413

Vertical 3D Bone Reconstruction with

Simultaneous Implantation:
A Case Series Report

Jochen Tunkel, Dr Med Dent1 Tooth loss due to endodontic or peri-

Robert Würdinger, Dr Med Dent2 odontal problems generally leads to
Luca de Stavola, Dr Med Dent3 a corresponding loss of supporting
bone structures. The subsequent
placement of a dental implant there-
fore requires restoration of bone
Tooth loss generally leads to a corresponding loss of supporting bone structures, structures. Bone block grafts and
jeopardizing correct implant placement. Bone augmentation procedures facilitate guided bone regeneration (GBR) are
reconstruction of the alveolar contours but lengthen treatment time by about 4 to generally considered predictable
9 months. The aim of this case series report is to describe the short-term results
and successful augmentation thera-
of the combination of three-dimensional bone augmentation using the shell
technique in conjunction with simultaneous implantation. A total of 10 patients pies in implant dentistry. Several
who underwent autologous bone augmentation using the shell technique with publications have reported data re-
simultaneous implantation were retrospectively examined. The shell technique garding modifications of techniques,
is an augmentation procedure using thin cortical bone plates adapted to the predictability, and failure and compli-
buccal and oral walls of the defect to rebuild the contours of the alveolar ridge. cation rates, but a systematic review
The remaining spaces are filled with bone chips. Healing time before second
by Rocchietta et al1 in 2008 could not
stage surgery was 4 months. The vertical bone defect at the beginning (VD), the
height of the vertical bone graft, resorption at the time of second-stage surgery find enough controlled or high-qual-
(BR1) and 1 year after prosthetic rehabilitation (BR2), the total resorption between ity studies to form any conclusion or
augmentation and 1 year (BRtot), and the vertical bone loss of the implant (VBL) even perform a meta-analysis. Only
were measured. VD was 3.1 mm. Values for BR1 and BR2 were 0.4 and 0.45 mm, by including case series and stud-
respectively, resulting in a total bone loss of 0.85 mm of bone loss (BRtot). ies of minor quality were they able
VBL was 0.45 mm 1 year after prosthetic rehabilitation. The simultaneous
to conclude that the generalizability
approach of vertical bone augmentation in the shell technique and implantation
shows excellent results in bone reconstruction and stability up to 1 year after of the approach is limited. Despite
prosthetic reconstruction and can shorten treatment time by 4 to 9 months. the paucity of high-quality studies,
Int J Periodontics Restorative Dent 2018;38:413–421. doi: 10.11607/prd.2689 autogenous bone is unequivocally
accepted as the gold standard for
augmentation procedures.2,3 How-
ever, intraoral bone harvesting has
been associated with insufficient
bone quantity related to the defect.
Private Practice, Bad Oeynhausen, Germany.
1
On the other hand, extraoral donor
Private Practice, Marburg, Germany.
2
sites capable of overcoming this limit
3Private Practice, Padua, Italy; Department of Periodontology, University of Padua,

Padua, Italy.
are associated with high morbidity
and hospitalization. Any two-step
Correspondence to: Dr Jochen Tunkel, tunkel & tunkel fachzahnarztpraxis, approach to augmentation and im-
Koenigstrasse 19, D-32545 Bad Oeynhausen, Germany.
plantation will extend the duration
Fax.: +49 5731 260898. Email: mail@dr-tunkel.de
of treatment by 4 to 9 months,4,5 but
©2018 by Quintessence Publishing Co Inc. patients want the shortest possible

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414
treatment, particularly where tem-
porary restorations are concerned.
To overcome this problem and to
better meet patient expectations,
simultaneous augmentation and
implantation procedures have been
published either with GBR proce-
dures6,7 or with autologous bone
block grafts.8,9 Several clinical trials
have proven the safety and feasibility
of these procedures. Nonetheless,
any augmentative procedure carries
a risk of complications. Rocchietta et
al1 reported complication rates of 0%
to 24% and 9% to 45.5% for autolo-
gous bone block transplantation and
GBR, respectively. In a two-stage
approach, bone deficiencies arising
from these complications might be
solved by a second augmentation
procedure performed during implant
placement or even in a second single
bone grafting treatment session. If
the implant is inserted simultaneous
to the augmentation procedure and
a severe complication occurs, the os-
seointegration of at least part of the
implant might be jeopardized. This
could lead to an implant failure or an
esthetic or functional problem of the
implant, challenging the long-term
success of the fixture.
Simultaneous implantation and
augmentation usually depends
on the situation of the bone bed
and is recommended if local bone
is present to build a 3D structure
around the implant (self-contained
defects).10 With titanium-reinforced
membranes in particular, one-stage
implantation and augmentation pro-
cedures have been performed even
when extremely atrophied ridges
had to be reconstructed.6,7 These
techniques are unequivocally con-
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sidered to be extremely technically
demanding. In addition, dehiscence
of the nonresorbable membranes
frequently leads to a complete loss
of the augmented tissues, especially
if the dehiscence occurs in an early
treatment phase.11
The 3D reconstruction or shell
technique is a special form of au-
tologous bone reconstruction. The
contours of the alveolar ridge are
reconstructed using thin cortical
bone blocks, and the resulting gaps
are then filled with autologous bone
chips.12 The complexity of the tech-
nique makes it difficult and surgically
demanding. Only two retrospective
case series have reported data about
complications and resorption rates
of the shell technique, both with a
limited number of patients but good
success rates.13,14 The principle of
the technique is accelerated vascu-
larization and regeneration of the
defect, resulting in less resorption
of the graft.13,15 During conventional
cortical bone block transplantations,
the instability of the regenerated
bone seems to jeopardize the effi-
cacy of the procedure. Widmark et
al16 reported bone resorption of up
to 60% of the original graft volume
at the time of implant-abutment
connection after lateral bone block
augmentation, and Cordaro et al17
recorded a 24% reduction of the
prepared material after vertical bone
augmentation. Using the 3D recon-
struction technique, de Stavola and
Tunkel13 reported a resorption rate of
< 10% in a prospective clinical cohort
study, making the dimensions of the
reconstructed alveolar ridge more
predictable. In horizontal augmenta-
tion procedures, 3D reconstruction
was shown to have a much lower re-
sorption rate compared to full corti-
cal bone block transplantations.13,18,19
With these improved resorption dy-
namics, a simultaneous implantation
and 3D bone augmentation proce-
dure might be a much more predict-
able treatment option.
Simultaneous implantation in
direct contact with a cortical bone
block is reported to lessen the
bone-to-implant contact due to the
implant surface not being covered
by a blood clot or vital local bone.20
The methodologic approach of
placing two thin bony walls buccally
and lingually of the defect opens
the option of placing an implant in
between and filling the gaps with
autogenous bone chips afterward.
The lack of direct contact between
the implant and the cortical bone
plates might even enhance bone-to-
implant contact.
The aim of this case series re-
port is to describe the short-term re-
sults of the combination of 3D bone
augmentation using the shell tech-
nique with simultaneous implanta-
tion regarding implant success and
the bone stability up to 1 year after
prosthetic rehabilitation.
Materials and Methods
A total of 10 consecutive partially
dentate patients between the ages
of 32 and 80 presenting with a ver-
tical bone defect in the mandible
or maxilla (Fig 1) requiring a fixed
single crown or fixed partial den-
ture who had been treated with 3D
reconstruction and simultaneous
implant placement were retrospec-

Fig 1 Case 1: Panoramic radiograph
showing a vertical defect in the area of the
mandibular left central incisor.
tively analyzed. Inclusion criteria for
the surgical procedure were verti-
cal defects of < 6 mm missing bone
volume and residual bone allow-
ing simultaneous placement of an
implant with a primary stability of
at least 20 Ncm. The following ex-
clusion criteria were applied: bone
defects following tumor resection,
tobacco smoking of > 10 cigarettes
a day, severe renal or liver disease or
any other disease that might impair
implant or bone healing, history of
radiotherapy or chemotherapy, and
insulin-dependent diabetes melli-
tus. Prior to implant surgery, all pa-
tients were treated for periodontal
disease and open caries lesions.
The donor site for the autologous
bone grafts was always the retro-
molar area of the same quadrant or
of the same side of the mouth. One
patient had a simultaneous sinus
floor elevation in combination with
the vertical augmentation.
Surgical Procedure
A crestal incision was made initially
to expose the alveolar process. This
could be placed buccally so that
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Fig 2 Case 1: Beginning of bone block har-
vesting using the MicroSaw (Dentsply).
Fig 4 Case 1: Insertion of two Bone Level
Implants (Straumann). The prior reconstruc-
tion of the alveolar process facilitated cor-
rect vertical and horizontal positioning.
the suture was positioned over the
middle of the augmented area after
the alveolar ridge was expanded.
Following exposure of the recipient
site, a bone block was harvested
from the retromolar region (Fig 2).
The MicroSaw (Dentsply) and other
diamond disks were used to divide
the block along its length, result-
ing in two thin cortical bone plates.
These bone plates were then adapt-
ed to the buccal and oral bone
wall of the defect and trimmed ac-
cording to the desired contours of
the alveolar ridge (Fig 3). The bone
block shells were fixed using narrow
osteosynthesis screws (Microscrew,
Stoma). Care was taken to ensure
415
Fig 3 Case 1: Reconstruction of the alveo-
lar process using the shell technique. The
osteosynthesis screws (Microscrew, Stoma)
are placed in such a way that the definitive
implant can be placed afterward.
Fig 5 Case 1: Gaps between bone plates
and implant are filled with autologous
bone chips. The implant is covered about
0.5 mm with bone.
that the screws did not cross the
position of the planned implant.
Because the bone block plates
were fixed first, the contour of the
alveolar ridge could be estimated
so that the implant could be placed
in its correct 3D position. This was
followed by careful preparation of
the implant bed, with care taken
that the local bone permitted place-
ment with sufficient primary stability
(Fig 4). Once the implant had been
placed and the closure screw insert-
ed, the gaps were filled with autolo-
gous bone chips obtained during
thinning of the bone blocks and by
chipping the remaining block sec-
tions (Fig 5). The implant was placed
Volume 38, Number 3, 2018
416

1.25 (Figs 6 to 9). The following linear

Fig 6 Case 1: Panoramic radiograph
after the implantation and augmentation
procedure.
a b
c d
Fig 8 Case 2: Radiographs taken (a) before treatment, (b) directly after augmentation and
implantation, (c) after second stage surgery, and (d) 1 year after prosthetic rehabilitation.
in slight infraocclusion so that the
bone chips completely covered the
implant shoulder. A tension-free
wound closure was created via a
periosteal incision. After a healing
time of 4 (maxilla) or 3 months (man-
dible), the implant was uncovered
by creating a fixed and keratinized
gingiva via an apical repositioned
flap or via vestibuloplasty, and the
healing abutment was inserted. Any
bone above the implant was care-
fully removed with a periosteal el-
evator until the healing cap could
Fig 7 Case 1: Panoramic radiograph 1 year
after prosthetic rehabilitation.
be inserted tension-free into the
implant.
Measurement Techniques
Panoramic radiographs were taken
at the following time points: prior to
augmentation, directly after augmen-
tation and implantation, immediately
after second-stage surgery, and 1
year after prosthetic rehabilitation,
using the same x-ray machine with
a standard magnification error of
radiographic measurements were
taken: the maximum extent of the
vertical defect (VD) from the residual
alveolar crest to the line connect-
ing the mesial and distal bone peak
measured on the radiograph before
augmentation, the vertical bone graft
(VBG) from the residual alveolar crest
to the most coronal portion of the
graft measured on the radiograph
directly after bone augmentation,
bone resorption during implant heal-
ing (BR1) measured as the distance
between the implant shoulder and
the bone level by comparing the ra-
diographs taken immediately after
implant placement to those taken af-
ter second-stage surgery, and bone
resorption after prosthetic rehabilita-
tion (BR2) measured as the distance
between the implant shoulder and
the bone level by comparing the ra-
diographs taken immediately after
abutment connection to those taken
1 year after prosthetic rehabilitation.
The total bone resorption (BRtot) was
calculated as the sum of BR1 and BR2.
The vertical implant bone loss (VBL)
was calculated as the distance be-
tween the implant shoulder and the
bone level 1 year after prosthetic re-
habilitation. All linear measurements
were taken with a caliper gauge, ad-
justed to the nearest 0.5 mm, and di-
vided by the magnification factor of
1.25 of the panoramic x-ray machine.
The study also included monitor-
ing of the following adverse effects:
dehiscence, osteosynthesis screw ex-
position, inflammation, abscess, early
implant exposure, sensory nerve
disturbance, necessity of a second
augmentation procedure, loss of the
graft, and implant loss.

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 417

Results

The study sample comprised 10

patients, 6 women and 4 men. Of
these patients, 2 were smokers and
4 had a history of periodontitis. All
of the periodontitis patients were
a b
actively treated before implant
procedures were performed. One
patient had one or more teeth with
remaining pockets of 4 or 5 mm. All
other patients had residual pockets
of < 4 mm. None of the patients had
residual pockets of 6 mm or more.
Before starting the augmentation
procedures, recipient sites had c d

healed at least 8 weeks after extrac- Fig 9 Case 3: Radiographs taken (a) before treatment, (b) directly after augmentation and
implantation, (c) after second stage surgery, and (d) 1 year after prosthetic rehabilitation.
tion of the teeth.
The mean VD was 3.1 mm at
the beginning of the augmentation
surgery (Table 1). The correspond-
ing value for VBG was 3.1 mm, so
the vertical defects were complete-
ly rebuilt during the procedures.
The bone resorption values were
0.4 and 0.45 mm for BR1 and BR2,
respectively. Hence, the total bone
resorption between augmentation
and 1 year after prosthetic reha-
bilitation was 0.85 mm. The VBL Fig 10 Case 1: Clinical situation 1 year after prosthetic
rehabilitation.
1 year after prosthetic rehabilita-
tion was 0.45 mm. The periodontal
condition 1 year after prosthetic
Table 1 Bone Measurements
placement (Fig 10) showed a mean
pocket probing depth of 2.55 mm. Patients (n) Mean SE SD 95% CI
None of the demographic or pa- VD (mm) 10 3.1 0.57 1.79 1.82 4.38
tient-centered variables showed VBG (mm) 10 3.1 0.57 1.81 1.81 4.39
a significant influence on bone re-
BR1 (mm) 10 0.4 0.15 0.46 0.07 0.73
sorption, VBL, or pocket probing
depth (data not shown). BR2 (mm) 10 0.45 0.16 0.50 0.09 0.81
All patients healed uneventfully, BRtot (mm) 10 0.85 0.20 0.63 0.20 1.10
and none of the mentioned compli- VBL (mm) 10 0.45 0.14 0.44 0.11 0.74
cations occurred. All implants could VD = vertical defect; VBG = vertical bone graft; BR1 = bone resorption during implant
be inserted in the prosthetically healing; BR2 = bone resorption after prosthetic rehabilitation; BRtot = total bone
resorption; VBL = vertical bone loss; SE = standard error; SD = standard deviation;
planned position. CI = confidence interval.

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418
Discussion
The aim of the present case report
series was to describe the bone sta-
bility of a vertical bone reconstruc-
tion using the shell technique with
immediate implant placement up to
1 year after prosthetic rehabilitation.
The idea of saving treatment time by
combining bone augmentation and
implantation has been described
several times.7,8 Nonetheless, the
simultaneous approach offers a
higher risk of severe treatment com-
plications that has to be accepted
by patient and operator.9 Success
and survival rates in particular have
to be considered, as an implant
might survive in the mouth following
a complication without completely
fulfilling functional and esthetic ex-
pectations, thus leading to lower
success rates.7 Therefore, the first
and most important proof of long-
term success and survival is the qual-
ity and quantity of the surrounding
bone and osseointegration of the
implant, especially when the implant
is placed in the correct vertical and
horizontal position. Published sur-
vival rates of implants placed using
a simultaneous approach are 93.75%
to 100% after 1 to 10 years (Michal-
czik and Terheyden8). Success rates,
however, of implants placed using a
simultaneous approach range from
61.5% to 100%.21–28 The success and
survival rate of 100% in the present
case series has only been previously
reached by Lorenzoni et al26 in a si-
multaneous approach. In the present
study, only a small group of 10 pa-
tients was analyzed retrospectively.
Retrospective studies usually show
fewer complications and higher suc-
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cess rates than prospective studies.1
Nevertheless, the shell technique
may be one of the parameters lead-
ing to the high success rate.
The 3D bone regeneration us-
ing the shell technique is faster and
shows lower resorption rates com-
pared to augmentation procedures
with compact cortical bone blocks
and GBR.9,13,14,16,17,29 The processing
of the bone block and augmentation
with two thin cortical bone plates
providing a provisional contour of
the alveolar process facilitates imme-
diate implant placement using only
the primary stability of the bone of
the recipient bed and not the aug-
mented bone. The advantage of the
shell technique over other simulta-
neous augmentation techniques is
the avoidance of direct contact of
the cortical block with the implant
and avoidance of the necessity to re-
duce local bone for placement of the
bone block graft.8,20 This favors a low
resorption rate and makes covering
of the transplant with a resorbable or
nonresorbable membrane unneces-
sary.14,18,19 Compared to GBR either
with resorbable or nonresorbable
membranes, the shell technique pro-
vides lower complication rates.1,30–32
However, data is scarce concerning
this approach, with a complete lack
of prospective or even randomized
controlled clinical trials. Due to the
complexity of the technique, how-
ever, it is difficult and surgically de-
manding. Its suitability for a broader
number of operators remains ques-
tionable. Wound dehiscence in par-
ticular during bone augmentation
might jeopardize the augmenta-
tion procedure, resulting in partial
or complete loss of the augmented
tissue with partial successful osseo­
integration of the implant, lead-
ing in turn to complex explantation
surgery and a need to repeat the
procedure, usually using a staged
approach. Historically, however, the
staged approach is usually favored9
because of the risks to the patient.7
This statement is supported by pub-
lished success rates, which at 61.5%
to 100% are lower in the simultane-
ous approach than the 75% to 98.3%
reported with the staged approach.7
The shell technique uses only
autogenous bone. Research in this
field is currently centered on testing
bone substitutes to decrease post-
operative morbidity, complications,
and cost to the patient. Another fo-
cal point of this research is finding a
simpler technique that can be per-
formed by every surgeon.33–35 The
results of these studies are not very
encouraging so far. A recent re-
view comparing vertical bone aug-
mentation to short dental implants
included four studies as clinically
controlled trials.36 In these studies,
the vertical augmentation was done
with either bovine bone mineral
and collagen membrane or equine
bone block with collagen mem-
brane or bovine block substitutes.
Of 85 patients in the augmented
groups, 56 (65%) experienced com-
plications. The survival rates of the
implants were not significantly dif-
ferent between groups. Regarding
a simpler technique to overcome
the problem of a vertical defect,
short dental implants might be a
valid treatment option.
In this case series, all im-
plants placed during the surgi-
cal procedures had a surface that

stabilizes blood clotting due to a
higher hydrophility than convention-
al surfaces (SLActive, Straumann).37,38
This surface has been shown to
enhance early blood clot forma-
tion, reducing the time of osseo-
integration, in animal and human
experiments.37,38 This might have
contributed in part to the success-
ful integration and bone healing of
the placed implants. The use of very
small osteosynthesis screws with
a diameter of 1 mm (Microscrew,
Stoma) helped to place the implant
combined with the vertical augmen-
tation in even smaller single-tooth
gaps when three or four screws had
to be placed between the implant
and neighboring teeth.
The present study was analyzed
retrospectively. Therefore, the ra-
diographs routinely taken after the
surgical procedures have been used
for analysis. Cone beam computed
tomography (CBCT) scans would
have provided much better informa-
tion about the bone stability in ver-
tical and in horizontal dimensions.
Nevertheless, a medical or radiolog-
ic indication to perform CBCT scans
after every surgical procedure was
not given. The standard magnifica-
tion factor of about 25% was rou-
tinely assessed with the panoramic
radiograph machine that was used
for all patients. Care was taken that
the radiographs were always cor-
rectly adjusted. Stainless steel balls
were not routinely used after the
surgical procedures. Therefore, the
accuracy of these radiographic mea-
surements could not be controlled
retrospectively.
Generally, resorption rates of
implants placed in pristine bone
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are calculated to be 0.4 to 1.6 mm
in the first year followed by 0.05 to
0.2 mm a year later.8,39 After 5 years,
resorption rates are about 1.73 mm.40
In regenerated bone, the resorption
rate is about 1.1 to 1.3 mm in the first
year and equals the pristine bone in
the following years.39 After 5 years,
resorption rates vary between 1.0
and 2.93 mm.41,42 These resorption
rates are even higher when hip trans-
plants for augmentation procedures
are used and have been recorded
at 2.3 to 4.76 mm after 5 years.43,44
When comparing the bone resorp-
tion rates of different implant sys-
tems, the abutment connection
system must also be considered. In
the present study, an implant with
a conical connection and platform
switching was used.45 These systems
generally show lower bone resorp-
tion rates compared to butt joint
implant systems.45–48 There are two
explanatory models for the reduc-
tion in bone resorption. The first is
that the greater distance between
the microgap and the bone level re-
duces the influence radius of bacte-
rial plaque of about 1.3 mm by the
distance of the platform switching.49
The second is that the conical abut-
ment systems no longer have a mi-
crogap due to a more perfect fit of
the abutment to the implant. There-
fore, the bone resorption properties
of the bacteria may no longer play a
role in the resorption pattern of the
implant.
There is a scarcity of literature
comparing bone resorption after
a simultaneous procedure to that
following a staged approach for
bone augmentation and implanta-
tion. Michalczik and Terheyden8
419
compared bone resorption for a
period of 5 years after autologous
bone block augmentation using a
staged or a combined approach.
In their study, the bone resorption
after 1 year was 0.63 mm in the si-
multaneous approach and 0.77 mm
in the staged procedure. After 5
years, bone resorption was 1.94 and
1.90 mm, respectively. Comparing
the 1-year data of the simultaneous
approach, these are quite similar
to the present results. In the study
by Michalczik and Terheyden,8 the
resorption rates increased in the
second and third year in particular.
This might be explained by the fact
that complete cortical blocks were
transplanted, and these have been
shown to have high resorption
rates in the first 2 years after trans-
plantation.16,17 As data older than
12 months is not yet available, the
5-year results cannot be compared
with those of the present study.
Some authors report a steady state
of bone level around implants just
3 years after placement regardless
of the timing of placement in the
autograft.44 Therefore, the bone
remodeling of implants 12 months
after prosthetic rehabilitation in the
present study may not be the end
point; further bone resorption may
occur.
Conclusions
The combination of implantation
and bone augmentation in a simul-
taneous approach using the shell
technique provides a therapeutic
option to vertically reconstruct defi-
cient alveolar ridges with a reduced
Volume 38, Number 3, 2018
420
treatment time while avoiding a 5. Esposito M, Grusovin MG, Felice P,
second surgical procedure. Due to Karatzopoulos G, Worthington HV,
Coulthard P. Interventions for replacing
the reduced occurrence of compli- missing teeth: Horizontal and vertical
cations and lower resorption rates, bone augmentation techniques for den-
tal implant treatment. Cochrane Data-
the risk to the patient can be calcu- base Syst Rev 2009(4):CD003607.
lated as good. The reduced treat- 6. Simion M, Trisi P, Piattelli A. Vertical
ment time leads to a better patient ridge augmentation using a membrane
technique associated with osseointe-
acceptance of the surgical proce- grated implants. Int J Periodontics Re-
dure. Because of the shortcomings storative Dent 1994;14:496–511.
7. Clementini M, Morlupi A, Agrestini C,
of the retrospective nature of this Barlattani A. Immediate versus delayed
study, a follow-up prospective study positioning of dental implants in guided
of this approach would be helpful. bone regeneration or onlay graft regen-
erated areas: A systematic review. Int J
Oral Maxillofac Surg 2013;42:643–650.
8. Michalczik V, Terheyden H. Stabilität
des Knochenniveaus an Implantaten
Acknowledgments nach Augmentation mit Unterkiefer-
Blocktransplantaten. Z Zahnärztl Im-
The authors are indebted to Prof Dr Bianca plantol 2007;23:266–279.
9. Jensen SS, Terheyden H. Bone augmen-
de Stavola and Tess Blundell for their careful
tation procedures in localized defects
help preparing the manuscript. The authors in the alveolar ridge: Clinical results
reported no conflicts of interest related to with different bone grafts and bone-
this study. substitute materials. Int J Oral Maxillo-
fac Implants 2009;24(suppl):s218–s236.
10. Schropp L, Isidor F. Timing of implant
placement relative to tooth extraction.
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