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Periodontology 2000. 2023;93:139–152.
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139wileyonlinelibrary.com/journal/prd
1 | WHY BONE BLOCK GRAFT FOR
ALVEOLAR RIDGE AUGMENTATION?
Edentulism has a high negative impact on people's quality of life
and despite the notable advances regarding treatment and pre-
vention of oral diseases, it affects a considerable portion of the
global population, that is, about 22% of the word population
have some type of edentulism.1,2 Dental implants are nowadays
a standard treatment for the rehabilitation of partially or totally
edentulous patients with very good long-term results, in terms of
high survival rates of the implants and the prostheses (i.e., around
85%–95% after 10 years in function)3 and improvement in quality
of life.4
Proper implant therapy dictates that the implant is fully sur-
rounded by bone; however, tooth loss often causes significant re-
duction in the alveolar ridge width which may prevent appropriate
implant installation,5,6 despite recent developments in dental im-
plant technology, providing implants of reduced dimensions7, 8 and
made of special alloys with increased strength.9 It is thus common
that with the available alveolar ridge dimensions proper implant in-
stallation is not possible10 or a harmonic (aesthetic) result cannot be
obtained.11 Thus, bone regeneration procedures are often needed to
generate bone, allowing proper implant installation.10
In this context, the possibilities for oral bone regeneration
procedures vary depending on the type of bone defect to be
treated.12,13 Bone defects can be divided in confined/contained
Received: 17 November 2023
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Accepted: 18 November 2023
DOI: 10.1111/p rd.12 543
REVIEW ARTICLE
Fresh-frozen allogeneic bone blocks grafts for alveolar ridge
augmentation: Biological and clinical aspects
Andreas Stavropoulos1,2,3 | Camila Chierici Marcantonio4 | Vithor Xavier Resende
de Oliveira5 | Élcio Marcantonio Jr4 | Guilherme José Pimentel Lopes de Oliveira5
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.
1Periodontology, Faculty of Odontology,
University of Malmö, Malmö, Sweden
2Division of Conservative Dentistry
and Periodontology, University Clinic of
Dentistry, Medical University of Vienna,
Vienna , Austria
3Department of Periodontolog y, School of
Dental Medicine, University of Bern, Bern,
Switzerland
4Department of Diagnosis and Surgery
School of Dentistr y at Arara quara,
Universidade Estadual Paulista,
Arara quara, Sã o Paulo, Brazil
5Department of Periodontology/
Implantodontolog y, School of Dentistry,
Universidade Federal de Uberlândia,
Uberlândia, Minas Gerais, Brazil
Correspondence
Andreas Stavropoulos, Periodontology,
Faculty of Odontology, Malmö University,
Malmö, Sweden.
Email: andreas.stavropoulos@mau.se
Abstract
The possibilities for oral bone regeneration procedures vary depending on the type of
bone defect to be treated, which in turn dictate the type of graft to be used. Atrophic
alveolar ridges are non-contained defects and pose a challenging defect morphol-
ogy for bone regeneration/augmentation. Successful results are regularly obtained
with the use of particulate grafts in combination with barrier membranes. In cases of
very narrow ridges with need of larger amount of bone augmentation, block grafts
are often used. Fresh-frozen allogeneic bone block grafts have been proposed as an
alternative to autogenous (AT) bone blocks. Based on a systematic appraisal of pre-
clinical in vivo studies and clinical trials including a direct comparison of fresh-frozen
bone (FFB) blocks versus AT bone blocks it can be concluded that a FFB block graft:
(a) cannot be considered as a reliable replacement of a AT bone block, and (b) should
only be considered in cases where the amount of necessary augmentation—in a lateral
direction—is relatively limited, so that the main portion of the body of the implant lies
within the inner (i.e., the vital) aspect of the block.
KEYWORDS
autogenous bone, block bone graft, fresh-frozen bone allograft
140
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STAVROPOULOS et al.
defects, for example the tooth post-extraction socket13 or
non-confined/non-contained, for example the atrophic (healed)
alveolar showing limited bone volume in thickness or height.12
Bone regeneration procedures in contained defects have better
predictability, due the greater number of bone walls that serve as
a source of tissue resources (e.g., undifferentiated mesenchymal
cells, matrix residing growt h fac tors etc.).13 ,14 Further, a contained
defect morphology facilitates use of bone grafts in particulate
form; bone graft particles exhibit a large contact surface and thus
increased potential for osteoconduction.15
In contrast, atrophic alveolar ridges are non-contained defects
and pose a more challenging defect morphology for bone regener-
ation/augmentation. This is partly to the reduced tissue resources
due to the reduced number/absence of bone walls, but also due to
the reduced vascularization of the area associated with the cortical-
ized recipient bed5,16; nevertheless, the latter issue is usually eas-
ily overcome in the clinic by perforating the recipient cortical bed,
providing access to the bone marrow compartment and enhancing
bleeding.16 Another major issue challenging bone augmentation in
atrophic ridges is the reduced mechanical stability of the wound
complex and of the regenerate after closure and during the early
healing period; mechanical stability is important for bone healing
per se, but also in terms of space provision regarding the shape/vol-
ume of the regenerated bone. In the clinic, mechanical stability of
the wound/regenerate in non-contained defects, when particulate
grafts are used, is attempted with the use of a membrane and ap-
propriate management (e.g., tightening and fixating the membrane
with pins) and/or using reinforced membranes (e.g., with titanium),
or using metal meshes.1 7,18 Indeed, successful results are regularly
obtained with the use of particulate grafts in combination with
membranes (i.e., with guided bone regeneration; GBR), more-or-less
irrespective of the type of graft.19 Nevertheless, pre-clinical studies
indicate that even with excellent space provision, there may be a
limit in the extent of bone regeneration from a horizontal cortical
bone wall or defects with limited-due to their shape-bone tissue re-
sources, despite grafting.20–2 4 This in turn would translate into that
there is a certain limit in the amount of augmentation that can be
achieved with GBR and particulate grafts in the clinic. Thus, in cases
of very narrow ridges, where there is a need of larger amount of
bone augmentation, block graft s can be an alternative. Indeed, larger
amounts of alveolar ridge augmentation have been reported with
the use of bone block grafts compared with what achieved with par-
ticulate grafts.25,26
2 | AUTOGENOUS- AND FRESH-FROZEN
ALLOGENEIC BONE BLOCK GRAFTS
Autogenous (AT) bone is the most complete grafting material, as it
provides not only the bone producing osteoblasts (i.e., osteogene-
sis), but also provides a scaffold for osteoblasts to proliferate and lay
bone upon (i.e., osteoconduction) and osteogenic growth factors, for
example, bone morphogenetic proteins, that enhance differentiation
and proliferation of undifferentiated cells towards osteoblasts (i.e.,
osteoinduction).27 Furthermore, AT bone is gradually largely re-
modeled (resorbed and replaced) and there are no problems with
histocompatibility and immunologic reactions, and obviously there
is no risk of disease transmission.27 Therefore, AT bone grafts are
often referred to as the gold standard. Nevertheless, harvesting an
AT bone block, has drawbacks; surgery is relatively cumbersome, as
it often necessitates the use of a second surgical site, thus adding
to patient suffering due to donor site morbidity, extended surgical
time, and increased post-surgical pain; there is also a risk for nerve
and soft tissue injuries; and occasionally, the quality and quantity of
available bone does not allow harvesting of a bone block, for exam-
ple, in small size jaws after long-term edentulism.28,29
Allogeneic (AL) bone, in particular fresh-frozen bone (FFB)
blocks (i.e., collected from another human, deceased or alive) have
been proposed as an alternative to AT bone blocks30 ,31; AL bone is
in general a widely used material, not only in dentistry, but also in or-
thopedics, with the obvious advantages of unlimited availability and
reduced surgical time.32 Concerns of the past about the use of AL
bone, in terms of risk of disease transmission (e.g., hepatitis or HIV )
and antigenicity33,34 have been lessened during recent years due to
the very strict guidelines for donor bone tissue sources and process-
ing.35 For example, in the protocol of the American Association of
Tissue Banks, strict screening of the medical and social background
of the donors is carried out; for example, no history of infection or
infectious potential prior to harvesting, afebrile hospital stay, no res-
pirator >72 h, no chronic or infectious disease, no chronic steroid
drug use, no lifestyle associated with high risk of HIV, etc. For the
FFB blocks, the harvested bone tissue is specifically processed, in-
cluding removal of all soft tissues and periosteum, serial washing in
sterile saline including antibiotics, and then packed and freezed at
temperatures varying from −20°36 to −40° or −80°.37,3 8 In this con-
text, it has been estimated that with the above processing, including
the donor screening process, the risk that a FFB graft is contami-
nated with HIV, is 1 in 8 million.39
This processing has the additional advantage that although it de-
vitalizes the very large majority of cells in the bone block, it does not
compromise the mechanical proper ties of the bone block, in contras t
with other methods of AL bone processing, for example, freeze-dr y-
ing under vacuum (lyophilization) and/or demineralization, which
weaken the bone block.4 0,41 Thus, FFB blocks are very similar to AT
bone blocks, regarding structural stability and composition in terms
of matrix and growth factors.
3 | FFB VERSUS AT BONE BLOCKS:
SYSTEMATIC APPRAISAL OF PRE-CLINICAL
IN VIVO AND CLINICAL STUDIES
For an objective evaluation of the potential of FFB blocks in com-
parison with AT bone blocks for alveolar ridge augmentation, a sys-
tematic search of the pre-clinical in vivo and clinical literature was
conducted, following a PICO question structure:
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141
STAVROPOULOS et al .
I. for pre-clinical in vivo studies: (P) In animals, (I) subjected to bone
augmentation, what is the effectiveness of (C) FFB blocks compared
with that of AT bone blocks in terms of (O) healing/integration, and/
or amount/volume of augmentation/block resorption, and/or dental
implant integration.
II. for clinical studies: (P) In patients, (I) subjected to alveolar ridge
augmentation, what is the effectiveness of (C) FFB blocks compared
with that of AT bone blocks in terms of (O) healing/integration, and/
or amount/volume of augmentation/block resorption, or dental im-
plant survival and/or early/late post-surgical complication rate.
Three databases were searched (PubMed, EMBASE, and Scopus),
with no time and language restrictions, independently by two evalu-
ators (V XRO and CCM); in case of disagreement on an article, a third
evaluator (GJO) decided whether to include or exclude the ar ticle.
Details of the search as well as of the flowchart of search results are
presented in Appendix A and Figure A1.
3.1 | Pre-clinical in vivo studies
Three publications from pre-clinical studies, on bone block aug-
mentation with FFB versus AT bone, using different rabbit models
(i.e., mandible,42,43 tibia44) were identified as suitable for inclusion
(Table 1). In two of the studies, bone block integration was assessed
with histology and immunohistochemistry,42,43 while in the third
study, titanium implant osseointegration in conjunction with bone
block grafting was assessed biomechanically and histologically.44 In
general, AT bone blocks showed faster resorption/remodeling and
integration compared to FFB blocks, thus AT bone blocks showed
some volume loss, while FFB blocks were more stable; further, the
vital portion of AT bone blocks was much larger compared with that
in FFB blocks, which were mainly acellular (necrotic) irrespective the
observation time and integration grade.42,43 In the single study in-
volving implants, no differences in terms of amount of implant osse-
ointegration, assessed histomorphometrically (i.e., amount of direct
bone-to-implant contact; BIC) and with biomechanical testing (i.e.,
implant removal torque test) was obser ved.44
3.2 | Clinical studies—performance and histological
results of FFB blocks versus AT bone blocks
Nine publications from clinical studies, on alveolar ridge augmentation
with FFB blocks versus AT bone blocks were identified as suitable for
inclusion. Seven publications focused on clinical, histological, and/or
aspects of FFB blocks and AT bone blocks,45 –51 while the remaining
2 publications focused on safety and patient-related outcomes52,53
(Table 2). Of these 9 publications, only 1 regarded a randomized con-
trolled trial46; the remaining 8 publications were from non-randomized
parallel-arm studies. Most of the studies report on aspects related to
FFB block versus AT bone block grating only until implant installation,
that is, they do not report on the outcome of implant therapy; only
2 publications refer to outcomes related to the implants installed.45, 51
TABLE 1 Overview of pre-clinical in vivo studies on bone augmentation with FFB blocks versus AT bone blocks.
Author, year
Animal
platform Sample/design Methods/analyses Main outcomes
Hawthorne et al. (2013) 42 Rabbit
mandible
56 New Zealand White rabbits
20 animals, as donors
36 animals grafted
FFB block and AT bone block as onlay, bilaterally on the mandible
6 animals sacrificed after 3, 5, 7, 10, 20, and 60 days post-op
Tomography for density and
volume assessment
Histology
Immunochemistry
No differences bet ween FFB and AT bone blocks
regarding bone density and volume
FFB blocks appeared intact at 20 and 60 days, while
AT bone blocks underwent remodeling and were
completely incorporated at Day 60
Garbin Junior et al.
(2017 )43
Rabbit
mandible
25 New Zealand White rabbits
1 animal, as donor
24 animals grafted
FFB block and AT bone block as onlay, bilaterally on the mandible
6 animals sacrificed after 15, 45, 120 and 180 days post-op
Histology
Histomorphometry
Immunohistochemistry
AT bone blocks presented faster graft integration and
more vital bone than FFB blocks after 45 days (47%
vs. 32%, respectively)
Ribeiro et al. (2018)44 Rabbit tibia 18 New Zealand White rabbits
6 animals, as donors
12 animals grafted
Two implants with a block graf t (FFB or AT bone), as onlay, on
each tibiae
All animals sacrificed at 18 weeks pos t-op
Implant stability (ISQ )
Removal torque
Histology
Histomorphometry
No differences bet ween FFB blocks and AT blocks
regarding implant stability, removal torque, bone-
to-implant contact, or bone area between the
implant threads at 18 week s
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STAVROPOULOS et al.
TABLE 2 Overview of clinical studies on alveolar ridge augmentation with FFB blocks versus AT bone blocks.
Author, year, study type Sample/design Methods/analyses Main outcomes Complications
Chiapasco et al. (2013)45
Non-randomized
prospective
12 patient s, 18–84 years
6 patients received FFB blocks; 44
implant s were installed 5–9 months
after grafting
6 patient s received AT bone blocks;
32 implants were installed
4–6 months after grafting
Bone-core biopsies harvested during
implant installation
Descriptive histology
Histomorphometry regarding the
relative bone composition in
the bone-core biopsies
No differences in the relative bone composition
between FFB blocks and AT bone blocks
FFB
Lamellar bone 24.7 ± 14.7%
New bone 28.4 ± 13.3%
Bone marrow 46.9 ± 16.9%
AT
Lamellar bone 25.3 ± 15.3%
New bone 22.9 ± 11.0 %
Bone marrow 51.7 ± 15.7%
FFB
1 patient with early complication; graft
loss due to infection
5 patients with late complications; soft
tissue dehiscence with exposure
of bone, bone sequestration,
accelerated graft resorption with no
apparent cause, peri-implantitis
AT
No complications
Spin Neto, Landazuri Del
Barrio, et al., (2013)47
Non-randomized
prospective
12 patient s, 25–60 year s
6 patients received 17 FFB blocks
6 patient s received 12 AT bone blocks
Bone core biopsies harvested
7 months af ter grafting
Descriptive histology All graf ts were found to be firm in consistency
and well-incorporated to the recipient bed.
However, a more clear distinction was
observed at the interface of the FFB block
and the native bone
Large amount of necrotic bone surrounded by
few spots of newly formed bone in the FFB
block group, suggesting low rate of graft
remodeling
No complications
Spin Neto, Stavropoulos,
et al., (2013)50
Non-randomized
prospective
26 patient s, 21–70 years
13 patients received 19 FFB blocks
13 patients received 19 AT bone
blocks
CBCTs recorded prior to- and 14 days
and 6 monhts after grafting
CBCT (i-CAT Classic) examinations
Planimetric measurements on
two-dimensional CBCT images
of the graf ted regions: CBA,
changes in bone area; TBA ,
total maxillary or mandibular
bone area
Larger bone graft resorption was seen in
patients treated with FFB block than in
those treated with AT bone block 6 months
following alveolar ridge augmentation
FBB
TBA Baseline (mm2)
140.20 ± 51. 14
Grafted bone block area (mm2)
54.39 ± 2 0.95
TBA 14 days (mm2)
194.10 ± 56.88
TBA 6 months (mm2)
182.60 ± 56.07
CBA%
−9. 33 ± 9. 57
AT
TBA baseline (mm2)
165.3 0 ± 54 .14
Grafted bone block area (mm2)
24.19 ± 8.50
TBA 14 days (mm2)
18 7.5 0 ± 56.65
TBA 6 months (mm2)
195 ± 65.13
CBA%
2.57 ± 14 .62
FFB
1 block exposed
2 blocks lost
Survival rate (84.21%)
AT
No complications
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143
STAVROPOULOS et al .
Author, year, study type Sample/design Methods/analyses Main outcomes Complications
Lumetti et al. (2014)46
Randomized controlled
trial
24 patients, 24–73 years
12 patients received 12 FFB blocks
12 patient s received 12 AT bone
blocks
Bone-core biopsies harvested 6
months after grafting
CBCTs recorded 7 days and 6 months
after grafting
Descriptive histology
CBCT (i-CAT Classic) examinations
Volume change between 7 days-
and 6 months after graf ting
FFB blocks had lower density than AT bone
blocks
FBB
Densit y T 7 days (HU)
619 ± 277
Densit y T 6 months (HU)
685 ± 385.1
Volume change (%)
−52% ± 25.87
AT
Densit y T 7 days (HU)
935 ± 250
Densit y T 6 months (HU)
1086 ± 202
Volume change (%)
−25% ± 12.73
There were no differences regarding the new
bone, residual bone graft, and bone marrow
areas between the groups (no descriptive
data were provided)
FFB
1 block totally resorbed.
AT
No complications
Spin Neto et al. (2014)48
Non-randomized
prospective
34 patients, 27–69 years
20 patients received 54 FFB blocks
14 patients received 20 AT bone
blocks
Bone-core biopsies harvested
6 months af ter grafting
Mini-implants were placed during
implant installation and harvested
4–6 months later
Histomorphometry of bone-core
biopsies
Evaluation of relative amounts (%)
of viable bone (VB), necrotic
bone (NcB), and soft tissues
(ST)
Histomorphometry of
mini-implants
Evaluation of the bone implant
contac t (BIC) and bone
between the threads (BBT).
Complications: Evaluated the
blocks lost before the implants
placement
Bone biopsies
FFB
NcB: 43.1
VB: 8.4
ST: 48.4
AT
NcB: 55.9
VB : 27. 6
ST: 16.4
Mini-implants
FFB
BIC: 38.1
BB T: 39.7
AT
BI C: 47.1
BB T: 42.0
FFB
4 blocks losted (92.59% of FFB survival)
AT
No complications
TABLE 2 (Continued)
(Continues)
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STAVROPOULOS et al.
Author, year, study type Sample/design Methods/analyses Main outcomes Complications
Spin Neto et al. (2015)49
Non-randomized
prospective
Twenty-four patients, 18–69 years
8 patients received 20 cortical FFB
blocks (C-FFB)
8 patients received 52
corticocancellous FFB blocks
(CC-FFB)
8 patient s received 20 AT bone blocks
Bone biopsies were harvested
6 months af ter AT bone- and CC-
FFB block grafting, and 8 months
after C-FFB block grafting
Tomographic images were obtained
at baseline, 14 days, and 6 months
after grafting for the AT bone-
and CC-FFB block groups, and at
baseline, 14 days and 8 months
after grafting for the C-FFB block
group
CBCT (i-CAT Classic) examinations
Differences in alveolar ridge area
among the various observation
times were evaluated by
planimetric measurements on
two-dimensional CBCT images
of the graf ted regions: CBA,
changes in bone area; TBA ,
total maxillary or mandibular
bone area
Histomorphometry of bone
biopsies
Evaluation of relative amounts (%)
of viable bone (VB), necrotic
bone (NcB), and soft tissues
(ST)
C-FBB
TBA Baseline (mm2): 178.7 ± 35.4
Grafted bone block area (mm2): 29.4 ± 10 .4
TBA 14 days (mm2): 20 4.6 ± 2 9.6
TBA 6 months (mm2): 211.0 ± 3 7.8
CBA%: 1.3 ± 14.9
NcB: 83.7 ± 10 .8
VB 3.9 ± 4.6
ST: 12.3 ± 8.5
CC-FBB
TBA Baseline (mm2): 136.4 ± 51.3
Grafted bone block area (mm2): 56.8 ± 1 7.0
TBA 14 days (mm2): 193.5 ± 63.9
TBA 6 months (mm2): 181.2 ± 55.8
CBA%: −8.3 ± 7.1
NcB: 38. 2 ± 12.1
VB: 9.3 ± 3.8
ST: 52.5 ± 11.7
AT
TBA Baseline (mm2): 182.9 ± 62.2
Grafted bone block area (mm2): 27.5 ± 7.4
TBA 14 days (mm2): 203.3 ± 63.3
TBA 6 months (mm2): 215.5 ± 76 .9
CBA%: 1.5 ± 20.6
NcB: 18.1 ± 17.1
VB: 25.1 ± 11.2
ST: 52.5 ± 11.7
No complications
Dellavia et al. (2016)51
Non-randomized
prospective
Twenty patients, 18–85 years
14 patients with FFB blocks; 69
implant s installed 5–9 months after
the grafting procedure
6 patient s with AT bone blocks; 32
implant s installed 5–9 months after
the grafting procedure
The patients received between 4 and
8 implants. The number of bone
blocks placed in each patient was
not clearly described
Histomorphometry of bone
biopsies
Evaluation of relative amounts
(%) of lamellar bone (LB) - new
bone (NB), and bone marrow
spaces (BM)
FFB
LB - 31.39% ± 19.41%
NB- 21.60% ± 12.88%
BM - 47.01% ±17.87%
AT
LB - 25.34% ± 15.33%
NB - 22.92% ± 11 .04%
BM 51.75% ± 15.74%
FFB
Peri-implantitis: 3 cases
Implants lost: 5 cases
Implant survival: 92.75%
Implant success: 88.40%
FFB block exposure: 1 case
FFB block lost: 4 cases
AT
Implant survival and success: 100%
TABLE 2 (Continued)
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STAVROPOULOS et al .
Noteworthy, the publications of Spin Neto et al. derive from the same
group of patients. In all studies, the FFB blocks were brought to room
temperature prior to use, then trimmed and adapted to fit, and fixed
onto the perforated recipient bed, with screws; the gaps between
the bone block and the recipient bed were commonly filled out with
bone particles from the same type of bone as the block (i.e., FFB or
AT bone), and everything was covered with a collagen membrane, and
submerged; patients received, as standard, systemic antibiotics pro-
phylactically and post-surgically; antiseptic chlorhexidine rinsing was
used for several days post-operatively; implants were inserted after a
period of 5–9 months of healing (Figure 1).
The histological results reported in the studies derive mainly
from bone-core biopsies—harvested by means of trephine burs—
during implant placement some months after the augmentation pro-
cedure, either from the implant site or from the buccal aspect of
the block-augmented alveolar ridge. In 3 publications, from the same
research group, the biopsies from the AT bone blocks presented
with larger areas with vital bone compared with those from the FFD
blocks, which were largely non-vital47– 49 (Figure 2). In particular, one
of the publications looked specifically in the histological differences
in FFB blocks depending on their spatial architecture in terms of cor-
tical/cancellous bone.49 In this study, it was observed that primarily
cortical FFB blocks, retrieved from the tibia, presented significantly
less areas of vital bone, compared with primarily corticocancellous
FFB blocks retrieved from the femoral head and/or patella (4% vs.
9%, respectively); in contrast, AT bone blocks, harvested from the
ramus (primarily cortical) showed 25% vital bone. Furthermore,
higher amounts of non-vital bone were regularly observed in the
part of the biopsies representing aspects of the FFB block distant
to resident bone. These observations may explain the contradictory
FIGURE 1 Representative case of a patient with a very thin alveolar ridge in the maxilla, treated with FFB block grafting (case provided
by Prof. Elcio Marcantonio Jr.). Clinical view (A), 3-D printed model of the maxilla (B), and intra-surgical clinical view (C). First the bone bed
was wounded with a bur to provide access to induce bleeding and/or provide access to the marrow (D), then FFB blocks were trimmed and
adapted, and fixed in place with screws (E, F), and the gaps in-between the blocks and the bed were filled with par ticulated FFB (G) and
covered with a collagen membrane (H). After about 6 months, the blocks appear well integrated (I) and the alveolar ridge is clearly wider (J),
except from the area between tooth 11–21, where the block was loose and had to be removed (K); this event, however, did not preclude
installation of implants in the planned position. FFB, fresh-frozen bone.
146
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STAVROPOULOS et al.
findings in the remaining 3 publications reporting histological data,
where no differences in the amount of vital bone between the two
types of bone blocks were observed.45, 46, 51 Indeed, in the studies
reporting no differences in terms of vitality between FFB blocks and
AT bone blocks, corticocancellous blocks from hip were used.45,4 6
Nevertheless, the difference in vitalit y between FFB and AT bone
blocks seems not to have a major negative impact on osseointegra-
tion; in one of the studies, where mini-implants were intentionally
placed perpendicularly to the bone block during the grafting pro-
cedure, in order to be retrieved later for histomorphometrical as-
sessment, no significant differences in terms of BIC were observed
between implants placed in FFB blocks and AT bone blocks (38.1%
vs. 47.1%, respectively).48
In terms of block graft volume stability, a larger resorption during
the integration face was reported for the FFB blocks compared with
the AT bone blocks.46, 49, 50 The extent of volume loss seems related
to the relative amount of the cancellus component of the graft, that
is, more volume loss, the more cancellous the block is45,49; how-
ever, this property (drawback) of FFB blocks did not compromise
implant installation significantly, that is, no big changes in terms of
patient rehabilitation were reported in those studies due to bone
block resorption. In two of the publications, the impact of FFB block
grafting on the immune system was addressed by assessing various
inflammatory markers in the systemic circulation of patients receiv-
ing either FFB blocks or AT bone blocks, 2 weeks after the grafting
procedure52,53; these studies showed, that irrespectively from the
number of bone blocks used (from 1 to 6 blocks), FFB block grafting
seem not to challenge the immune system significantly.
3.3 | Clinical studies—complications with FFB
versus AT bone block grafting
A relevant aspect when considering FFB blocks as an alternative
to AT bone blocks is potential differences in the rate of early/late
complications, either associated with the grafting procedure itself
(e.g., block exposure and/or loss) or implant-related complications
(e.g., early/late implant loss or peri-implantitis). Indeed, early com-
plications were seldom with AT bone blocks, which seem to almost
never fail when the grafting procedure is performed by experienced
surgeons. In contrast, FFB block grafting seems to be more prone for
early post-operative complications compared with AB blocks graft-
ing. Specifically, wound dehiscence and FFB block exposure was the
commonly reported complication, while FFB block loss was a rather
rare event and occurred in only a few patients, and regarded only a
few of the grafts.45,48,51 Lack of FFB block integration, is more often
a late complication, discovered during second stage surgery for im-
plant installation (Figure 1I–K). Management of wound dehiscence
depends on the size of block exposure and the quality of fixation
of the block. Smaller exposures with properly fixed blocks can be
treated with removal/trimming of the exposed necrotic part of the
block an d application of chl orhexidine lo cally; in cases of l arge wound
dehiscence and poor block fixation, the block must be removed.48,51
When lack of bone block integration is discovered at second stage,
then the procedure may need to be repeated or the prosthetic plan
revised.51 In this context, recipient bed perforation to the bone mar-
row and good adaptation and fixation of the FFB block on the bed,
similarly to the standard procedure for AT bone block grafting,54 are
factors considered reducing the risk for block failure.
In the only 2 publications reporting about the implants in-
stalled,45, 51 late complications were observed in several patients
treated with FFB blocks (e.g., soft tissue dehiscence and bone se-
questration, graft resorption, implant associated infection/loss of
osseointegration, peri-implantitis), while no remarkable late com-
plications were reported regarding AT bone blocks. The reported
implant survival and success rates ranged from 89%–93% and
82%–88%, respectively, regarding the implants installed in the FFB
block-augmented sites; no late complications were reported regard-
ing implant s inserted in AT bone block-augmented ridges in these
studies. Nevertheless, the timeframe the complications occurred,
or the implant survival/success rates are referring to, is unclear
in these 2 publications. In this context, several, non-comparative
FIGURE 2 Representative aspects from bone-core biopsies from FFB and AT bone blocks, harvested at the timepoint of implant
installation, about 6 months post-graf ting. (A) The FFB blocks were often largely non-vital, as evident from the empty ostocyte lacunae (red
arrowheads), although signs of revitalization could be observed at the peripher y of the graft, as evident by the presence of vascular elements
within the haversian channels (green arrowheads) and new bone apposition (blue arrowheads). (B) The AT bone blocks were largely vital,
as evident from the presence of ostocytes and areas of new bone formation (blue arrowheads), and by the presence of vascular elements
within the haversian channels (green arrowheads). Areas where the block was non-vital, as evident from the empty ostocyte lacunae (red
arrowheads), were also observed. FFB, fresh-frozen bone.
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STAVROPOULOS et al .
studies (i.e., studies not including a direct comparison with AT bone
blocks), mostly with short- or medium-term observation time, report
high survival rates for implants in FFB block-augmented jaws. For
example, in a study with 16 patients and 34 implants, all implants
survived from 18 to 30 months,55 while in another, retrospective,
study with an average follow-up of 23 months a survival rate of
99.2% was reported for 133 implants installed in 41 patients.56 In
contrast, relatively low survival rates have been presented in other
studies, reporting on long-term outcomes of implants installed in
FFB block-augmented jaws. For example, in a study including 45 pa-
tients with 262 implants, an implant survival rate of about 91% after
an average follow-up time of about 4 years was reported; most of the
losses occurred af ter 3.5 years from implant installation.57 Similarly,
in a retrospective study of 262 implants installed in 45 patients,
an implant survival rate of 91% after an average observation time
of 5 years was reported; implant losses were due to loss of osse-
ointegration and occurred between 2.5 and 7 years (the majority of
implants were lost after 4–5 years of loading).58 In yet another publi-
cation on 69 patients with 287 implants, a survival rate of 98% over
an average follow-up time of 26 months was observed; however, in-
creased marginal peri-implant bone loss (>2.1 mm) at 4 years post-op
was observed, resulting in a success rate of only 40%.59 In this con-
text, a recently published systematic review on survival rates of im-
plants placed in connection all t ypes of AL bone blocks, concluded
that FFB blocks are associated with in rather unfavorable outcomes
compared with AT bone blocks; in this review, an average implant
survival rate of 96% after an average follow-up of 3 years was cal-
culated from 77 publications including 6861 implants placed in con-
nection with 2397 AT bone blocks in 2195 patients.60 The increased
rates of complications and/or failures associated with FFB block
grafting—especially regarding the early complications—has been at-
tributed partly on the fact that in most studies, patients were fully
edentulous and in the need of large augmentations, which in turn in-
creases the risks of complications; indeed, in several studies, lack of
enough autogenous bone for harvesting was the reason for patient
inclusion in the FFB block group (e.g., Spin Neto et al.). Another ex-
planation, however, for the increased rate of implant loss and/or fail-
ures should be attributed in the lack of complete integration of the
FFB blocks. This results into larger portions of the block remaining
non-vital, and thus, being more prone to develop microcracks during
implant loading compared to vital bone; consequently, as there is
basically no capacity for microcrack repair in non-vital bone, these
propagate and result in complete fractured bone pieces that exfoli-
ate (bone sequestration) or loss of implant osseointegration.
4 | CONCLUDING REMARKS
Based on the histological observations in the pre-clinical studies,
together with the histological observations from the bone-core bi-
opsies in the clinical studies herein, and considering the long-term
complications reported, it seems reasonable to conclude that a FFB
block graft: (a) cannot be considered as a reliable replacement of a
AT bone block, and (b) should only be considered in cases where the
amount of necessary augmentation—in a lateral direction—is rela-
tively limited, so that the main portion of the body of the implant lies
within the inner (i.e., the vital) aspect of the block.
AUTHOR CONTRIBUTIONS
All listed authors should have contributed to the manuscript sub-
stantially and have agreed to the final submitted version.
FUNDING INFORMATION
No funding received for this manuscript.
CONFLICT OF INTEREST STATEMENT
No conflict of interest related to this manuscript.
DATA AVAIL ABILI TY STATEMENT
Not relevant.
ETHICS STATEMENT
Not relevant.
CONSENT
Not relevant.
PERMISSION TO REPRODUCE MATERIAL FROM
OTHER SOURCES
Not relevant.
CLINICAL TRIAL REGISTRATION
Not relevant.
ORCID
Andreas Stavropoulos https://orcid.org/0000-0001-8161-3754
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How to cite this article: Stavropoulos A, Marcantonio CC, de
Oliveira VXR, Marcantonio É Jr, de Oliveira GJPL. Fresh-
frozen allogeneic bone blocks grafts for alveolar ridge
augmentation: Biological and clinical aspects. Periodontol
2000. 2023;93:139-152. doi:10.1111/prd.12543
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APPENDIX A
Search strategy for PubMed, Embase and Scopus
Database Search strategy
Main databases
PubMed
http:// www.
ncbi. nlm. nih.
gov/ pubmed
#1 “Allografts”[Mesh] OR “Allograft” OR “Allogeneic Transplants” OR “Allogeneic Transplant” OR “Transplant, Allogeneic” OR
“Transplants, Allogeneic” OR “Allogeneic Graft s” OR “Allogeneic G raft” OR “Graft, Allogeneic” OR “Graft s, Allogeneic”
OR “Homografts” OR “Homograft” OR “Homologous Transplants” OR “Homologous Transplant” OR “Transplant,
Homologous” OR “Transplants, Homologous” OR “Transplantation, Homologous”[Mesh] OR “Allogeneic Transplantation” OR
“Transplantation, Allogeneic” OR “Homograf ting” OR “Homologous Transplantation” OR “Allogeneic Grafting” OR “Grafting,
Allogeneic” OR “Allograf ting”
#2 “Autografts”[Mesh] OR “Autograf t” OR “Autologous Transplants” OR “Autologous Transplant” OR “Transplant, Autologous”
OR “Transplants, Autologous” OR “Autotransplants” OR “Autotransplant” OR “Transplantation, Autologous”[Mesh] OR
“Autotransplantation” OR “Autotransplantations” OR “Autografting” OR “Autograftings” OR “Autologous Transplantation”
OR “Autologous Transplantations” OR “Transplantations, Autologous” OR “Heterografts”[Mesh] OR “Heterograft ” OR
“Xenografts” OR “Xenograft” OR “Transplantation, Heterologous”[Mesh] OR “Heterografting” OR “Xenotransplantation”
OR “Xenograft Transplant ation” OR “Transplantation, Xenograft” OR “Xenograf ting” OR “Heterograft Transplantation” OR
“Transplantation, Heterograft ” OR “Heterologous Transplantation” OR “Bone Substitutes”[Mesh] OR “Replacement Material,
Bone” OR “Replacement Materials, Bone” OR “Materials, Bone Replacement” OR “Bone Substitute” OR “Substitute, Bone” OR
“Substitutes, Bone” OR “Bone Replacement Material” OR “Material, Bone Replacement” OR “Bone Replacement Materials”
#3“Alveolar Ridge Augmentation”[Mesh] OR “Alveolar Ridge Augmentations” OR “Augmentation, Alveolar Ridge” OR
“Augmentations, Alveolar Ridge” OR “Ridge Augmentation, Alveolar” OR “Ridge Augmentations , Alveolar” OR “Mandibular
Ridge Augmentation” OR “Augmentation, Mandibular Ridge” OR “Augmentations, Mandibular Ridge” OR “Mandibular
Ridge Augmentations” OR “Ridge Augmentation, Mandibular” OR “Ridge Augment ations, Mandibular” OR “Maxillary Ridge
Augment ation” OR “Augmentation, Maxillary Ridge” OR “Augmentations, Maxillary Ridge” OR “Maxillary Ridge Augmentations”
OR “Ridge Augmentation, Maxillar y” OR “Ridge Augmentations, Maxillary” OR “Alveolar Bone Grafting”[Mesh] OR “Alveolar
Cleft Grafting” OR “Graft Sur vival”[Mesh] OR “Graft Survivals” OR “Survival, Graft ” OR “Survivals, Graf t” OR “Bone
Transplantation”[Mesh] OR “Grafting, Bone” OR “Bone Gr afting” OR “Transplantation, Bone” OR “Dental Implants”[Mesh] OR
“Implant, Dental” OR “Implants, Dental” OR “Dental Implant” OR “Dental Implants , Mini” OR “Dental Implant, Mini” OR “Mini
Dental Implant” OR “Mini Dental Implants” OR “Dental Prostheses, Surgical” OR “Dent al Prosthesis, Surgical” OR “Surgic al
Dental Prostheses” OR “Surgical Dental Prosthesis” OR “Prostheses, Surgical Dental” OR “Prosthesis, Surgical Dental”
#1 AND #2 AND #3
Embase
http:// www.
embase. com
#1 ‘allograft’/exp OR ‘allo inplant’ OR ‘allogeneic graft’ OR ‘allografts’ OR ‘alloplastic graft’ OR ‘alloplastic implant’ OR
‘allotransplant’ OR ‘graft, allogenic’ OR ‘graft, homologous’ OR ‘homograft’ OR ‘homograft sensitivity’ OR ‘homologous
graft’ OR ‘homotransplant’ OR ‘transplant, homo’ OR ‘allograft’ OR ‘bone allograft’/exp OR ‘allogenic bone graft’ OR
‘AlloQuent’ OR ‘fiberFUSE’ OR ‘fiberFUSE Advanced’ OR ‘maxgraft’ OR ‘Trinity ELITE (bone allograft)’ OR ‘Trinity
Evolution (bone allograft)’ OR ‘bone allograft’ OR ‘allotransplantation’/exp OR ‘allogeneic transplantation’ OR ‘allogenic
transplantation’ OR ‘allograft transplantation’ OR ‘homoiotransplantation’ OR ‘homologous transplantation’ OR
‘homotransplantation’ OR ‘transplantation, homologous’ OR ‘allotransplantation’
#2 ‘autograft’/exp OR ‘autogenous graft’ OR ‘autografts’ OR ‘autotransplant’ OR ‘autotransplants’ OR ‘graft, auto’ OR ‘autograft’
OR ‘autotransplantation’/exp OR ‘autologous transplantation’ OR ‘transplantation, auto’ OR ‘transplantation, autologous’
OR ‘autotransplantation’ OR ‘xenograft’/exp OR ‘graft, heterologous’ OR ‘graft, xenogeneic’ OR ‘heterogenous graft’ OR
‘heterograft’ OR ‘heterografts’ OR ‘heterologous graft’ OR ‘heterologous transplantation’ OR ‘heterotransplant’ OR ‘peritoneum
heterograft’ OR ‘system xenograft’ OR ‘transplantation, heterologous’ OR ‘xenogeneic graft’ OR ‘xenograft system’ OR
‘xenografts’ OR ‘xenotransplant’ OR ‘xenograft’ OR ‘bone prosthesis’/exp OR ‘bone endoprosthesis’ OR ‘bone prosthesis
(physical object)’ OR ‘bone substitute’ OR ‘bone substitutes’ OR ‘Hydroset’ OR ‘bone prosthesis’ OR ‘bone graft’/exp OR
‘autograft, bone’ OR ‘autograft, spongy bone’ OR ‘autologous bone graft’ OR ‘bone autograft’ OR ‘bone flap’ OR ‘bone flaps’
OR ‘bone grafts’ OR ‘bone transplant’ OR ‘BoneCeramic’ OR ‘compact bone autograft’ OR ‘free bone graft’ OR ‘graft, bone’ OR
‘osseous flap’ OR ‘osseous flaps’ OR ‘osseous graft’ OR ‘osseous grafts’ OR ‘osteoarticular graft’ OR ‘rib autograft’ OR ‘spongy
bone autograft’ OR ‘Straumann XenoGraft’ OR ‘viable bone graft’ OR ‘bone graft’
#3 ‘alveolar ridge augmentation’/exp OR ‘ridge augmentation procedure’ OR ‘alveolar ridge augmentation’ OR ‘alveolar bone
grafting’/exp OR ‘graft survival’/exp OR ‘allograft survival’ OR ‘graft survival prolongation’ OR ‘homograft survival’ OR ‘survival,
graft’ OR ‘transplant survival’ OR ‘transplantation survival’ OR ‘graft survival’ OR ‘bone transplantation’/exp OR ‘bone grafting’
OR ‘bone reimplantation’ OR ‘transplantation, bone’ OR ‘bone transplantation’
#4 ‘tooth implant’/exp OR ‘Bicon’ OR ‘dental implant’ OR ‘dental implants’ OR ‘Grafton’ OR ‘implant, teeth’ OR ‘implant, tooth’
OR ‘implants, teeth’ OR ‘implants, tooth’ OR ‘intramucosal dental implant’ OR ‘Straumann Mini’ OR ‘Straumann PURE’ OR
‘Swish Ac tive’ OR ‘Swish Tapered’ OR ‘teeth implant ’ OR ‘teeth implants’ OR ‘tooth implants’ OR ‘Variobase’ OR ‘tooth
implant’ OR ‘histology’/exp OR ‘bone demineralization technique’ OR ‘comparative histology’ OR ‘decalcification technique’
OR ‘histocytological preparation techniques’ OR ‘histologic stain’ OR ‘histologic studies’ OR ‘histologic study’ OR ‘histologic
technique’ OR ‘histological diagnosis’ OR ‘histological method’ OR ‘histological staining’ OR ‘histological studies’ OR
‘histological study’ OR ‘histological technique’ OR ‘histological techniques’ OR ‘histology, comparative’ OR ‘neurohistology’
OR ‘replica techniques’ OR ‘histology’
‘
#1 AND #2 AND #3 AND #4
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Database Search strategy
Scopus
http:// www.
scopus. com/
#1 TITLE-ABS-K EY “Allograf ts” OR “Allograft” OR “Allogeneic Transplant s” OR “Allogeneic Transplant” OR “Transplant,
Allogeneic” OR “Transplants, Allogeneic” OR “Allogeneic Grafts” OR “Allogeneic Graft” OR “Graft , Allogeneic” OR “Grafts,
Allogeneic” OR “Homografts” OR “Homograft” OR “Homologous Transplants” OR “Homologous Transplant” OR “Transplant,
Homologous” OR “Transplants, Homologous” OR TITLE-ABS-KEY “Transplantation, Homologous” OR “Allogeneic
Transplantation” OR “Transplantation, Allogeneic” OR “Homografting” OR “Homologous Transplantation” OR “Allogeneic
Grafting” OR “Grafting, Allogeneic” OR “Allografting”
#2 TITLE-ABS-KEY (“Autograft s” OR “Autograft ” OR “Autologous Transplants” OR “Autologous Transplant” OR “Transplant,
Autologous” OR “Transplant s, Autologous” OR “Autotransplants” OR “Autotransplant”) OR TITLE-ABS-KEY (“ Transplantation,
Autologous” OR “Autotransplantation” OR “Autotransplantations” OR “Autografting” OR “Autograf tings” OR “Autologous
Transplantation” OR “Autologous Transplantations” OR “Transplantations, Autologous”) OR TITLE-ABS-KEY (“Heterografts”
OR “Heterograft” OR “Xenografts” OR “Xenograft”) OR TITLE-ABS-KEY (“ Transplantation, Heterologous” OR “Heterografting”
OR “Xenotr ansplantation” OR “Xenogr aft Transplant ation” OR “Transplantation, Xenograft” OR “Xenograf ting” OR
“Heterograft Transplantation” OR “Transplantation, Heterograf t” OR “Heterologous Transplantation”) OR TITLE-ABS-KEY
(“Bone Substitutes” OR “Replacement Material, Bone” OR “Replacement Materials, Bone” OR “Materials, Bone Replacement”
OR “Bone Substitute” OR “Substitute, Bone” OR “Substitutes, Bone” OR “Bone Replacement Material” OR “Material, Bone
Replacement” OR “Bone Replacement Materials”) OR TITLE-ABS-KEY (“Bone Transplantation” OR “Grafting, Bone” OR “Bone
Grafting” OR “Transplantation, Bone”)
#3 TITLE-ABS-KEY (“Alveolar R idge Augmentation” OR “Alveolar Ridge Augmentations” OR “Augmentation, Alveolar Ridge” OR
“Augmentations, Alveolar Ridge” OR “R idge Augment ation, Alveolar” OR “Ridge Augmentations, Alveolar” OR “Mandibular
Ridge Augmentation” OR “Augmentation, Mandibular Ridge” OR “Augment ations, Mandibular Ridge” OR “Mandibular
Ridge Augmentations” OR “Ridge Augmentation, Mandibular” OR “Ridge Augmentations, Mandibular” OR “Ma xillary
Ridge Augmentation” OR “Augmentation, Maxillar y Ridge” OR “Augmentations, Maxillary R idge” OR “Maxillary Ridge
Augment ations” OR “Ridge Augment ation, Maxillary” OR “Ridge Augmentations, Maxillar y”) OR TITLE-ABS-KEY (“Alveolar
Bone Grafting” OR “Alveolar Cleft Grafting”) OR TITLE-ABS-KEY (“Graft Sur vival” OR “G raft Sur vivals” OR “Survival, Graft ”
OR “Sur vivals, Graft”) OR TITLE-ABS-KEY (“Dental Implants” OR “Implant, Dental” OR “Implant s, Dental” OR “Dental
Implant ” OR “Dental Implants, Mini” OR “Dental Implant, Mini” OR “Mini Dental Implant” OR “Mini Dental Implants”
OR “Dent al Prosthe ses, Surgical” OR “Dental Prosthesis, Surgical” OR “Surgical Dental Prostheses” OR “Surgical Dental
Prosthesis” OR “Prostheses, Surgical Dental” OR “Prosthesis, Surgical Dental”)
#1 AND #2 AND #3
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FIGURE A1 Flowchart of the search of the studies.
