**6. Guided bone regeneration**

**Figure 16.** Histomorphometric image of Group I (Auto BT®

422 Advances in Biomaterials Science and Biomedical Applications

x200. scale bar measures 200um)

scale bar measures 100um)

graft material (asterisks). Confluent new bone formation was observed (open asterisk) (Hematoxylin & Eosin stain,

**Figure 17.** Microphotograph 4 months after Orthoblast/Biocera transplantation (Group II). Higher magnification demonstrated new bone formation (arrows) around the implant chips (asterisks). (Hematoxylin & Eosin stain, x200.

). New bone formation (arrows) was identified around the

Bone dehiscence or bone fenestration often develops after dental implant placement, and guided bone regeneration using bone graft materials has become a popular method. The most ideal material for guided bone regeneration is autogenous bone, but autogenous bone graft has limited sources and high risk of complications at the donor site and causes high resorption after bone graft. Therefore, alternative bone materials have been developed and used clinically, such as allogenic bone, xenogenic bone, and synthetic bone. Note, however, that they are often mixed with autogenous bone to maximize their advantages.

Autogenous teeth bone graft materials have very good osteoinductive and osteoconductive properties due to the organic and inorganic contents of the teeth, such as collagen, bone growth factors, and various forms of calcium phosphate. In our study, we achieved 46~74% new bone formation in 3~6 months compared with the results of Babbush [3,67]. Considering the histological healing of the sites where autogenous teeth bone graft materials were applied, bone graft materials were replaced with new bone following resorption, and new bone directly fused with the remaining autogenous teeth bone graft materials. A healing process associated with excellent osteoinduction and osteoconduction was observed in every sample, including abundant lamella bone; thus indicating that rapid bone reconduction was occurring [50,51,59,65,66]. Kim, et al [68] installed implants combined with guided bone regeneration using autogenous tooth bone graft material in 6 patients. In the 6 months' histological examination after operation, excellent osteoconductive bone healing was noted. A clinically favorable outcome was obtained (Figure 19~21). healing of the sites where autogenous teeth bone graft materials were applied, bone graft materials were replaced with new bone following resorption, and new bone directly fused with the remaining autogenous teeth bone graft materials. A healing process associated with excellent osteoinduction and osteoconduction was observed in every sample, including abundant lamella bone; thus indicating that rapid bone reconduction was occurring [50,51,59,65,66]. Kim, et al [68] installed implants combined with

Autogenous teeth bone graft materials have very good osteoinductive and osteoconductive properties due to the organic and inorganic contents of the teeth, such as collagen, bone growth factors, and various forms of calcium phosphate. In our study, we achieved 46~74% new bone formation in 3~6 months compared with the results of Babbush [3,67]. Considering the histological

**Figure 19.** Guided bone regeneration using AutoBT powder (Kim Y.K., et al. Guided bone regeneration using autoge‐ nous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Initial panoramic radiography of a 44-yearold male patient. b): Preoperative intraoral view. Teeth were extracted 2 months ago. c): Implants were placed, and dehiscence defects were covered with autogenous tooth bone graft material. d): Periapical radiography 6 months af‐ ter implant placement. e): Secondary surgery was performed, and flap was elevated. Excellent bone healing was ob‐ served. f): Periapical radiography 6 months after the final prosthetic delivery. Figure 19.Guided bone regeneration using AutoBT powder (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Initial panoramic radiography of a 44-year-old male patient. b): Preoperative intraoral view. Teeth were extracted 2 months ago. c): Implants were placed, and dehiscence defects were covered with autogenous tooth bone graft material. d): Periapical radiography 6 months after implant placement. e): Secondary surgery was performed, and flap was elevated. Excellent bone healing was observed. f): The remodeling of new bone formed in the vicinity of graft materials was observed. a): graft materials, b): newly formed bone (hematoxylin-eosin stain, X100). f): Periapical radiography 6 months after the final prosthetic delivery. (d) (e) (f)

Figure 20.GBR was performed on the right mandibular 1st molar area of a 49-year-old female patient. (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Autogenous tooth bone graft material and collagen membrane (BioGuide) were used. b): Periapical radiography 3 weeks after bone graft. c): Periapical radiography 6 months after bone graft. The alveolar crestal level was stable. d): Implant was installed 6 months after bone graft. Bone quality was type I. e): Periapical radiography after the **Figure 20.** GBR was performed on the right mandibular 1st molar area of a 49-year-old female patient. (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Au‐ togenous tooth bone graft material and collagen membrane (BioGuide) were used. b): Periapical radiography 3 weeks after bone graft. c): Periapical radiography 6 months after bone graft. The alveolar crestal level was stable. d): Implant was installed 6 months after bone graft. Bone quality was type I. e): Periapical radiography after the final prosthetic delivery. f): Microphotograph 6 months after AutoBT transplantation. Higher magnification demonstrated new bone formation (arrows) around the implant chips (asterisks). Hematoxylin & Eosin stain, x100.

(arrows) around the implant chips (asterisks). Hematoxylin & Eosin stain, x100.

final prosthetic delivery. f): Microphotograph 6 months after AutoBT transplantation. Higher magnification demonstrated new bone formation

Figure 21.GBR was performed on the mandibular left 1st molar. (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Periapical radiography of a 50-year-old male patient 2 months after the extraction of the mandibular left 1st molar. b): Periapical radiography 2 weeks after autogenous tooth bone graft. c): Periapical radiography 5 months after autogenous tooth bone graft. Alveolar crestal bone level was stable. d): Implant was placed 6 months after bone graft. The adjacent 2nd molar was extracted. e): Second surgery was performed at the #36 area. Additional implant was placed at the #37 area. f): Periapical radiography after the final prosthetic delivery. g): Microphotograph 6 months after AutoBT transplantation. Higher magnification demonstrated new bone formation around the implant chips. Hematoxylin & Eosin stain, x200 **7. Ridge augmentation (Figure 22) Figure 21.** GBR was performed on the mandibular left 1st molar. (Kim Y.K., et al. Guided bone regeneration using au‐ togenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Periapical radiography of a 50-year-old male patient 2 months after the extraction of the mandibular left 1st molar. b): Periapical radiography 2 weeks after autogenous tooth bone graft. c): Periapical radiography 5 months after autogenous tooth bone graft. Alveolar crestal bone level was stable. d): Implant was placed 6 months after bone graft. The adjacent 2nd molar was extracted. e): Second surgery was performed at the #36 area. Additional implant was placed at the #37 area. f): Periapical radiogra‐ phy after the final prosthetic delivery. g): Microphotograph 6 months after AutoBT transplantation. Higher magnifica‐ tion demonstrated new bone formation around the implant chips. Hematoxylin & Eosin stain, x200

Autogenous bone grafting produces the best results in case a large volume of bone increase is required, as in the reconstruction of a site with lots of bone defects or ridge augmentation. The autograft may be taken from the endochondral bone such as ilium, rib, tibia, etc., and from the intramembranous bone such as calvaria, facial bone, etc. Alveolar ridge augmentation is a method of

done simultaneously, but it may also be carried out individually. Since it is a kind of onlay graft, bone absorption occurs considerably after grafting, and dehiscence on the upper soft tissue easily arises [69]. Meanwhile, as for the autogenous bone graft,

#### augmenting the height or width of the alveolar ridge by implementing bone grafting on the upper part or lateral part of the ridge in particulate or block type in case bone volume is insufficient vertically or horizontally; vertical and horizontal augmentation may be **7. Ridge augmentation (Figure 22)**

examination after operation, excellent osteoconductive bone healing was noted. A clinically

Autogenous teeth bone graft materials have very good osteoinductive and osteoconductive properties due to the organic and inorganic contents of the teeth, such as collagen, bone growth factors, and various forms of calcium phosphate. In our study, we achieved 46~74% new bone formation in 3~6 months compared with the results of Babbush [3,67]. Considering the histological healing of the sites where autogenous teeth bone graft materials were applied, bone graft materials were replaced with new bone following resorption, and new bone directly fused with the remaining autogenous teeth bone graft materials. A healing process associated with excellent osteoinduction and osteoconduction was observed in every sample, including abundant lamella bone; thus indicating that rapid bone reconduction was occurring [50,51,59,65,66]. Kim, et al [68] installed implants combined with guided bone regeneration using autogenous tooth bone graft material in 6 patients. In the 6 months' histological examination after operation, excellent osteoconductive bone healing was noted. A clinically favorable outcome was obtained (Figure 19~21).

**Figure 19.** Guided bone regeneration using AutoBT powder (Kim Y.K., et al. Guided bone regeneration using autoge‐ nous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Initial panoramic radiography of a 44-yearold male patient. b): Preoperative intraoral view. Teeth were extracted 2 months ago. c): Implants were placed, and dehiscence defects were covered with autogenous tooth bone graft material. d): Periapical radiography 6 months af‐ ter implant placement. e): Secondary surgery was performed, and flap was elevated. Excellent bone healing was ob‐

Figure 19.Guided bone regeneration using AutoBT powder (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Initial panoramic radiography of a 44-year-old male patient. b): Preoperative intraoral view. Teeth were extracted 2 months ago. c): Implants were placed, and dehiscence defects were covered with autogenous tooth bone graft material. d): Periapical radiography 6 months after implant placement. e): Secondary surgery was performed, and flap was elevated. Excellent bone healing was observed. f): The remodeling of new bone formed in the vicinity of graft materials was observed. a): graft materials, b): newly formed bone

Figure 20.GBR was performed on the right mandibular 1st molar area of a 49-year-old female patient. (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Autogenous tooth bone graft material and collagen membrane (BioGuide) were used. b): Periapical radiography 3 weeks after bone graft. c): Periapical radiography 6 months after bone graft. The alveolar crestal level was stable. d): Implant was installed 6 months after bone graft. Bone quality was type I. e): Periapical radiography after the

**Figure 20.** GBR was performed on the right mandibular 1st molar area of a 49-year-old female patient. (Kim Y.K., et al. Guided bone regeneration using autogenous teeth: case reports. J. Korean Assoc. Oral Maxillofac. Surg., 2011.) a): Au‐ togenous tooth bone graft material and collagen membrane (BioGuide) were used. b): Periapical radiography 3 weeks after bone graft. c): Periapical radiography 6 months after bone graft. The alveolar crestal level was stable. d): Implant was installed 6 months after bone graft. Bone quality was type I. e): Periapical radiography after the final prosthetic delivery. f): Microphotograph 6 months after AutoBT transplantation. Higher magnification demonstrated new bone

favorable outcome was obtained (Figure 19~21).

424 Advances in Biomaterials Science and Biomedical Applications

(a) (b) (c)

(a) (b) (c)

(d) (e) (f)

(d) (e) (f)

(hematoxylin-eosin stain, X100). f): Periapical radiography 6 months after the final prosthetic delivery.

(a) (b) (c)

(d) (e) (f)

formation (arrows) around the implant chips (asterisks). Hematoxylin & Eosin stain, x100.

served. f): Periapical radiography 6 months after the final prosthetic delivery.

there may be some complications on the donor site, and doing the grafting takes time. Likewise, there are several problems such as limit to the volume of collection. Consequently, patients and clinical doctors are inclined to avoid it in many cases. As substitutes for autograft, bone graft materials such as allograft, xenograft, synthetic bone, etc., were developed, but the single use of each is not recommended in the method of augmenting bone tissue vertically or horizontally [69,70]. For the vertical or horizontal ridge augmentation, AutoBTR may be a substitute method for autogenous bone graft and may be very useful in clinical practices when used in mixture with other graft materials in case of insufficient volume. Kim, et al. [71,72] reported the successful case of alveolar ridge augmentation using various autogenous tooth bone graft materials. Autogenous bone grafting produces the best results in case a large volume of bone increase is required, as in the reconstruction of a site with lots of bone defects or ridge augmentation. The autograft may be taken from the endochondral bone such as ilium, rib, tibia, etc., and from the intramembranous bone such as calvaria, facial bone, etc. Alveolar ridge augmentation is a method of augmenting the height or width of the alveolar ridge by implementing bone grafting on the upper part or lateral part of the ridge in particulate or block type in case bone volume is insufficient vertically or horizontally; vertical and horizontal augmentation may be done simultaneously, but it may also be carried out individually. Since it is a kind of onlay graft, bone resorption occurs considerably after grafting, and dehiscence on the upper soft tissue easily arises [69]. Meanwhile, as for the autogenous bone graft, there may be some complica‐ tions on the donor site, and doing the grafting takes time. Likewise, there are several problems such as limit to the volume of collection. Consequently, patients and clinical doctors are inclined to avoid it in many cases. As substitutes for autograft, bone graft materials such as allograft, xenograft, synthetic bone, etc., were developed, but the single use of each is not recommended in the method of augmenting bone tissue vertically or horizontally [69,70]. For the vertical or horizontal ridge augmentation, AutoBT may be a substitute method for autogenous bone graft and may be very useful in clinical practices when used in mixture with

other graft materials in case of insufficient volume. Kim, et al. [71,72] reported the successful case of alveolar ridge augmentation using various autogenous tooth bone graft materials.

(p) (q) (r)

other graft materials in case of insufficient volume. Kim, et al. [71,72] reported the successful

case of alveolar ridge augmentation using various autogenous tooth bone graft materials.

(a) (b) (c)

426 Advances in Biomaterials Science and Biomedical Applications

(d) (e) (f)

(g) (h) (i)

(j) (k) (l)

(m) (n) (o)

(p) (q) (r)

**Figure 22.** Placement of implants after the ridge augmentation of the maxillary anterior and maxillary/mandibular poste‐ rior area. a): Panoramic radiography at the first examination. Alveolar resorption was in considerable progress on the whole. b): Intraoral photograph taken just before the ridge augmentation of the maxillary anterior area. One month passed after extraction. c): View of the elevated mucoperiosteal flap. The labial side concavity is observed. d): View of fixa‐ tion with titanium screws after applying the AutoBT block on the labial side. e): View of grafting the AutoBT powder addi‐ tionally. f): Sutured after covering the resorbable collagen membrane (Ossix plus). g): View of the sinus bone graft on the right side using the AutoBT powder. h): View of fixation with titanium screws after vertical ridge augmentation with the AutoBT block. i): Panoramic radiography after grafting the bone on the maxillary anterior area and the right posterior area. j): Intraoral photograph prior to the right mandibular posterior bone grafting. One month passed after extraction. k): View of the elevated mucoperiosteal flap. The vertical bone defects on the ridge is observed. l): After applying the AutoBT block on the #45 area, the AutoBT powder was grafted on the surrounding sites. The AutoBT block was hydrated in saline solution for 15 ~ 30 minutes and operated. m): After covering the Ossix plus, the wound was closed. n): Panoramic radiog‐ raphy after bone graft. o): View of the elevated mucoperiosteal flap on the #45 and 46 sites after 2 months of ridge aug‐ mentation. Some Ossix plus that were not resorbed is observed. p): After removing Ossix plus, very excellent bone healing was observed. q): View of #45 and 46 implant placement. r):View of the elevated mucoperiosteal flap on the maxillary an‐ terior area 4 months after bone grafting. Good bone healing is observed. There was not much bone resorption when the state of titanium screws was examined. s): After removing the titanium screws, the implants were placed. t): Exposed #15 and16 areas. The titanium screws fixing the block is observed, and bone healing was very good. u): View of implants placed on the site. v): Panoramic radiography after the #12, 21, 15, and 16 implants were placed. w): View of the #45 and 46 im‐ plants exposed while doing the secondary surgery after 2 months. x): Panoramic radiography 6 months after the final pros‐ thetic delivery.

### **8. Extraction socket preservation or reconstruction (Figure 23)**

The resorption of the residual alveolar bone in the vicinity of extraction sockets reportedly occurs primarily during the initial period after tooth extraction; in cases wherein teeth are infected with periodontal diseases, it shows more severe resorption [73]. Severe resorption of the alveolar bone may cause aesthetic problems in the anterior teeth. In addition, normal, natural healing may be difficult since the soft tissues may fall down into the defective area if there is progressive periodontal disease or periapical inflammatory lesion, or in case of serious defects of the surrounding bone wall after tooth extraction. Therefore, the preservation or reconstruction of the extraction sockets should be considered positively in case of serious defects after tooth extraction [74]. Ridge preservation methods using various bone graft materials were introduced and reported to be effective in preventing vertical and horizontal ridge resorption [75-77]. Kim, et al [78] reported an actual case of extraction socket preservation and reconstruction using autogenous tooth bone powder and block. They reported good healing of extraction socket after 3~3.5 months, and they could successfully perform the placement of implants.

**Figure 23.** Extraction socket graft and delayed implant placement were performed on a 48-year-old male patient. (Kim Y.K., et al. Extraction socket preservation and reconstruction using autogenous tooth bone graft. J. Korean Assoc. Maxillofac. Plast. Reconstr. Surg., 2011.). a): Initial panoramic radiographic view, Periapical radiolucent lesion was ob‐ served at #37, 47 area. Radiolucent lesion was extended to the vicinity of the inferior alveolar canal. b):. Panoramic radiograph 3 months after extraction. c): The mucoperiosteal flap was elevated for implant placement 3 months after #47 extraction. The healing of extraction socket was poor. It was impossible to install the implants because of inade‐ quate stability. d): Autogenous tooth bone graft powder was grafted into the socket. e): Postoperative periapical ra‐ diograph. f): Implant was installed 3 months after socket graft. Primary implant stability was excellent. g): Second surgery was performed 2.5 months after implant placement. h): Periapical radiograph 14 months after the final pros‐ thetic delivery.
