Autogenous bone graft harvesting

BONE HARVESTING FOR LOCALISED ALVEOLAR RIDGE DEFECTS

RAKESH CHANDRAN

• Localized alveolar ridge defect is intended to refer to a volumetric deficit of limited extent in bone and soft tissue within the alveolar process.

• Classified according to defect expanse as a one-, two-, three-, or four-tooth defect.

Localized alveolar ridge defect

Studer et al 1997. Adjustment of localized alveolar ridge defects by soft tissue transplantation to improve mucogingivalesthetics: a proposal for clinical classification and an evaluation of procedures. Quintessence Int.

Bone blocks can be processed in a bone mill to obtain particulate graftsTibia grafts can be performed in an outpatient setting

Indication for extraoral bone grafts

Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub

Site Indication

Tibia 5 – 40 mL uncompressed cancellous marrow

Anterior ilium 30 – 50 mL of corticocancellous marrow1- 5 cm corticocancellous bone block

Posterior ilium 40 – 120 mL uncompressed cancellous marrow4 – 12 cm corticocancellous bone block

Cranial bone corticocancellous bone block (onlay graft) for midface, orbital, zygomatic and nasal reconstructions


Posterior IliumAnterior Ilium

CraniumRib

Bone blocks can be processed in a bone mill to obtain particulate grafts

Greatest volume and greatest volume of cortical bone Ramus> Chin

Greatest volume of cancellous bone Chin> Ramus

Comparison of intraoral sites

Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence PubStern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmCarlson and Marx 1996. Mandibular Reconstruction Using Cancellous Cellular Bone Grafts. J Oral Maxillofac SurgNkenke and Neukam 2014. Autogenous bone harvesting and grafting in advanced jaw resorption: Morbidity, resorption

and implant survival. Eur J Oral Implantol

Site Indication

Chin 0.5 X 1.5 X 6 cm corticocancellous bone block

Mandibular ramus 0.4 X 3 X 5 cm mostly cortical bone block, J graft (thin)

Maxillary tuberosity 1 -3 mL cancellous marrow

• Proximity to recipient region• Possibility of simultaneous graft• Same embryonic origin- decreased resorption

Benefits of oral bone harvesting


Development of any given bone happens along one of two general pathways:1. Endochondral ossification: bone replaces a hyaline cartilage precursor (long bones

such as tibia, fibula, femur and iliac crest)2. Intramembranous ossification: direct mineralization of the organic matrix without

cartilage intermediate (bones of the cranio-facial complex with limited exception e.g. condylar process)

Membranous origin vs cartilaginous origin

Faverani et al 2014. Surgical techniques for maxillary bone grafting – literature review. Rev. Col. Bras. Cir.

• Comparative studies of craniofacial reconstructions in animals and man appears to show that intramembranous bone grafts tend to maintain their volume whereas endochondral grafts are associated with delayed, sometimes dramatic resorption and the associated implant success ranges between 25 – 86% (Jensen et al 2009).

• Membranous bone is superior to enchondral bone in maintaining volume in the initial phase following the augmentation procedure (Nkenke and Neukam 2014).

• For the bone, after reaching the embryonic ossification process, is “bone tissue”, with its unique characteristics, be it more cortical or more medullary. Thus is perhaps associated more with the rate of resorption of the different donor sites as opposed to the origin of the bone (Faverani et al 2014).

Membranous origin vs cartilaginous origin

Jensen et al. 1990. Reconstruction of the severely resorbed maxilla with bone grafting and osseointegrated implants: A preliminary report. J Oral Maxillofac Surg.Nkenke and Neukam 2014. Autogenous bone harvesting and grafting in advanced jaw resorption: Morbidity, resorption and implant survival. Eur J Oral ImplantolFaverani et al 2014. Surgical techniques for maxillary bone grafting – literature review. Rev. Col. Bras. Cir.

• Horizontal ridge augmentation• Vertical ridge augmentation• Sinus elevation procedures• Ridge preservation• Dental implant salvage

Utilization of bone grafting in implantology


Autografts are the gold standard

Properties of various grafting materials

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmMarx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub

Site Osteconductive Osteoinductive Osteogenic

alloplasts ✓

xenografts ✓

allograft ✓

recombinant human BMP ✓

autografts ✓ ✓ ✓

2 conflicting theories of bone graft healing • Osteoblastic theory- based on the belief that bone marrow and the periosteum

survived implantation and produced bone. • Induction theory- proposed that the entire graft underwent an aseptic necrosis

and was replaced (creeping substitution) by bone produced by the connective tissue stem cells of the host–recipient bed or host–bone ends. Bone necrosis was linked with new bone formation.

It is now known that the osteoblastic and induction theories of cancellous bone are not mutually exclusive. Current concept of cancellous cellular bone graft healing involves a 2-phased theory.

Graft healing

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmCarlson and Marx 1996. Mandibular Reconstruction Using Cancellous Cellular Bone Grafts. J Oral Maxillofac SurgMcAllister and Haghighat 2007. Bone Augmentation Techniques. J Periodontol.

• Cortical bone does not possess a high concentration of osteocompetent cells; therefore, maintenance of viable osteoblasts or osteoprogenitor cells becomes difficult.

• Revascularization (McAllister and Haghighat 2007)cortical bone autografts< corticocancellous block grafts < particulate autografts

• Aggressive recipient bed preparation with decortication, intramarrow penetration, and inlay shaping also has been supported to improve revascularization.

• Cortical bone, owing to its high lamellar concentration, has little surface area and is more susceptible to infection.

• It is absolutely crucial to maintain the soft tissue coverage over the graft. In the event that soft tissue cover is compromised, graft viability will be lost.

• The stabilization and intimate contact of these block grafts to the recipient bed has been considered crucial to a successful outcome. This can be achieved with the use of bone fixation screws or the simultaneous placement of dental implants.

Graft healing: cortical bone

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmMcAllister and Haghighat 2007. Bone Augmentation Techniques. J Periodontol.

1. Choose the least morbid harvest site, and harvest the graft with least morbidity2. Graft into a vascular tissue bed

Must imbibe nutrients from the recipient tissue bed for the first 3-5 days-Plasmatic circulation. Capillary ingrowth begins during day 3 and is complete by day 21

3. Graft into an infection-free and contamination-free tissue bedBecause the graft is not completely vascularised for 14-21 days, immunoglobulins and WBC have little access to the graft site, making the graft prone to infection

4. Ensure the stability of the graft for at least 21 daysThe capillaries sprouting are only 6-8 μm in diameter and are not able to resist the compressive or shear forces.

Principles of autogenous bone harvesting


Local apical infectionMetabolic bone disease (osteopetrosis, BRONJ, osteogenesis imperfecta etc.) pyknodystosis)Radiation therapyCysts or tumors

IV or oral bisphosphonate useLong term or current methotrexate or steroid medications

Smoking?

General contraindications or cautions


• “use of CT in combination with suitable software is a good method for determining the dimensions and surface of possible bone grafts.

• Furthermore, this is a more accurate method than that used by previous studies that involved the use of calipers or measured displaced saline for evaluation of the graft size.

• it is possible to perform planning of the implant position at the same time as making an analysis of the jaw for potential donor areas, by using a corresponding software program (Pro Plan 3.0)”

Evaluation of donor sites

Möhlhenrich et al 2015. Three-dimensional evaluation of the different donor sites of the mandible for autologous bone grafts. Clin Oral Invest

Harvesting techniques for particulate autogenous bone

1. cortico-cancellous block grafts harvested with a 6-mm trephine and ground to particulated bone chips in a bone mill

2. bone chips harvested with a sharp bone scraper 3. bone particles collected from the aspirator with a bone trap filter during the

preparation of the osteotomy4. bone particles harvested with a piezo-surgery device

Harvesting techniques for particulate autogenous bone

Miron et al 2011. Osteogenic Potential of Autogenous Bone Grafts Harvested with Four Different Surgical Techniques. J Dent Res.

Bone mill Bone scraper Bone trap filter

• Safescrapers, a specially designed cortical bone collector.• Safescraper can harvest bone chips up to 5 ml in length in a single scoop

• Particulate bone collected with the bone mill or by rotating electrical instruments appears to reduce the amount of viable bone cells supplied and impoverish the quality of the collected bone.

• Bone can be collected during implant surgery with bone trap filters, but they need an implant site and may incur microbial contamination.

Safescrapers

Zaffe and D’Avenia 2007. A novel bone scraper for intraoral harvesting: a device for filling small bone defects. Clin. Oral Impl. Res

Bone harvesting: Maxillary tuberosity

Bone harvesting from the maxillary tuberosity


Bone harvesting from the maxillary tuberosity


Bone harvesting from the maxillary tuberosity- complications


• Autogenous bone blocks result in higher gains in ridge height and width compared to particulate grafts

Consensus statements: autogenous bone block vs particulate bone in treating localized alveolar ridge defects

Chen et al 2009. Consensus statements and recommended clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants

Bone harvesting: Chin

Corticocancellous bone graft of limited size (1.5 x 6 cm) if taken across the midlineCortococancellous particulate graft (5 to 7mL) if processed in a bone mill

Bone harvesting from the chin-indications


Bone harvesting from the chin- anatomy


Bone harvesting from the chin- anatomy


McDonnell et al 1994. The mandibular lingual foramen: a consistent arterial foramen in the middle of the mandible. J. Anat.

Mandibular lingual foramen and lingual plexus

• 701 tapered fissure bur/ piezo• Saline/ PRP/ aluminium foil• Round bur/ bone file• Bone substitutes: allogenic/ xenograft or tricalcium phosphate hydroxyapatite cements• Collagen fleece• elastic tape (microfoam tape)• Cautery/ bone wax/ epinephrine or thrombin-soaked sponges.

Bone harvesting from the chin- preparation


Bone harvesting from the chin


A classic chin dressing—that is, placement of fluffed sponges or cotton rolls over the chin prominence and mentolabial crease followed by elastic tape (microfoam tape is best) with crossover slits—is recommended. These crossover slits at the end of the elastic tape allows the inferior segment and superior segments to overlap, which applies a greater adaptation to the chin and makes it a true pressure dressing.

Bone harvesting from the chin- dressing


• Non abrasive soft diet for 1 week• Dressing removed after 5 days• Ice not recommended as the dressing prevents benefits

Bone harvesting from the chin- post operative


• Rare• most common-paresthesia of the lower lip vermillion• Damage to apices of incisor or canine roots• Bleeding- intraoperative- cautery (if brisk- bone wax –always keep in stock)- or

surgical, or temporary packing with epinephrine or thrombin-soaked sponges.• Assure the patient that a hematoma or ecchymosis may occur (esp fair skin)

• If site worsen with infection- after even antibiotics and culture- after 3 days- wound exploration for cultures, debridement, and irrigation with 0.12% chlorhexidine is recommended.

Bone harvesting from the chin- complications

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmMarx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub

Bone harvesting: Mandibular ramus

A thin cortical block of limited size (0.4 X 3 X 5cm)Possibility of harvesting from both sides to obtain double the volume

Utilization• Horizontal ridge augmentation in the anterior maxilla that overlaps onto the ridge

crest—known as a ‘J’ graft• General horizontal or vertical ridge augmentation of either the maxillary or

mandibular ridge as site preparation for dental implants

Limitations• The graft is almost 100% cortical bone.

Bone harvesting from the mandibular ramus- indications and utilization


Bone harvesting from the mandibular ramus- anatomy


Bone harvesting from the mandibular ramus- anatomy


• Rare• Inferior alveolar nerve injury- avoid by concluding the innermost part of the

osteotomy 5mm above the radiographic presentation of the mandibular canal, also instrument against the inner cortical wall allows a layer of trabecular bone between graft and nerve

• If damage occurs- immediate microneural reanastamosis/ epineural nerve repair or refer for secondary repair to be done within 3 months

• After 3 months, nerve regeneration rapidly declines up to 6 months after which one cannot expect much nerve regeneration with a microneural repair.

• If no nerve injury is observed but post operative paresthesia of the lip and chin region, best avoid re-entry and allow the nerve to recover. Maximum return of sensation is complete within 6 to 9 months

• Lingual nerve injury• Hematoma• Wound infection• Fracture

Complications


• Mandibular bone blocks (external oblique ridge), which consist primarily of cortical bone and a low percentage of cancellous bone, are more resistant to revascularization and consequently may have poor regeneration potential. For this reason, the harvested thick bone blocks were split into two thin bone blocks with the diamond disk according to the split bone block technique of the biologic concept of grafting procedures.

• Splitting the thick blocks into two thin blocks not only increases the number of bone blocks, offering the possibility to graft more surfaces in different forms, but also improves revascularization and regeneration.

• The thin blocks were stabilized at the recipient site with microscrews, and any gaps were filled with autogenous bone chips harvested from the donor site with a bone scraper.

• No biomaterials or membranes are used. • This technique with pure autogenous bone, which has been used for 20 years, has

shown a high success rate.

Khoury technique/ split bone block technique/ shell technique

Khoury and Hanser 2015. Mandibular Bone Block Harvesting from the Retromolar Region: A 10-Year Prospective Clinical Study. Int J Oral Maxillofac Implants

Khoury technique- Micro-Saw®

• The MicroSaw® consists of a thin diamond disk with a diameter of 8 mm that is mounted on an angle piece or a hand piece, with a disk protector to prevent any injuries of the soft tissue.

• Three osteotomies are performed with the diamond disk: two proximo-vertical and one baso-horizontal. The final osteotomy, on the occlusal crestal site, is achieved with a thin, 1-mm drill bur because of poor access to this site with the MicroSaw


• Donor sites, treated with collagen fleece, usually healed without re-formation of the lamina dura of the external oblique line.

• Regeneration of the donor site was nearly complete, if one of the blocks left after grafting was replaced at its donor site. This was shown clinically within 6 to 40 months when reentry of the harvested area was performed and radiologically within 18 to 36 months when a CBCT scan was made.

• Because the diamond disk in the MicroSaw is thin, it makes a precise osteotomy, and in 47.1% of cases, half bone blocks were placed back into the donor site within the contour of the external oblique line over the collagen fleece, without the need for a stabilizing screw. The remaining 52.9% of repositioned bone blocks were stabilized with a small screw. In all cases, a well regenerated and healed external oblique ridge was found.

• The complete regeneration of the donor site allows for future re-harvesting of a well dimensioned bone block if needed for another bone augmentation procedure

Khoury technique- modified


Harvesting the bone shells and extraoral trimming with a cutting wheel is very technique-sensitive. Additional harvesting of bone chips is also necessary. Therefore, the authors modified and simplified this technique.

Modified shell technique

Stimmelmayr et al 2012. Use of a modified shell technique for three-dimensional bone grafting: description of a technique. Aust Dent J

Stimmelmayr et al 2012. Use of a modified shell technique for three-dimensional bone grafting: description of a technique. Aust Dent J

Palatal bone block

Gluckman et al 2016. The Palatal Bone Block Graft for Onlay Grafting Combined with Maxillary Implant Placement: A Case Series. Int J Periodontics Restorative Dent.

Saline• Preserves more than 95% of graft cell viability for at least 4 hours

Platelet rich plasma• Growth factors in PRP bind to cell membranes and act to upregulate

osteocompetent cell proliferations during this time their cell adhesion molecules enhance the matrix of the graft by connecting the mineral components

Aluminium foil?• foil protects the graft from airborne bacteria and fungi spores, and retains

moisture so that the graft does not dry out as quickly.

Never water• Due to an osmotic gradient, the hypotonicity of water causes the cells to swell and

burst

Storage of harvested bone


• The symphysis has lower associated morbidity compared with ramus (Stern and Barzani 2015).

• The mandibular ramus was preferred by the patients. Patients’ acceptance of chin bone harvesting was low. Patients even preferred iliac crest bone harvesting over bone harvesting from the chin, although this distant donor site required general anaesthesiaand a hospital stay (Nkenke and Neukam 2014).

COMPARISON OF MORBIDITY OF ORAL SITES

Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N AmNkenke and Neukam 2014. Autogenous bone harvesting and grafting in advanced jaw resorption: Morbidity, resorption

and implant survival. Eur J Oral Implantol

• Bone harvesting from the mental symphysis is associated with relevant morbidity, and the quantity of available bone is frequently limited. Neural damage to the incisal nerve occurs frequently. Therefore, the mental symphysis should not be the first choice for harvesting.

• Bone harvesting from the maxillary tuberosity is followed by low morbidity but is not well documented. The quality and quantity of available bone is often poor. Indications are limited to reconstruction of small defects.

• Bone harvesting from the mandibular ramus offers good quality and quantity of available bone, due to the possibility of harvesting from both sides.

Consensus statements


Recombinant human BMP

Among all of the BMPs that were examined, BMP-2, 6, and 9 may be the most potent agents to induce osteoblast lineage-specific differentiation of mesenchymal progenitor cells while most BMPs can effectively promote the terminal differentiation of committed osteoblastic precursors and osteoblasts. It is conceivable that combinations of BMPs also may be able to induce osteogenesis in early mesenchymal stem cells.

Osteogenic hierarchy of BMPs

Cheng et al 2003. Osteogenic Activity of 14 types of human BMPs. JBJS

1. RhBMP2• rhBMP2 100% active (filter sterilized)• 1.5mg/cc

2. Absorbable Collagen sponge• Type 1 bovine collagen sponge• Binds BMP to localize concentration• Over 20 years of clinical use

INFUSE Bone graft (Rh-BMP2/ACS)

Wiki

INFUSE Bone graft (Rh-BMP2/ACS) kit

INFUSE BONE GRAFT. MEDTRONIC. www.infusebonegraft.com. Assessed 12 Sep2016

Total graft volume 0.7cc

Sterile water for injection Sterile rhBMP-2 Sterile absorbable collagen sponge

The sterile water is drawn up into the supplied syringe and injected into the vial of powdered rhBMP-2. Allow 5 minutes for complete dissolution of rhBMP-2. After 5 minutes, the solution is drawn up and added to the acellular collagen sponge a drop at a time until the entire sponge/sponges are wetted. Wait 15 minutes.

• Placed into a bony defect, the bound BMP in the acellular collagen sponge is chemotactic to stem cells and preosteoblasts. As these cells migrate into the sponge, they undergo proliferation and differentiation into osteoblasts, which then synthesize osteoid. Once this process is initiated, the osteoid will undergo the standard resorption-remodeling cycle of bone to a mature ossicle in 6 months

Mechanisms of Action


• tissue healing is limited by cell capabilities during the described phases of bone healing with cell recruitment, chemotaxis, differentiation, and specific tissue matrix production and cannot be speeded beyond biological limits by external growth factors.

• application of growth factors and their influence on adult and embryonic stem cells and differentiated tissues bears the risk of carcinogenic transformation

Concerns with regard to rhBMP2/ACS

Draenert et al 2013. Vertical bone augmentation procedures: Basics and techniques in dental implantology. J Biomed Mater Res Part A 2014

Nkenke and Neukam 2014• 24 studies were included in the review• The data on implant survival and success do not allow the identification of a bone graft

that is associated with a significant improvement of these parameters. Even with complete resorption of the grafted bone, an implant survival rate of 100% can be reached. It seems that the type of bone graft has only a limited influence on implant survival and success.

• Instead, confounders like the type of implant installed seem to have a major influence on implant survival and success.

IMPLANT SURVIVAL AND SUCCESS

Nkenke and Neukam 2014. Autogenous bone harvesting and grafting in advanced jaw resorption: Morbidity, resorption and implant survival. Eur J Oral Implantol

• Autogenous bone blocks result in higher gains in ridge height and width compared to particulate grafts.

• Accurate modeling and stabilization of the graft with screws, and tension-free primary closure of the overlying flaps, are fundamental for the success of the procedure.

• Overcorrection of the defect is recommended to compensate for the potential risk of bone resorption.

• Coverage of the bone grafts with a low-resorption—rate xenograft/alloplastic material, with or without a membrane, may be indicated to reduce bone resorption.

• Use of membranes does not significantly influence the outcome.• The predictability of vertical ridge augmentation is substantially lower and the

complication rate substantially higher than with horizontal ridge augmentation procedures.

• Survival rates of implants placed in augmented alveolar ridges are high.

Conclusion- Consensus statements


Thank you for your attention

To compare volumetric changes after sinus augmentation of completely edentulous maxillae with either autogenous or allogeneic fresh-frozen bone particles.MATERIALS AND METHODS:This split-mouth study in patients who required bilateral sinus grafting used autograft particles for one sinus and allograft particles for the contralateral sinus. The grafted sinuses were left to heal for 6 months prior to implant insertion. All patients underwent four computed tomography scans: prior to augmentation and 1 week, 6 months, and 12 months after grafting. Computer software was used to analyze bone graft volume in each scan.

Maxillary Sinus Grafting with Autograft Versus Fresh-Frozen Allograft

Xavier et al 2015. Maxillary Sinus Grafting with Autograft Versus Fresh-Frozen Allograft: A Split-Mouth Evaluation of Bone Volume Dynamics. Int J Oral Maxillofac Implants

RESULTS:Fifteen patients (8 men, 7 women) with a mean age of 54 ± 5 years (range, 48 to 60 years) took part and underwent 30 sinus augmentation procedures. Mean autograft and allograft volumes were not statistically significantly different at each time point (1 week: 2.01 ± 0.43 cm³ vs 2.46 ± 0.79 cm³; 6 months: 1.53 ± 0.49 cm³ vs 1.75 ± 0.64 cm³; and 12 months: 1.38 ± 0.43 cm³ vs 1.59 ± 0.56 cm³, respectively). Mean volumetric reductions of 31.35% and 35.36% (23.9% and 29.9% in the 6 months prior to implant insertion, followed by an additional 9% and 9% in the following 6 months), relative to 1 week postgrafting, were noted for the autograft and allograft groups, respectively, after 12 months.CONCLUSION:On the basis of this split-mouth study of 15 patients, there was no statistically significant volumetric difference after 12 months between the use of autograft or allografts for sinus augmentation. Fresh-frozen bone allograft may serve as an alternative that avoids the morbidity associated with autograft harvesting.

Maxillary Sinus Grafting with Autograft Versus Fresh-Frozen Allograft

Xavier et al 2015. Maxillary Sinus Grafting with Autograft Versus Fresh-Frozen Allograft: A Split-Mouth Evaluation of Bone Volume Dynamics. Int J Oral Maxillofac Implants

Literature regarding the outcome of maxillary sinus floor elevation to create sufficient bone fraction to enable implant placement was systematically reviewed. Bone fraction and implant survival rate were assessed to determine whether grafting material or applied growth factor affected bone fraction. Trials where sinus floor elevations with autogenous bone (controls) were compared with autogenous bone combined with growth factors or bone substitutes, or solely with bone substitutes (test groups) were identified; 12 of 1124 fulfilled all inclusion criteria. Meta-analyses comparing the bone fraction after applying: autogenous bone; autologous bone with growth factors (platelet rich plasma); or autogenous bone and bone substitutes (bovine hydroxyapatite, bioactive glass, corticocancellous pig bone) revealed no significant differences in bone formation after 5 months.

Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes.

Rickert et al 2012. Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. Int J Oral Maxillofac Implants

A significantly higher bone fraction was found in the autogenous bone group compared to the sole use of β-tricalciumphosphate (P=0.036). The one-year overall implant survival rate showed no significant difference between implants. Bone substitutes combined with autogenous bone provide a reliable alternative for autogenous bone as sole grafting material to reconstruct maxillary sinus bony deficiencies, for supporting dental implants after 5 months. Adding growth factors (platelet rich plasma) to grafting material and the sole use of β-tricalciumphosphate did not promote bone formation.

Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes.

Rickert et al 2012. Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. Int J Oral Maxillofac Implants

Health & Medicine

Autogenous bone graft harvesting