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REVIEW ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 46-50  

Biomaterial selection for bone augmentation in implant dentistry: A systematic review


1 Student, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Periodontics, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Private Practitioner, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication12-Apr-2019

Correspondence Address:
Mr. Behzad Houshmand
Department of Periodontics, Dental School, Shahid Beheshti University of Medical Science, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japtr.JAPTR_327_18

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  Abstract 


In the present study, a systematic review was conducted to evaluate the biomaterials and their effectiveness for bone augmentation in implant dentistry. The databases of Cochrane Library, Google Scholar, PubMed (National Center for Biotechnology Information), and Scopus were searched for published studies between 2006 and March 30, 2018. We only included clinical studies in this research. Due to a lack of quantitative evidence and the vast heterogeneity of the biomaterials, implant surgery sites, implant types, follow-up periods, and various implant placement techniques (1-stage or 2-stage), we could not manage to do a meta-analysis on the 13 included studies. Several techniques can result in vertical bone augmentation. Complications can be seen in vertical bone augmentation and especially in the autogenous bone grafting; however, some biomaterials showed promising results to be practical substitutes for autogenous bone. Bio-Oss and beta-tricalcium phosphate are our second-level candidates for vertical bone augmentation due to their promising clinical results with the least infection and immunologic response risk. The gold standard, however, remains the autogenous bone graft. Further clinical studies in the future with exact report of bone measures are needed to develop new comparisons and quantitative analyses.

Keywords: Biomaterial, dental implant, osteoconduction, osteogenesis, osteoinduction, vertical bone augmentation


How to cite this article:
Shamsoddin E, Houshmand B, Golabgiran M. Biomaterial selection for bone augmentation in implant dentistry: A systematic review. J Adv Pharm Technol Res 2019;10:46-50

How to cite this URL:
Shamsoddin E, Houshmand B, Golabgiran M. Biomaterial selection for bone augmentation in implant dentistry: A systematic review. J Adv Pharm Technol Res [serial online] 2019 [cited 2021 Dec 5];10:46-50. Available from: https://www.japtr.org/text.asp?2019/10/2/46/256012




  Introduction Top


Augmenting alveolar bone tissue around the dental implants is of great concern due to its critical role in the long-term treatment success.[1] We focused on the vertical alveolar ridge augmentation technique for this study. Due to an increase in peri-implantitis conditions in the past decade, it is crucial to provide the best bone augmenting biomaterial to accomplish the best treatment results. Tissue engineering is one of the most critical and expanding fields, which mainly cooperates with regenerative medicine and has indicated a remarkable potential in clinical dental practice applications. Biomaterials are one of the three basics in tissue engineering, namely cells, scaffolds/biomaterials, and growth/differentiation factors.[2],[3],[4],[5] Considering their role, many biomaterials have been applied and suggested to use as an alternative to the autogenous bone which is still the gold standard for bone augmentation.[6] Aside from autogenous, xenogenic, and allogenic grafting materials, other natural and synthetic biomaterials have also been playing critical roles in dental clinical cases.[7] Till today, different types of these biomaterials have established their practical roles in dental clinics mainly based on their ease of application and predictable results. To decide which biomaterial to choose, we should consider some factors to mimic the autogenous bone structure, e.g., crystal structure, micro- and macroporosity, and intercrystalline spaces.[8] Chemical, physical, and mechanical properties of the scaffolds should be as similar as possible to that of a natural bone structure.[9],[10] A good bone substituting scaffold should be settled by the resident bone cells or undifferentiated mesenchymal cells.[11],[12],[13] Various biomaterials have been applied into the bone defects using different surgical techniques. Autogenic, allogenic, xenogenic, and synthetic biomaterials are currently on-the-board options for a dental bone grafting process. Lack of immunological responses and a high-volume augmented bone can be considered as the main advantages of autogenic grafts, while they showed a higher infection rate. Other natural biomaterials such as xenogenic grafts can also be encouraged due to their low-content inflammatory reactions and high longevity.[14] Synthetic biomaterials such as bioactive glasses are also another promising choice for bone augmentation considering their notable neosynthetized bone and low amount of residual graft. We retrieved relevant studies about alveolar bone augmentation in implant dentistry and systematically reviewed them based on the PRISMA protocol. This study aimed to systematically review the biomaterials and their effectiveness for bone augmentation in implant dentistry.


  Methods Top


Searching and selection of studies

We have searched four databases of Google Scholar, PubMed, Scopus, and Cochrane Library with the keywords, “Biomaterials,” “Bone Augmentation,” and “Dental Implant.” Searching query was modified for each database if needed to achieve most relevant studies. Then, we collected data, based on the relevance to the study topic and the main objective. Any conflicts between the authors were resolved by abstract and full-text reading to determine the criteria which were used in the studies. Twenty-one studies were chosen according to the title skimming and abstract screening, and then the references of these studies were manually searched and checked in Google Scholar. After removing duplicates, we added the relevant ones based on the title and abstract screening. Only clinical trials and case reports were included; the exclusion criteria were as follows: studies which included patients with any systemic disease (e.g., diabetes, cancer, and angina pectoris) and patients older than 65 years of age or younger than 15 years, studies with implant surface modification interventions or maxillary sinus lifting or sinus floor augmentation procedures, non-English language studies, and those reflecting information from before 2006. In the final step, inclusion was according to a consensus between the two authors and 13 studies were chosen for data extraction.

Risk of bias and quality of studies

Both authors independently evaluated the risk of bias for the studies using the Cochrane Collaboration's tool for clinical trials named as grades of recommendation, assessment, development, and evaluation (GRADE) [Supplementary Table 1]. Furthermore, the complications, blinding, source of funding, sample size, and the inclusion and exclusion criteria were assessed for each study. The risk of bias was determined based on these evaluations as “low,” “moderate,” or “high.” Conflicts between the authors were resolved by a consensus. Finally, the overall quality of each study was defined as “high” or “moderate” using the GRADEpro online service. Also, the “importance” of each study was determined by a consensus between authors, based on all of the evaluations in a range from 1 to 9 as defined in the GRADE protocol. The importance of studies was reported as “not important,” “important,” or “critical” according to their related scores.



Measures of treatment effect

The mean vertical bone augmentation at implant sites and peri-implant marginal bone losses were reported as we did not get enough statistical data to calculate the standard error. The unit of analysis to determine the study quality was the number of implant abutments. Within final studies, we did not find necessary data for the analysis; thus, we sent E-mails to the electronic links or E-mail addresses provided in the studies, but we did not get any response back from them. In the other six studies, weighted mean differences and standard deviations with 95% confidence intervals were used for each study to express the effect measures on continuous outcomes (i.e., vertical bone augmentation and peri-implant marginal bone loss).

Software and applications

The Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014. of Cochrane Library was used to create the flow diagram of searching and selecting the studies. The GRADEpro online service was used to create the study quality table. The tables of quantitative and qualitative analysis were created by excel software (Microsoft, Redmond, Washington, 2016), and all of the references were inputted by Endnote (Version X7, Thomson reuters, Canada).


  Results Top


The search results and the number of chosen studies in each step are shown in [Figure 1].
Figure 1: Study selection flow chart

Click here to view


Some qualitative [Supplementary Table 2] and quantitative [Supplementary Table 3] data were extracted.



The risk of bias in the included studies was determined by Cochrane's GRADEpro online tool [Supplementary [Table 1]. Vertical bone augmentation was considered as the first continuous outcome and the second continuous outcome was peri-implant marginal bone loss. Due to a lack of evidence, the measurement of effect size and heterogeneity assessment was not accomplished and no meta-analysis could be done.


  Discussion Top


We aimed to systematically review the biomaterials and their effectiveness for bone augmentation in implant dentistry. Between the included studies, three articles have used autogenous bone fragments. Autogenous bone grafts exhibit three main features as being osteogenic, osteoconductive, and osteoinductive.[7],[15]

Iliac crest bone and bovine anorganic bone were used in two different groups of patients in a randomized controlled trial. The residual graft in the xenograft group (bovine bone) was significantly more than the autogenous bone. The main advantage of the xenograft over the autogenous graft was reported as its less invasiveness.[16] Also, a mixture of autogenous bone and anorganic bovine bone in association with micro-titanium mesh were used for bone augmentation in another case series.[17]

We observed that a mixed xenograft material (Bio-Oss) with autogenous bone and a collagen or titanium mesh membrane as a part of GBR technique can provide an adequate bone augmentation during 6 months after grafting without any specific bone resorption in the follow-up periods.[18]

Bio-Oss was the most common material being used in our data and showed some promising results comparable to autogenous bone grafts in every study.[19] Some of the best characteristics featured about this material can be listed as follows: adequate new bone formation, low reabsorption rate, osteoconductive characteristics, and compensation for the natural bone resorption caused by remodeling.[19] Bio-Oss has also been applicated in sinus floor elevation,[20] extraction socket filling,[21] and treatment of periodontal defects.[22]

Another randomized clinical trial has used autogenous demineralized dentin matrix (AutoBT) from the extracted tooth in comparison with anorganic bovine bone (Bio-Oss) for bone augmentation. Their work showed that AutoBT exhibits osteoconductivity and biocompatibility comparable to Bio-Oss.[23]

Beta-tricalcium phosphate (β-TCP) scaffold materials are eminent as bone substitutes according to their biocompatibility, practically extensive availability, ease of sterilization, long shelf life, and low infection risk.[24] β-TCP exhibits a good balance among absorption, degradation, and new bone formation and can also sustain its structural stability by discharging a large quantity of calcium (Ca2+) and sulfate (SO42−) ions, which are crucial inorganic salts for new bone formation.[25],[26]

β-TCP granule-scaffolds with sizes of 1 mm and 1–2.5 mm can also improve the proliferation of BMSCs and promote the expression of osteogenic genes and osteogenesis-related proteins.[12]

Two case series studies had used β-TCP and bioactive glass as the filling biomaterials. Autologous bone marrow-derived mononuclear cells (BMMNCs) were combined with β-TCP, and the role of BMMNCs in reducing early absorption of β-TCP alloplasts in the implant sites was asserted.[24] Bioactive glass provided adequate bone height for implant placement without any complications for implant stability and peri-implant tissue health.[27] The most important aspect here was the “osteostimulation” effect of bioactive glass.[14],[28]

Our data also showed the effectiveness of xenogeneic biomaterials alone to augment the bone defects. Porcine-derived bone and flexible equine bone sheets without membranes have also yielded insufficient bone augmentation for implant placement with no significant resorption of the graft material during a 3-year follow-up period.[29],[30]

Cecchetti et al.[31] showed enough bone preservation after tooth extraction using deproteinized bovine bone mineral to conduct an implant-supported treatment.

The limitations of our systematic review were the heterogeneity in the implant sizes, the different timing of implant placement, the technique of placement (1-stage or 2-stage), and also lack of studies using a single type of scaffold to specifically evaluate its effect. The included studies have used different antibiotic regimens before and after bone grafting for their patients which could possibly affect the bone augmentation results. Various sites of implant placement and different characteristics of bone regions in the maxilla and mandible were the most important limiting factors in our study, and we did not sort our results based on the implant placement locations due to their wide heterogeneity.


  Conclusions Top


Several biomaterials have been used for bone augmentation in implant dentistry, but there are not enough predictable results to show one or more of them as an alternative to the autogenous bone. In general, after the autogenous grafts, we can introduce the Bio-Oss and β-TCP as the most trusted and widely used biomaterials in the xenogenic and synthetic biomaterial categories of grafting materials in dentistry, respectively. These two can give predictable, sustainable, and adequate new bone formation with the least infection rates in implant placement cases, which is the current goal of vertical bone augmentation in dentistry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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