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Table 1 Features of included studies

From: Clinical and histological sequelae of surgical complications in horizontal guided bone regeneration: a systematic review and proposal for management

Author/year

Study design

No. of subjects

Mean age ± S.D. (range)

Smoking status (%)

Periodontal status (%)

Test

Control

No. of implants placed

Staged/simultaneous GBR

Implant survival rate (%)

Implant success rate (%)

Follow-up period

Horizontal bone gained after surgery

Graft resorption

Baseline horizontal ridge crest thickness

Complications

Sakkas et al. 2016 [16]

Retrospective CS

112

34.3 (20–61.5)

74 smokers (66%) 38 non-smokers (34%)

7 generalised advanced periodontal disease, treated (6.3%)

105 periodontally healthy (93.7%)

Zygomatic ABG + rCM

NA

134

Staged

100%

100%

NR

NR

NR

NR

24 reports of incision line dehiscence, swelling, or wound infection (20 recipient sites, 4 donor sites)

2 pts: postop sinusitis with persistent fistula due to maxillary sinus perforation (donor site)

2 pts: (1.7%) temporary infraorbital nerve paraesthesia (donor site)

2 pts: (1.7%) total graft exposure with wound infection and suppuration

Minor complications treated with CHX rinse and antibiotics (either orally or IV)

Sinusitis treated surgically and with antibiotics

Graft removed in 2 cases with total graft exposure

Pts with paraesthesia were given follow-up until resolution at 6w

Wessing et al. 2016 [17]

Retrospective CS

36

57.7 ± 12.0 (32–76)

5 smokers (14%)

31 non-smokers (86%)

21 treated periodontal disease (58%)

15 periodontally healthy (42%)

pDBBM only or DBBM + pABG in 1:1 mixture vol + non-cross-linked CM

NA

103

7 (19%) staged, 29 (81%) simultaneous

100%

100%

18.3mo (6.3–28.6)

NR

NR

< 6 mm ridges were staged augmentations

6 dehiscences: 3 in simultaneous GBR cases, 3 in staged GBR cases

4 sites with spontaneous closure and no full membrane exposure or graft exposure

2 sites failed; required graft and membrane removals

Altiparmak et al. 2017 [18]

Retrospective cohort

48

44.8

NR

All periodontally healthy

Ramus block ABG + pDBBM + rCM

Ridge split + DBBM + rCM

42 (T)

43 (C)

Staged (T)

Simultaneous (C)

92% (T)

100% (C)

NR

38.33 mo (T)

31.6 mo (C)

NR

NR

3–4 mm

T:

6 temporary graft exposures (14.3%); 3 mild infections (7.1%); 3 temporary paraesthesias (7.1%); 2 permanent graft exposures (4.8%)

C:

1 temporary graft exposure (2.3%); 2 mild infections (4.7%); 3 bad split (7.1%)

Chappuis et al. 2017 [19]

Prospective CS

38

45 ± 13

5 light smokers (≤ 10 cig/day) (13%)

1 heavy smoker (3%)

32 non-smokers (84%)

NR

Symphysis/Ramus block ABG + pDBBM + rCM

NA

52

Staged

98.1%

98.1%

10y

3.16 ± 0.76 mm pre-op to 8.1 ± 1.02 mm post-op

− 0.34 mm (6.9%) (6mo); − 0.38 mm (7.7%) (10y)

≤ 5 mm

7 pts: temporary neurosensory disturbance at chin harvesting sites (3 at lower lip, 3 experienced negative pulp sensitivity of lower incisors, 1 had both), complete resolution between 2 and 6mo

Gurler et al. 2017 [20]

Retrospective cohort

50

31 (23–53)

NR

NR

Ramus block ABG + rCM

Ridge split + pDBBM + rCM

44 (T)

33 (C)

Staged (T, C)

93.1%

93.9%

3.3 (T)

3.1 (C)

1.8–2.7 mm (mean 2.5 mm) pre-op to 4.2–7.75 mm (mean 6.3 mm) post-op (T)

3.2–3.7 mm (mean 3.2 mm) pre-op to 4.0–7.08 mm (mean 5.85 mm) post-op (C)

(4–6mo)

− 1.5–2.0 mm (mean -1.62 mm) (T)

− 0.3–0.6 mm (mean − 0.5 mm) (C)

(1y)

< 3 mm

T:

4 wound dehiscences (17.4%)

C: 2 bad split (11.8%), 1 wound dehiscence (5.9%)

Wound dehiscence managed with antimicrobial rinse and systemic antibiotics

Bad split managed with titanium mini screw and operation resumed.

No severe infection, neurosensory disturbance, bleeding

Naenni et al. 2017 [21], Basler et al. 2018 [22]

RCT

27

51.85 ± 29.7

6 light smokers (≤ 10 cig/day) (22.2%)

21 non-smokers (77.8%)

3 treated periodontal disease (11.1%)

24 periodontally healthy (88.9%)

pDBBBM + rCM

pDBBM + non-resorbable membrane

16(T)

11(C)

Simultaneous

100%

NR

6mo

3.46 ± 0.52 (T)

2.82 ± 0.50 C)

− 2.23 ± 1.21 mm (T)

− 0.14 ± 0.79 mm (C)

(6mo)

NR

T: 4 wound dehiscences resolved within 4w

C: 1 dehiscence resolved within 3mo, 1 dehiscence persisted till 6mo at re-entry

Treated with local disinfecting agents once a week for 4w and later once a mo

Wessing et al. 2017 [23]

RCT

49

38.6 ± 15.3 (T)

48.9 ± 17.0 (C)

11 light smokers (≤ 10 cig/day) (22.4%)

38 non-smokers (77.6%)

6 treated periodontal disease (12.2%)

43 periodontally healthy (87.8%)

pABG + pDBMM + rCM

pABG + pDBMM + non-cross-linked rCM

24 (T)

25 (C)

Simultaneous

100%

NR

6mo

NR

NR

NR

33 pts: swelling (67.3%)

19 pts: redness (38.8%)

11 pts: wound dehiscence (22.4%)

6 pts membrane exposure (12.2%)

No reported infection

Arunjaroensuk et al. 2018 [24]

RCT

48

51.22 ± 16.19

NR

NR

pABG covered with biphasic calcium phosphate bone + resorbable PLA membrane

pABG covered with biphasic calcium phosphate bone + rCM

30 (T)

30 (C)

Simultaneous

100%(T)

100%(C)

NR

6 mo

3.22 ± 1.00 mm (T)

3.42 ± 0.85 mm (C)

− 34.3 ± 23.85% (T)

− 34.8 ± 23.68%(C)

(6mo)

NR

Minor gingival inflammation and membrane exposure noted, all sites recovered uneventfully

Meloni et al. 2018 [25]

Prospective CS

45

52.1 (24–78)

13 moderate smokers (28.8%)

FMPI < 25% and FMBoP < 25%

pABG + pDBBM + rCM + Ti pins

NR

63

Simultaneous

100%

NR

3y

NR

NR

4–6 mm

6 pts: CM exposure after 1–2w

Treated with 0.5% CHX gel twice a day for 3w, complete soft tissue healing

Benic et al. 2019 [26]

RCT

24

62.0 (43.5–78.6) (T)

58.1 (28.7–78.8) (C)

None with heavy smoking (> 20cig/day)

No active periodontal disease

DBBM block + rCM + fixation pins

pDBBM + native bilayer CM + fixation pins

12 (T)

12 (C)

Simultaneous

100%

NR

6mo

3.38 ± 0.59 mm (T)

2.73 ± 0.69 mm (C)

− 0.68 ± 0.82 mm/− 22.5 ± 30.9% (T)

− 2.21 ± 0.98 mm/− 81.8 ± 27.4%(C)

(6mo)

NR

T: 1 pt mucosal dehiscence, 1 pt swollen mucosa

C: 1 pt mucosal dehiscence, 1 pt swollen mucosa

Meloni et al. 2017 [27], 2019 [28]

Prospective CS

18

56.8 (24–78)

8 light smokers (≤ 10 cig/day) (44.4%)

10 non-smokers (55.6%)

No active periodontal disease

FMPI < 25% and FMBoP < 25%

pABG + pDBBM + rCM + Ti pins

NA

55

Staged

100%

NR

1y, 3y

5.03 ± 2.15 mm (7mo)

NR

≤ 4 mm (mean 3.07 ± 0.54 mm)

3 pts: CM exposure after 2w

Treated with 0.5% CHX gel twice a day for 3w, complete soft tissue healing

Mendoza-Azpur et al. 2019 [29]

RCT

42

49.62 ± 10.22 (38–67) (T)

55.06 ± 10.78 (36–69)

None smoking more than 10cig/day

No untreated periodontal disease

Ramus block ABG + pDBBM + rCM

pDBBM + rCM

31 (T)

34 (C)

Staged

100%

NR

18–21mo

5.1 ± 0.87 mm (T)

5.6 ± 1.35 mm (C) (6mo)

NR

< 4 mm

T:

15 pts (68.1%) swelling

15 pts (68.1%) haematoma

7 pts (31.8%) minor sensory disturbance

1 pt (4.5%) infection

4 pts (18.1%) graft exposure

C:

10 pts (50%) swelling

4 pts (20%) haematoma

1 pt (5%) minor sensory disturbance

2 pts (10%) graft exposure

Sensory disturbances treated with vitamin B, resolved within 6mo

Graft exposure occurred 3–4mo postop, treated with 0.5% CHX gel, 0.12% CHX rinse, 1 g augmentin bd 7d

Solakoglu et al. 2019 [30]

RCT

20

59.6 ± 10.5 (38.8–78.3)

All non-smokers

11 treated periodontal disease (55%)

9 periodontally healthy (45%)

Particulate allograft (Maxgraft) + PRGF + rCM

Particulate allograft (Puros) + PRGF + rCM

NR

Simultaneous

NR

NR

5mo (4–7mo)

NR

NR

NR

No postoperative complications, except for 3 pts who experienced slight wound dehiscences and slightly delayed wound healing

G F Tresguerres et al. 2019 [31]

RCT

28

67.1 (T)

64.5 (C)

Smokers and non-smokers

31

NR

Corticocancellous freeze dried bone allograft (iliac block) + PRGF membrane

Cancellous freeze dried bone allograft (iliac block) + PRGF membrane

53 (T)

39 (C)

Staged

100%

NR

2y

NR

− 19.27 ± 2.31 mm (T)

− 29.17 ± 2.58 mm (C)

(4mo)

< 4 mm

2 partial graft exposures

None with significant pain, no infection

Dehiscences sealed with PRGF membrane

Bartols et al. 2018 [32]

RCT

30

43.1 ± 17.2 (T)

51.5 ± 17.3 (C)

NR

NR

pABG + pDBBM + rCM

Ramus shell ABG + pABG

10 (T)

14 (C)

Staged

80% (T)

100% (C)

NR

1y

2.20 ± 0.86 mm (preop) to 9.00 ± 1.20 mm (postop) (T)

2.67 ± 0.61 mm (preop) to 8.93 ± 1.05 mm (postop) (C)

− 0.68 ± 0.98 mm (T)

− 0.94 ± 0.99 mm (C)

(1y)

≤ 3 mm

T:

5 of 15 sites loss of bone graft (1 due to infection, 4 due to complete resorption)

5 sites wound dehiscence

1 site inflammation (pus) at graft

1 donor site hypaesthesia

C:

1 of 15 sites loss of bone graft due to infection

0 sites wound dehiscence

1 site inflammation (pus) at graft

0 donor sites hypaesthesia

Deeb et al. 2016 [33]

Retrospective cohort

52

NR

None smoking more than 20cig/day

NR

Particulate allograft + pDBBM (tunnel incision)

Particulate allograft + pDBBM + non-resorbable PTFE membrane (crestal incision)

18 (T)

22 (C)

Staged

NR

NR

6mo

NR

NR

NR

T:

4 of 21 sites wound dehiscence/membrane exposure

4 sites graft loss

C:

16 of 31 sites wound dehiscence/membrane exposure

12 sites graft loss

Ersanli et al. 2016 [34]

Prospective cohort

32

NR

NR

NR

Ramus block ABG + pDBBM + rCM

Symphyseal block ABG + pDBBM + rCM

28 (T)

17 (C)

Staged

94.11% (T)

96.42% (C)

94.11% (T)

96.42% (C)

1y

4.36 ± 1.01 mm (T) 6.29 ± 0.86 mm (C)

− 0.80 ± 0.56 mm (T)

− 0.60 ± 0.78 mm (C)

(1y)

NR

T:

4 of 14 patients bleeding

4 hematoma

2 flap dehiscence

1 infection

0 numbness (donor site)

C:

5 of 18 patients bleeding

5 hematoma

2 flap dehiscence

2 infection

1 numbness (persisting at the end of 1y follow-up)

Bleeding treated with firm gauze compress

Amoxicillin and clavulanic acid 1 g bd 10d for other complications

All flap dehiscences resolved except for 1 case, treated with free gingival graft at 5th week postop

Jensen et al. 2016 [35]

Retrospective CS

171

NR

None smoking more than 10cig/day

No active periodontal disease

pABG + pDBBM + rCM (simultaneous)

pABG/block ABG + pDBBM + rCM (staged)

NA

275

171pts simultaneous; 23pts staged

98.4% (simultaneous); 0% (staged)

NR

NR

NR

NR

NR

Simultaneous GBR:

2 of 240 sites early dehiscence (≤ 21d postop)

2 late dehiscence (> 21d postop)

1 early infection

4 late infection

0 sensory disturbances

Staged GBR (pABG):

0 early/late dehiscence, early/late infection, 0 sensory disturbances

Staged GBR (block ABG):

2 of 15 sites early dehiscence

5 late dehiscence

2 early infection

1 late infection

1 transient sensory disturbance

Lee et al. 2015 [36]

RCT

30

53.3 (31–75)

None smoking more than 20cig/day

None with advanced or untreated periodontal disease

pDBBM + non-cross-linked rCM

pDBBM + cross-linked rCM

30

Simultaneous

93.3% (T)

100% (C)

NR

16w

2.6 ± 0.8 mm (T)

2.3 ± 0.8 mm (C)

1 mm below implant platform

NR

NR

T:

2 of 30 sites wound dehiscence/membrane exposure

C:

1 of 30 sites local infection

3 of 30 sites wound dehiscence/membrane exposure

Merli et al. 2018 [37]

RCT

50

56.0 ± 13.0 (T)

53.4 ± 12.4 (C)

None smoking more than 20cig/day

NR

pDBBM + rCM

Particulate alloplast + rCM

61

Simultaneous

100%

NR

3y

NR

NR

NR

T:

1 of 32 sites mucosal dehiscence 90 days postop

1 purulent exudate 60d postop

1 tingling sensation and hyposensitivity 7d postop

C:

1 of 29 sites mucosal dehiscence 30d postop

2 purulent exudate 14d postop

Moslemi et al. 2016 [38]

Prospective CS

17

31–65

All non-smokers

NR

Particulate allograft + rCM

NA

17

Simultaneous

100%

100%

6mo

NR

NR

NR

0 wound dehiscence

0 infection

0 swelling spreading beyond surgical zone

9 of 17 sites extraoral swelling

  1. ABG autogenous bone graft, C control group, CHX chlorhexidine, cig cigarette, CM collagen membrane, CS case series, d day, DBBM deproteinised bovine bone mineral, ePTFE expanded polytetrafluoroethylene, FMBoP full mouth bleeding on probing, FMPI full mouth plaque index, IV intravenous, mo month, NA not applicable, NR not reported, No number, pABG particulate autogenous bone graft, pDBBM particulate deproteinised bovine bone mineral, PRGF plasma rich in growth factors, PLA polylactic acid, pt(s) patient(s), rCM resorbable collagen membrane, RCT randomised controlled trial, T test group, Ti titanium, w week, y year