Bone Biology, Harvesting, Grafting for Dental Implants: Rationale and Clinical Applications Arun K. Garg

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Bone Biology, Harvesting, Grafting for Dental Implants: Rationale and Clinical Applications Arun K. Garg
March 2005
Kraut, Richard A. DDS
Section Editor(s): English, Charles E. DDS, MDS, PhD; Kraut, Richard A. DDS
Implant Dentistry: Volume 14(1) March 2005 pp 12-13
Lippincott Williams & Wilkins
Bone Biology, Harvesting, Grafting for Dental Implants: Rationale and Clinical Applications Arun K. Garg, 279 pp., illustrated. Chicago: Quintessence Publishing; 2004.
Bone Biology, Harvesting, Grafting for Dental Implants is an ambitious book with beautiful color photographs and illustrations. The subject matter, bone augmentation for dental implant therapy, is an important one that is of interest to many dental practitioners. According to the author, the book is directed primarily toward advanced clinicians in periodontics and oral and maxillofacial surgery.
The first section-bone biology-includes chapters on physiology, grafting materials, barrier membranes, and alveolar ridge preservation. Chapter One provides a concise review of bone physiology. The author reminds the reader that bone regeneration is an ongoing process. Approximately 0.7% of the human skeleton is resorbed and replaced by new bone each day; in approximately 142 days, the entire skeleton is replaced. Chapter Two is a review of graft materials. The information is summarized in a well-structured table at the end of the chapter. Graft materials are divided into three categories: autogenous, allografts, and alloplasts. For each graft material, the reader is given an approximate resorption time, a designation of relative quality of the material vis-?Ü-vis bone formation, and a relative cost per application. No histology is presented in support of the quality designations, although the extensive references to literature are included. Much of this information is repeated in the chapters on alveolar ridge and maxillary sinus augmentation. Chapter Three is a review of membrane materials and includes a helpful table similar to the one for graft materials. Once again, no histology is presented. Chapter Four takes the reader through the process of using graft material and membranes to preserve the alveolar ridge. The author uses nomenclature from periodontal literature in categorizing defects according to the number of bony walls that remain intact after extraction. With the array of products and techniques available today, advanced clinicians with extensive grafting experience may find that their own techniques, and the materials they use, differ significantly from those suggested by the author.
In the second section, Chapters Five through Seven offer concise, easy to follow technical guidance on harvesting bone from the mandibular ramus and symphysis as well as the tibia. All three chapters are superbly illustrated with relevant anatomical structures clearly identified. Tibial harvesting will be new to some readers but the author presents the technique with appropriate detail and emphasis on the need for true sterility. The author completes the chapter by providing the clinical and radiographic records of a patient whose antra were grafted with tibial bone and then reconstructed with endosteal implants. The photographs in these chapters could serve as an excellent resource for clinicians wanting to review surgical techniques that they don't use on a day-to-day basis. Text accompanying the photographs is detailed and precise though somewhat difficult to follow in the paragraph format. The lack of significant discussion and illustration of techniques for harvesting bone from the iliac crest makes this chapter of less value to oral and maxillofacial surgeons.
The third section-bone grafting-includes chapters on augmentation of the maxillary sinus, the maxillary anterior alveolar ridges, and subnasal elevation and augmentation. Chapter Eight provides a brief historical perspective on maxillary sinus augmentation and then focuses on the lateral approach. The author provides a brief review of graft materials. Within this chapter, Dr. Garg discusses the use of CT scans and provides helpful diagrams for those clinicians not familiar with interpreting scans. As with the rest of the text, the illustrations are plentiful and serve to provide ample guidance for those who wish to review both anatomy and technique. The cases used to illustrate this chapter are diverse and representative of clinical presentations readers will encounter in practice. As with the rest of the text, the references abound, there are 76 in this chapter alone.
Chapter Nine provides an excellent discussion of procedures for maxillary anterior alveolar ridge augmentation. Implant therapy and bone augmentation for the anterior maxilla is particularly challenging since it is of major aesthetic consequence to patients. The chapter discusses treatment for single and multiple tooth sites. This chapter also shows the importance of surgical guides when reconstructing the anterior maxilla. Those not familiar with the use of surgical guides for reconstruction of the anterior maxilla will find Figure 9-5 particularly useful. Repetition of the material from Chapter Six on harvesting of bone from the symphysis is helpful since it puts the material within the context of treatment techniques and procedures.
Chapter Ten discusses subnasal elevation and bone augmentation, procedures that are less common than others discussed in the text. However, their inclusion serves to enhance the stature of this book as a comprehensive guide to grafting. This chapter includes a beautifully illustrated discussion of both block and particulate grafts for the subnasal area.
The final section-future directions-addresses growth factors and bone morphogenetic proteins. The author provides a tempting glimpse into the future. If further research shows that bone morphogens and growth factors can significantly improve bone generation, and if resulting products can be adapted to the dental market, much of what is contained in this book will become significant only from a historical perspective.
As a clinician, I approach most topics based on the need to solve a problem. The organization of this book makes that approach difficult. Readers must go through 97 pages of material on bone physiology, graft materials, and membranes before they are presented with any significant discussion about why or how those materials are relevant to specific patient treatment. Much of the preliminary material is repeated in the context of describing and illustrating techniques and procedures for harvesting or augmentation. The information seems more appropriate and more accessible when placed within the context of those discussions. Furthermore, as a result of the book's organization, many photographs, diagrams and considerable text are repeated, sometimes more than once. More pictures of clinical cases, with short- and long-term results (including histology) would add value for the reader.
Poor editing is evident throughout the book and detracts from the excellent material presented. Some errors should have been identified by the most rudimentary of word processing software. Other errors are more significant. For example, the first sentence in the second chapter reads, Although alveolar bone can be a contraindication for dental implants, bone grafting can provide the structural or functional support necessary in such cases. Clearly it is the lack of alveolar bone that is a contraindication for implant therapy. Furthermore, in a number of instances, editing has slightly altered meaning. For example, the text states, Because grafted bone integrates with implants to a higher degree than does natural host bone, bone grafting is recommended around implants placed in sites where bone volume or density is deficient or where there is a history of implant failure. Rather I believe the author intended that the sentence should read Where bone volume or density is deficient, or where there is a history of implant failure, bone grafting is recommended since, other things being equal, implants will integrate with grafted bone to a higher degree than with low volume, low density natural host bone. The first sentence incorrectly suggests that in all cases grafted bone is better than natural host bone.
This book provides a wealth of information on an important topic and as such will be a valuable resource for those clinicians who use bone augmentation as part of their practice. The author provides a reasonable structure for comparison of the many grafting and membrane materials that are available to the clinician. Further, the author has provided an extensive bibliography that will enable readers to further advance their understanding. Photographs, diagrams, and text outlining techniques for harvesting and application of graft materials are outstanding.
Richard A. Kraut, DDS
Montefiore Medical Center, Department of Dentistry
Bronx, New York
¨© 2005 Lippincott Williams & Wilkins, Inc.