Guided Bone Regeneration
GBR = Guided Bone Regeneration
Guided Bone Regeneration (GBR) is a bone grafting technique that uses a barrier to create space for the patient’s native bone to form. Guide bone regeneration can use resorbable collagen membranes, titanium reinforced ePTFE, tiyanium mesh, and/or tenting screws.
Guided Bone Regeneration ADA dental code
The GBR dental code is D7950.
When to recommend GBR?
It seems obvious to say when there is not enough bone. However, with the increasingly popularity of short implants, the notion of what is not enough bone is changing.
For the posterior mandible Felice IJPRD 2021 came up with a nice decision criteria.
GBR healing time
Typical GBR healing time is 6-9 months before reentry.
Guided Bone Regeneration – Vertical bone augmentation VBA
Vertical bone augmentation is more technically and biologically challenging than horizontal grafting. Anything outside the osseous contour is more difficult to achieve. A vertical deficiency such as a dehiscence, fenestration, or post extraction defect, is much easier to treat.
vGBR complication rate is 25%, but GBR does have the lowest complication rate of any vertical technique. Elnayef JOMI 2017 The most common frequent complication is wound dehiscence. Urban JCP 2019 The amount of augmentation, surgeon experience, smoking, and quality of the soft tissue are main factors for wound dehiscence.
If need 4mm all techniques about same but if need more than that DO or IBG is the way to go.
Guided Bone Regeneration – Horizontal
Horizontal deficiency – Staged approach most common
hGBR 18% complication rate
ERE most common complication buccal plate fracture
GBR v. ERE 96-100% v 87-100%
Need decortication? Greenstein 2009 JPerio The role of bone decortication in enhancing the results of guided bone regeneration: a literature review. Lit review Maybe not but seems some benefits
rhBMP-2/ACS with cancellous bone and PRP is = autogenous but more edema 1
Guided bone regeneration with tenting screws or bone dowels
Tenting with cortical bone pin = “Alabama graft” using BonePin. Other companies with bone dowels include Osteolife and Maxxeus cortical pins.
Guide bone regneration membranes, pins, screws, and tacks.
When is the best time to use each technique? There are so many options that there is likely no right answer. More about membranes can be found on the link.
PTFE needs to be secure, which means tacks or screws.
Exposure and infection are the two biggest complications. There are a lot of exposures, although resorbable membranes have less exposures than non-resorbable do. Poomprakobsri JOI 22 Fontana 2011 Int J Perio Rest Dent made four classifications of healing complications and their recommendations are in blue. The rest are from Gallo JOMI 2019. To manage them first diagnosis what they are by taking CBCT.
For Class I complications, which are small exposure (≤ 3mm) without exudate.
- Weekly cleaning with CHX and digital pressure ensure no exudate.
- Patient gently brushes and applies CHX bid.
- If occurs within first 2 months then leave membrane in for 8 additional weeks.
- If occurs after 2 months leave as long as possible
- Remove after 1 month maximum
For Class II complications, which are a >3mm exposure without exudate.
- Same as Class I
- Remove at 8 weeks no matter when occurs
- Patient cleans with CHX gauze tid
- Remove immediately and resuture flaps for 4-5 months
For Class III complications, which are exposure with exudate.
- Clinical signs are pain and exudate upon palpation
- Antibiotic RX (Gallo JOMI 2019 says Augmentin 1g bid for 7 days)
- Removal all granulomatous tissue between membrane and graft
- Wash with tetracycline and place a collagen membrane
- Reeval in 3 months
For Class IV complications, which are abscesses without exposure
- Clinical sign is pain and exudate from fistula or gingival sulcus
- Same as Class III
- Removal all graft, local and systemic antibiotics
– See more at:
– See more at:
What is Sausage bone augmentation technique?
Use native animal collagen membrane not long lasting so blood can get through BioGide is one he uses 30×40 need a big one! May use Bio-Gide Compressed now. In his article in Perio and Rest Dent 2017 Urban utilizes a Ti reinforced PTFE membrane. 50/50 auto with bone scaper from ramus area and bovine. Horizontal matress suture and then interrupted to close edges of the flap. PTFE single interrupted sutures from apical to coronal to close the vertical releases. 6-8 months heal then implant and then load @14 months once in sausage should be able to push with finger and feel firm.
First of all place pins 1-3 before placing any bone graft. Follow the numbering sequence up to #7. Finally place pin #8 if the membrane is not stable enough. Be sure to pull membrane down tight before placing pin #8.
SauFRa Technique to fix mebrane
Kamat JOI 2020 uses the SauFRa technique for a horizontal graft.
Bioresorbable dome barrier bone graft
We have a entire post on the dome barrier technique, hence I will not write anymore here about it.
LASSO GBR is a technique that involves membrane stabilization via internal periosteal sutures for the guided bone regeneration. Silva 21 has some nice photos. The membranes in use for this technique are long lasting membranes. Neiva 2019 COIR shows nice results with this technique. Neiva Comp 2022 shows a nice case of LASSO technique for an implant fenestration.
Khoury Block technique
An autogenous block graft of sorts. Using cortical graft as a shield for the area wish to one graft.
The “shell” technique is a similar idea using a pre-hydrated cortical plate donor such as what Salvin and Blue Sky Bio offer. OsteoWrap is the name brand of the Blue Sky Bio demineralized cortical plate membrane. Salvin has a pre-hydrated cortical plate from LifeNet, which since is not demineralized should last longer but be harder to manipulate.
Bone ring GBR technique
Guided Bone Regeneration using the bone ring technique is an interesting concept for defects. A good use can be seen in Nord JOI 2019 and the case below too. It is not common, therefore, you will not see a lot of information on it but you can find a nice CE course on bone ring technique on Botiss.
Using the bone ring for grafting and coming back later seems to work well as Chandra JOMI 2019 shows.
Titanium and zirconia mesh
Cory Glen and Danny show a cool zirconia mesh case here. That case is also on dentaltown. Important to remember that these cases need collagen or pericardium over the top and you will experience some exposures so need to know how to deal with those. A nice example of the titanium mesh from Maggie Misch.
Ribose cross linked membrane GBR
A few studies show a ribose cross linked membrane can add bone if in direct contact with bone. Chackartchi IJRPD 2022 12 and 13
- Full thickness flap deep enough for ribose cross linked membrane (Ossix Volumax)
- Split thockness at apical portion flap
- Internal cross mattress suture from split thickness area to lingual of papilla. Over top of membrane with long lasting resorbable sutures
- SECTG over the top sutured with similar.
- Suture flap
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