Advances in implantology have transformed modern dentistry, providing an effective and increasingly long-term solution for tooth loss.[i] However, resorption of the edentulous or partially edentulous alveolar ridge can compromise dental implant placement, and can present challenges in the rehabilitation of a severely atrophic maxilla.
Augmentation of insufficient bone volume can be required prior to or in conjunction with implant placement to ensure stability for long-term function and aesthetics.[ii] Once a patient has lost teeth, bone grafts are the only solution to reverse dental bone loss, and are used to treat resorption in about one-in-four dental implants.[iii]
Zygomatic implants are an increasingly effective solution for patients with a severely atrophic maxilla, and are used to treat patients who are unable or unwilling to undergo grafting treatments, or in cases where grafts or other interventions have failed. However, innovations in zygomatic implants have developed alongside promising new grafting techniques, biomaterials and treatments.[iv]
Patients with resorption so severe they required zygomatic implants in the past may be successfully treated today with new types of bone grafts, which are increasingly able to create a sufficient foundation for implants. In addition, growing evidence behind reduced diameter, short and ultra-short implants may have also changed what clinicians previously considered as the minimum available bone for conventional implant placement.[v]
Advances in the use of dental cone beam CT (CBCT) scans and imaging software also allow clinicians to perform a more accurate analysis of the alveolar and midface structures, including bone quality and volumetric measurements. Outcomes have been improved by innovations in virtual planning and guided surgery.[vi]
Bones and resorption
Bones are not static, but constantly changing to better carry out their functions as storehouses for minerals, maintaining vital structure and protection for the body. Resorption is part of a normal, essential cycle in the development of living bone.[vii] However, severe gingival inflammation or periodontal disease can cause excessive bone loss due to the direct damaging effect of bacteria, as well as the production of resorbing factors by white cells.[viii] The local immune response against periodontitis disturbs the homeostatic balance of bone formation and resorption in favour of bone loss.[ix]
In addition, once edentulism occurs, whether due to infection, trauma, surgery or congenital malformation, there is rapid resorption of alveolar bone due to lack of intraosseous stimulation by periodontal ligament (PDL) fibres.[x] This is further complicated in older patients, as the processes around bone regeneration are slowed.[xi]
Optimising the development of new bone
Bone grafting is possible because bone tissue has the ability to regenerate completely if provided the space and opportunity to 
grow. As natural bone grows, it should replace the graft material completely, resulting in a fully integrated region of new bone.[xii]
The development of science around bone grafts has been phenomenal in recent years, particularly in the development of synthetic bone substitutes. Autogenous bone was always considered the gold standard for reconstructive techniques due to its biocompatibility and having osteogenic, osteoconductive, and osteoinductive properties. However, autografts present some disadvantages such as the need for an additional surgical site, associated morbidity, and rapid resorption rate.[xiii]
Other natural biomaterials such as xenogenic grafts have been notable for low-content inflammatory reactions and high longevity. Synthetic biomaterials such as bioactive glasses are another promising choice for bone augmentation considering their notable neosynthesised bone and low amount of graft residue.[xiv]
Bioactive glass is used in combination with polymethylmethacrylate to form bioactive bone cement. Used on metal implants as a coating to form a calcium-deficient carbonated calcium phosphate layer, it facilitates osseointegration. Calcium phosphate materials can be mixed with ions such as strontium or with bone marrow aspirate to increase biological activity. The presence of strontium can result in higher bone mineral density.[xv]
Advanced study with those at the forefront of the discipline
To assist experienced implant dentists in incorporating the latest innovations into their practice, eminent Specialist Oral Surgeon, Professor Cemal Ucer and Professor Simon Wright MBE have developed the Advanced Certificate in Full Mouth Oral Implant Rehabilitation at ICE Postgraduate Dental institute and Hospital. As part of this highly structured, comprehensive course, there will be a review of the current use of grafting techniques and biomaterials in modern implantology. Alongside excellent lectures and mentoring support, there will be hands-on training in a number of advanced surgical options for treating the atrophic/fully edentulous jaw, including short implants, zygomatic implants and 3D printed customised implants.
Oral rehabilitation for a patient with severe loss of alveolar bone presents a challenge to clinicians. In a rapidly advancing field, advanced knowledge about bone grafting as well as other cutting-edge surgical methods will enable clinicians to offer the best support for their patients through life-changing treatment.
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
Professor Cemal Ucer (BDS, MSc, PhD, Oral Surgeon, ITI Fellow)
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
[i] Gargallo-Albiol J. How to Enhance Dental Implant Therapies and Definitive Restoration Outcomes to Reduce Complications and Improve Patient Well-Being. Materials (Basel). 2023 May 15;16(10):3730. doi: 10.3390/ma16103730. PMID: 37241357; PMCID: PMC10223492.
[ii] Mckenna Gj, Gjengedal H, Harkin J, Holland N, Moore , Srinivasan M,
Effect of autogenous bone graft site on dental implant survival and donor site complications: a systematic review and meta-analysis, Journal of Evidence-Based Dental Practice, Volume 22, Issue 3, 2022
[iii] Zhao R, Yang R, Cooper PR, Khurshid Z, Shavandi A, Ratnayake J. Bone Grafts and Substitutes in Dentistry: A Review of Current Trends and Developments. Molecules. 2021 May 18;26(10):3007. doi: 10.3390/molecules26103007. PMID: 34070157; PMCID: PMC8158510.
[iv] Polido WD, Machado-Fernandez A, Lin WS, Aghaloo T. Indications for zygomatic implants: a systematic review. Int J Implant Dent. 2023 Jul 1;9(1):17. doi: 10.1186/s40729-023-00480-4. PMID: 37391575; PMCID: PMC10313639.
[v] Polido WD, Machado-Fernandez A, Lin WS, Aghaloo T. Indications for zygomatic implants: a systematic review. Int J Implant Dent. 2023 Jul 1;9(1):17. doi: 10.1186/s40729-023-00480-4. PMID: 37391575; PMCID: PMC10313639.
[vi] Polido WD, Machado-Fernandez A, Lin WS, Aghaloo T. Indications for zygomatic implants: a systematic review. Int J Implant Dent. 2023 Jul 1;9(1):17. doi: 10.1186/s40729-023-00480-4. PMID: 37391575; PMCID: PMC10313639.
[vii] Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. 2, The Basics of Bone in Health and Disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45504/
[viii] Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. 2, The Basics of Bone in Health and Disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45504/
[ix] Hienz SA, Paliwal S, Ivanovski S. Mechanisms of Bone Resorption in Periodontitis. J Immunol Res. 2015;2015:615486. doi: 10.1155/2015/615486. Epub 2015 May 3. PMID: 26065002; PMCID: PMC4433701.
[x] Kumar P, Vinitha B, Fathima G. Bone grafts in dentistry. J Pharm Bioallied Sci. 2013 Jun;5(Suppl 1):S125-7. doi: 10.4103/0975-7406.113312. PMID: 23946565; PMCID: PMC3722694.
[xi] Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. 2, The Basics of Bone in Health and Disease. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45504/
[xii] Kumar P, Vinitha B, Fathima G. Bone grafts in dentistry. J Pharm Bioallied Sci. 2013 Jun;5(Suppl 1):S125-7. doi: 10.4103/0975-7406.113312. PMID: 23946565; PMCID: PMC3722694.
[xiii] Kumar P, Vinitha B, Fathima G. Bone grafts in dentistry. J Pharm Bioallied Sci. 2013 Jun;5(Suppl 1):S125-7. doi: 10.4103/0975-7406.113312. PMID: 23946565; PMCID: PMC3722694.
[xiv] Shamsoddin E, Houshmand B, Golabgiran M. Biomaterial selection for bone augmentation in implant dentistry: A systematic review. J Adv Pharm Technol Res. 2019 Apr-Jun;10(2):46-50. doi: 10.4103/japtr.JAPTR_327_18. PMID: 31041181; PMCID: PMC6474167.
[xv] Kumar P, Vinitha B, Fathima G. Bone grafts in dentistry. J Pharm Bioallied Sci. 2013 Jun;5(Suppl 1):S125-7. doi: 10.4103/0975-7406.113312. PMID: 23946565; PMCID: PMC3722694.
