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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