Bone regeneration: Is cortical perforation a benefit?


Bone regeneration procedures are often employed to facilitated dental implant placement. It has been suggested that bone perforation in order to improve the presence of blood at the donor site enhances regeneration. Some studies have suggested that perforations favour bone formation.

The aim of this review was to determine the effect of cortical perforations in bone regeneration considering the surgical technique.


Searches were conducted in the PubMed/Medline and ScienceDirect databases and supplemented by searches in the journals; Clinical Implant Dentistry and Related Research, Journal of Periodontology, Clinical Oral Implants Research, International Journal of Oral and Maxillofacial Surgery, International Journal of Oral and Maxillofacial Implants, Journal of Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Implant Dentistry, and Journal of Dental Research. Controlled studies examining cortical perforations were considered. Two reviewers independently selected studies and assessed risk of bias using the Cochrane approach. A qualitative summary was presented.


  • 16 studies were included
  • 8 studies were considered to be at high risk of bias, 6 at moderate risk and 2 at low risk.
  • The studies were grouped into 3 surgical areas, guided tissue regeneration (GTR), bone block (BB) and periosteal distraction (PD).
  • 6 studies looked at GTR with 5 studies being conducted in an animal model with 4 out of 6 studies finding increased bone formation but only in relation to early bone formation.  No increase in bone formation was seen in the one human study.
  • 6 studies assessed perforations in autologous bone blocks, but heterogeneity did not permit comparisons and perforation showed contradictory results.
  • 4 studies assessed perforations in the recipient area using distraction devices (titanium mesh with a screw) for regeneration again using animal models.


The authors concluded: –

the evidence for creating perforations in guided bone regeneration and also in combination with autologous bone blocks in order to increase bone formation is limited. Several authors agree that perforations have a beneficial effect on angiogenesis, especially in the initial stages considering the results of the studies performed in animals. Although the only study in humans concluded that there are some advantages, the fact that no other randomised clinical trials in humans are included in this review emphasizes the very weak evidence of the role of cortical perforations in bone regeneration techniques.


Two major databases and a wide range of dental journals were searched for this review. However, all the included except one study was conducted in animal models which raises important questions in relation to clinical applicability. All the studies were small and showed marked heterogeneity and only 2 of the 16 included studies were considered to be at low risk of bias.

There is currently little clinical evidence to support the use of cortical perforation to improve bone regeneration procedures well conducted and reported randomised trials or appropriate size and duration are needed to explore the efficacy of this approach.


Primary Paper

Alvira-González J, De Stavola L. The role of cortical perforations in bone regeneration: a systematic review [published online ahead of print, 2019 Nov 9]. Int J Oral Maxillofac Surg. 2019; S0901-5027(19)31359-1. doi: 10.1016/j.ijom.2019.10.01





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