The efficacy of horizontal and vertical bone augmentation procedures for dental implants - a Cochrane systematic review

Background: dental implants require sufficient bone to be adequately stabilised. For some patients implant treatment would not be an option without horizontal or vertical bone augmentation. A variety of materials and surgical techniques are available for bone augmentation. Objectives: to test whether and when augmentation procedures are necessary and which is the most effective technique for horizontal and vertical bone augmentation. Search methods: the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were hand searched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. The last electronic search was conducted on 11 June 2009. Selection criteria: randomised controlled trials (RCTs) of different techniques and materials for augmenting bone horizontally and/or vertically for implant treatment that reported the outcome of implant therapy at least to abutment connection. Trials were divided into two broad categories: horizontal augmentation and vertical augmentation techniques. Data collection and analysis: screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit of the analysis was the patient. Results: 13 RCTs out of 18 potentially eligible trials were suitable for inclusion. Three RCTs (106 patients) dealt with horizontal and 10 trials (218 patients) with vertical augmentation. Since different techniques were evaluated in different trials, only one meta-analysis could be performed. When comparing whether vertical augmentation procedures were more advantageous than short implants, a meta-analysis of two trials resulted in more implant failures OR = 5.74 (95% CI 0.92 to 35.82; borderline significance, P = 0.06) and statistically significantly more complications OR = 4.97 (95% CI 1.10 to 22.40) in the vertically augmented group. When comparing various horizontal augmentation techniques (three trials) no statistically significant differences were observed. When comparing various vertical bone augmentation techniques (eight trials) no statistically significant differences were observed except for three trials which showed that more vertical bone gain could be obtained with osteodistraction than with inlay autogenous grafts (mean difference 3.25 mm; 95% CI 1.66 to 4.84), and with bone substitutes rather than autogenous bone in guided bone regeneration (mean difference 0.60 mm; 95% CI 0.21 to 0.99) in posterior atrophic mandibles, and that patients preferred a bone substitute block over a block of autogenous bone taken from the iliac crest (OR = 0.03; 95% CI 0.00 to 0.64; P = 0.02). Conclusions: conclusions are based on few trials including few patients, sometimes having a short follow-up, and often being judged to be at high risk of bias. Various techniques can augment bone horizontally and vertically, but it is unclear which are the most efficient. Short implants appear to be a better alternative to vertical bone grafting of resorbed mandibles. Complications, especially for vertical augmentation, are common. Some bone substitutes could be a preferable alternative to autogenous bone. Osteodistraction osteogenesis allows for more vertical bone augmentation than other techniques, which, on the other hand, can allow for horizontal augmentation at the same time. Titanium screws may be preferable to resorbable screws to fixate onlay bone grafts. Keywords: autogenous bone, bone substitutes, randomised controlled clinical trial, systematic review