BLOCK BONE GRAFTS

Block Graft Vertical augmentation Horizontal augmentation Total

No. of Blocks 37 92 129

Complications 4 4

No. of Implants Placed 47 115 162

No. of Implants Failed 2 5 7

Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

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MAXILLARY ALVEOLAR RIDGE RECONSTRUCTION

Table 2. NUMBER AND CHARACTERISTIC OF COMPLICATIONS OCCURRING AFTER ONLAY BONE GRAFT

Patients # # # # 1 2 3 4

Block Graft Vertical Vertical Vertical Vertical

Type of Complications Graft exposure Graft exposure Graft exposure Infection

Time of Occurrence 3 3 5 12 wks wks wks wks

Outcome Block removal Block removal Block removal Healing*

*Complete healing after screws removal. Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

Discussion
Autogenous bone grafts have been widely used to augment alveolar ridges affected by severe atrophy. Autogenous bone can be harvested from the intraoral and/or extraoral sites and can serve as a good treatment procedure for alveolar ridges augmentation. The present study showed that the corticocancellous block grafts, harvested from the anterosuperior edge of the iliac wing, was a reliable treatment with a high success rate for extensive reconstruction of atrophic maxillas. Morbidity was very low in all treated cases; moreover, the postoperative pain and gait disturbances were referred by only 6 out 56 patients until to the third week after surgery. The success rate of the autogenous grafts in this study (96.8%) was consistent with those reported by other authors.11,27,28 Sometimes the resorption of the edentulous maxilla can create a reverse maxillomandibular relation or an increased vertical distance between the jaws. The latter situation may require a vertical augmentation. In the present study, 37 block grafts were used for vertical augmentation and were responsible for the 4 failures observed in the whole study. Therefore, from these ndings it can be suggested that the failure rate for vertical augmentation was higher than for horizontal augmentation. The exposure of block grafts was observed in 4 patients. Three patients showed an early exposure that caused a partial necrosis of the graft and required complete removal, while the patient with the late exposure was easily treated with xation screw removal and implant placement. Although the number of cases was limited, it might be

Table 3. MARGINAL BONE LEVEL FOR 155 IMPLANTS PLACED IN AUTOGENOUS BLOCK GRAFT

Marginal Bone Level (mm) Mean SD Range

*Evaluation at implant placement.

Baseline* 0.3 0.4 01.6

6 Mo 0.1 0.3 01

Barone and Covani. Maxillary Alveolar Ridge Reconstruction. J Oral Maxillofac Surg 2007.

suggested that the time of exposure is a determining factor in the outcome of this complication. Some controversies still exist regarding the placement of implants simultaneously with bone grafting. Some authors have reported the placement of dental implants simultaneously with block grafts.11,29,30 One-stage surgery reduces the number of surgical interventions and the healing time. However, most of the authors have reported better results with the 2-stage than with the 1-stage approach.11,27,31,32 The ndings from the above reported studies have shown that the condition for implant integration was improved after an initial period of healing for the bone graft.33 This has been associated with the revascularization process of the block grafts allowing a good integration to the recipient site. Thereafter, when implants are placed the conditions can be considered similar to those of nongrafted bone. Several authors reported that membranous bone grafts maintain their volume to a greater extent compared with endochondral bone grafts.21,34,35 The reason for that could be that bone grafts of membranous origin have higher cortical bone quality than those of endochondral origin. Moreover, some other authors observed that cortical bone grafts will maintain their volume better than cancellous bone grafts, independent of embryogenic origin.22,23 The underlying mechanisms behind bone graft resorption are not still understood, but factors such as the microarchitecture of the graft, degree of vascularization during healing, and local trauma to the graft, might play a fundamental role. The cancellous portion of the bone grafts has an important function, stimulating the osteogenic cells and undifferentiated marrow cells to grow and lay down bone on their surface. Cancellous bone grafts revascularize much more quickly than cortical bone grafts; however, cortical bone is much stronger.36 The combination of cortical and cancellous bone in grafts promotes early vascularization and maximum graft maintenance. Corticocancellous bone grafts, harvested from the anterosuperior margin of the iliac wing, were used in this study. This is a different harvesting site compared with traditional sites such as the medial wall of the iliac crest. The present study showed reduced resorption for endo-

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7. Thorwarth M, Schultze-Mosgau S, Kessler P, et al: Bone regeneration in osseous defects using a resorbable nanoparticular hydroxyapatite. J Oral Maxillofac Surg 63:1626, 2005 8. Orsini G, Traini T, Scarano A, et al: Maxillary sinus augmentation with Bio-Oss particles: A light, scanning, and transmission electron microscopic study in man. J Biomed Mater Res 74B: 448, 2005 9. Donovan MG, Dickerson NC, Hellstein JW, et al: Autologous calvarial and iliac bone graft in miniature swine. J Oral Maxillofac Surg 51:898, 1993 10. Iturriaga MTM, Ruiz CC: Maxillary reconstruction with calvarium bone graft and endosseous implants. J Oral Maxillofac Surg 62:344, 2004 11. Sjostrom M, Lundgren S, Sennerby L: A histomorphometric comparison of the bone graft-titanium interface between interpositional and onlay/inlay bone grafting technique. Int J Oral Maxillofac Implants 21:52, 2006 12. Reinert S, Konig S, Bremerich A, et al: Stability of bone grafting and placement of implants in the severely atrophic maxilla. Br J Oral Maxillofac Surg 41:249, 2003 13. Astrand P, Nord PG, Branemark PI: Titanium implants and onlay bone graft to the atrophic edentulous maxilla: A 3-year longitudinal study. Int J Oral Maxillofac Surg 25:25, 1996 14. Marciani RD, Conty AA, Synhorst JB, et al: Cancellous bone marrow grafts in irradiated dog and monkey mandibles. Oral Surg Oral Med Oral Pathol 47:17, 1979 15. Enneking WF, Eady JL, Burchardt H: Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg Am 62:1039, 1980 16. Albrektsson T: Repair of the bone graft. Scand J Plast Reconstr Surg 14:1, 1980 17. Siebert JW, Angrigiani C, McCarthy JG, et al: Blood supply of the Le Fort I maxillary segment: An anatomic study. Plast Reconstr Surg 100:843, 1997 18. Pinkerton KC, Wimsmatt JA: A simple, atraumatic technique for the dissection of nasal mucosa during Le Fort I osteotomy. J Oral Maxillofac Surg 56:687, 1998 19. Zins JE, Whitaker LA: Membranous vs. endochondral bone: Implication for craniofacial reconstruction. Plast Reconstr Surg 72:778, 1983 20. Borstlap WA, Heidbuchel KLWM, Freihofer HPM, et al: Early secondary bone grafting of alveolar cleft defects: A comparison between chin and rib grafts. J Craniomaxillofac Surg 18:210, 1990 21. Iizuka T, Smolka W, Hallerman W, et al: Extensive augmentation of the alveolar ridge using autogenous calvarial split bone grafts for dental rehabilitation. Clin Oral Implant Res 15:607, 2004 22. Ozaki W, Buchman SR: Volume maintenance of onlay bone graft in the craniofacial skeleton: Microarchitecture versus embryologic origin. Plast Reconstr Surg 102:291, 1998 23. Rosenthal AH, Buchman SR: Volume maintenance of inlay bone graft in the craniofacial skeleton. Plast Reconstr Surg 112:802, 2003 24. Weber HP, Buser D, Fiorellini JP, et al: Radiographic evaluation of crestal bone levels adjacent to nonsubmerged titanium implants. Clin Oral Implants Res 3:181, 1992 25. Buser D, Weber HP, Bragger U, et al: Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study with hollow-cylinder and hollow-screw implants. Int J Oral Maxillofac Implants 6:405, 1991 26. Albrektsson T, Zarb GA, Worthington P, et al: The long-term efcacy of currently used dental implants: A review and criteria of success. Int J Oral Maxillofac Implants 1:11, 1986 27. Lundgren S, Rasmusson L, Sjostrom M, et al: Simultaneous or delayed placement of titanium implants in free autogenous iliac bone grafts. Int J Oral Maxillofac Surg 28:31, 1999 28. Schwartz-Arad D, Levin L: Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges. J Periodontol 76:636, 2005 29. Verhoeven JW, Cune MS, Ruijter J: Permucosal implants combined with iliac crest onlay grafts used in extreme atrophy of the mandible: Long-term results of a prospective study. Clin Oral Implant Res 17:58, 2006

chondral bone grafts, evaluating the bone loss around the xation screws (4 to 5 months after bone grafting) and the dental implants (6 months after placement). Implant treatment of severely resorbed maxillas is considered a demanding procedure showing a higher failure rate compared with the implant treatment of patients with adequate bone volume. The implant failure was divided into early (before loading) and late (after loading). Several studies on bone grafting technique reported that the rate of early implant failure was higher than the late failure.37,38 In the present investigation, the failure rate was 5.1%. It should be taken into account that all the implant failures occurred during the rst 6 months after placement and without any prosthetic treatment. The marginal bone level of 0.3 mm at the baseline was higher than the value of 0.1 mm 6 months after placement, which suggested an increase of the bone level after 6 months. On the contrary, the clinical evaluation using a probe showed a stability of the bone level. One interpretation was that the bone adjacent to the implants increased the mineralization and incorporation at the recipient site through time. In conclusion, the use of onlay block bone (harvested from the anterosuperior edge of iliac wing) for the reconstruction of severely atrophic maxillas has been shown to be a reliable treatment procedure. The success rate of the block grafts was very successful and comparable with those reported by other authors. Moreover, the augmentation procedure allowed the insertion of implants in the grafted area 4 to 5 months after surgery. The clinical and radiographic observations showed a very low rate of bone resorption after bone graft and implant placement. Therefore, on the basis of this preliminary study, iliac bone grafts from the anterosuperior edge of the iliac wing can be considered a promising treatment for severe maxillary atrophy.

References
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30. van Steenberghe D, Naert I, Bossuyt M, et al: The rehabilitation of the severely resorbed maxilla by simultaneous placement of autogenous bone grafts and implants: A 10-year evaluation. Clin Oral Invest 102, 1997 31. Lundgren S, Rasmusson L, Sjostrom M, et al: Simultaneous or delayed placement of titanium implants in free autogenous iliac bone grafts. Histological analysis of the bone graft-titanium interface in 10 consecutive patients. Int J Oral Maxillofac Surg 28:31, 1999 32. Triplett RG, Schow S: Autologous bone grafts and endosseous implants: Complementary techniques. J Oral Maxillofac Surg 54:486, 1996 33. Lundgren S, Nystrom E, Nilson H, et al: Bone grafting to the maxillary sinuses, nasal oor and anterior maxilla in the atrophic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg 26:428, 1997

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34. Mish CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997 35. Smolka W, Eggensperger N, Carollo V, et al: Changes in the volume and density of calvarial split bone grafts after alveolar ridge augmentation Clin Oral Implant Res 17:149, 2006 36. Burchardt H: The biology of bone graft repair. Clin Orthop Relat Res 174:28, 1983 37. Esposito M, Hirsch J-M, Lekholm U, et al: Biological factors contributing to failures of osseointegrated oral implants (I). Success criteria and epidemiology. Eur J Oral Sci 106:527, 1998 38. Joansson B, Wannfors K, Ekenbach J, et al: Implant and sinus bone grafts in 1-stage procedure on severely atrophied maxillae: Surgical aspects of a 3-year follow-up period. Int J Oral Maxillofac Implants 14:811, 1999