Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 4  |  Issue : 2  |  Page : 148-152

Localized ridge augmentation using autogenous block bone graft followed by dental implant placement


1 Department of Periodontics and Oral Implantology, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of Periodontics and Oral Implantology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India

Date of Web Publication17-Jan-2013

Correspondence Address:
K V Prabhakara Rao
Department of Periodontics and Oral Implantology, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh - 530 045
India
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Source of Support: GITAM dental college and hospital, Conflict of Interest: None


DOI: 10.4103/0975-8844.106219

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  Abstract 

The placement of endosseous dental implants is often hampered by unfavourable anatomy of the alveolar bone. Most frequently patients lose their teeth due to alveolar bone loss, tooth extraction; trauma and long term use of removable appliances tend to lose the bone making it difficult for the placement of implant in an optimal prosthetic position. The loss of width of the residual alveolar ridge necessitated measures which could refurbish the lost dimensions. Here we report the successful management of such a condition wherein placement of implant was made possible by placement of autogenous bone block graft obtained from the mandibular symphysis region and predictable osseointegration thus achieved.

Keywords: Atrophy of residual ridge, autogenous bone block graft, endosseous implant, mandibular symphysis


How to cite this article:
Prabhakara Rao K V, Pagadala S. Localized ridge augmentation using autogenous block bone graft followed by dental implant placement. J Orofac Sci 2012;4:148-52

How to cite this URL:
Prabhakara Rao K V, Pagadala S. Localized ridge augmentation using autogenous block bone graft followed by dental implant placement. J Orofac Sci [serial online] 2012 [cited 2018 Sep 24];4:148-52. Available from: http://www.jofs.in/text.asp?2012/4/2/148/106219


  Introduction Top


The availability of adequate bone volume for dental implant placement is often diminished by trauma, pathology, periodontal disease, and tooth loss. [1] Grafting with autogenous bone has been documented to be highly effective in reconstructing jaw anatomy, restoring esthetics and providing biomechanical support for the placement of dental implants. [2] The use of block autografts is indicated primarily when an increase in ridge volume is desired, especially as part of implant site development.

Regardless of the donor site for autogenous blockgrafts, 4-6 months of healing is necessary before dental implants can be placed into the region. This staged technique using autogenous bone blocks harvested at the time of surgery is the most frequently used grafting technique because of its general clinical success and predictability in implant site development. [3],[4]

Implant placement in augmented areas have reported high survival and success rates, with minimal bone loss. The case presented in this article clinically demonstrates the efficacy of using a block graft for dental implant placement in the region of right maxillary central incisor.


  Case Report Top


A 23 year old male reported with the chief complaint of missing right maxillary central incisor from past 3 years and requested for replacement of the tooth with fixed appliance. The patient had a non-contributory medical history. On intraoral examination the buccal plate had undergone severe resorption, on bone mapping the width of the bone was found to be only 3 mm which was highly insufficient for implant placement [Figure 1].
Figure 1: Pre-operative

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A mandibular symphysis block autograft was planned for ridge augmentation and to facilitate implant placement.

Surgical procedure

An intrasulcular incision and two vertical releasing incisions were made adjacent to the recipient area and a full thickness mucoperiosteal flap was reflected at the facial side [Figure 2]. After exposing the symphysis and locating the mental foramina, a straight fissure tungsten carbide bur with 20:1 implant hand piece (NSK Company) was used to outline a rectangle of the required size [Figure 3]. The superior aspect of the rectangle was ≥3-5 mm below the tooth apex, and the integrity of the lower border of the mandible was maintained. Laterally, the osteotomy performed was ≥5 mm anterior to the mental foramina. Osteotomes were used to free the block graft.
Figure 2: Recipient site

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Figure 3: Donor site

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The closure of the donor site was done by placing the hydroxyapatite bone graft material. After trimming the sharp borders and making the recipient site fresh with increased blood supply the bone block was stabilized at the recipient site with the help of screw [Figure 4].
Figure 4: Block graft fixed to the recipient site

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Bone blocks were successfully stabilized at the recipient site with screw and the remaining defect was filled with Hydroxyapatite bone grafting material (Osteogen) [Figure 5].
Figure 5: Remaining defect filled with hydroxyapatite bone graft

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The recipient site was sutured back. Amoxicillin 500 mg was given thrice daily for 5 days. Diclofenac sodium was given twice daily for 3 days. Patients were advised to rinse with 0.12% chlorhexidiene gluconate for a period of 15 days. Oral hygiene instructions were reinforced. The healing period of six months was given for adequate bone remodeling [Figure 6] and [Figure 7].
Figure 6: Pre-operative

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Figure 7: Post-operative

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Implant placement

After six months, the surgical re-entry of the recipient site was done to access the viability of bone width. An endosseous implant of 3.3 mm × 13 mm (ADIN Dental implant-Israel) was inserted and again the site was closed. Patient was kept under antibiotics and analgesics. Oral hygiene instructions were reinforced. During the entire healing phase patient was given Maryland Bridge with wings on the palatal surfaces of adjacent teeth [Figure 7], [Figure 9], [Figure 10] and [Figure 11].
Figure 8: Permanent restoration

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Figure 9: Six months after ridge augmentation

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Figure 10: Flap elevation

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Figure 11: Implant placement

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After one week suture removal was done and gingival healing abutment of 3.3 mm diameter was placed. Due to unavoidable angulation of the implant and proclination of anterior teeth angulated customised abutment was used to get the proper aesthetic and the emergence profile.

Immediate restoration was done with provisional crowns for three months followed by replacement with permanent crowns made of porcelain fused to metal [Figure 8] and [Figure 12].
Figure 12: Permanent restoration

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  Discussion Top


The most important questions arising after a bone reconstructive procedure are whether the regenerated bone can sustain functional loads during the follow-up period and whether crestal bone resorption occurs.

Labial ridge deformity can be more severe if there is damage to the buccal plate during tooth removal. Bone resorption activity continues throughout the life, as a result it is anticipated that many patients with tooth loss will have varying degrees of alveolar ridge resorption. This resorption can lead to compromise in the position of the implant fixture.

Osseous grafting has been shown to be clinically successful in the management of human periodontal defects. Successful bone regeneration requires a concurrent revascularization and substitution of the graft material with host bone without a significant loss of strength. The pattern, rate, and quality of new bone substitution are determined, in part, by complex reactions between the healing processes of the biological host and the nature of the graft material. [5]

A three dimensional outcome assessment of alveolar ridge augmentation procedures with computed tomography scans could make the measuring process more accurate and reliable. [6],[7] However, the significant health concern regarding the high exposure of the patients to ionizing radiation continues to limit the application of this procedure. Predictable increase average 4 or 5 mm (maximum, 6 or 7 mm) in ridge width and 2 mm (maximum 3 mm) in vertical ridge height have been documented with intraoral block grafting procedures.

Adequate occlusion is the best way to minimize and control the mechanical loading (i.e., minimal centric and eccentric contacts). Furthermore, the occlusal forces exerted by the patient can be reduced by limiting the diet to soft foods for approximately 2-4 weeks after implant insertion. [8]

In the repair of alveolar defects, bone grafts from the symphysis and ramus offer several benefits, such as conventional surgical access; proximity of donor and recipient sites; and reduced operative and anesthesia time, making it ideal for outpatient implant surgery. There is also no cutaneous scarring, minimal discomfort, and less morbidity compared to extra oral locations. When extensive resorption occurs, or when there is a need for further bone augmentation in another area, it is important to understand the mechanism of bone reformation in the donor site. [9]

However no such complications were encountered in this particular case while following up. Graft resorption and donor site morbidity are clinical concerns associated with autogenous grafting procedures. Membranous grafts have shown less resorption than endochondral bone grafts, which suggests that intraoral donor sites may provide an advantage in harvesting block grafts for augmentation of the alveolar ridge, and they can be easily accessed in an office setting. [10]

Although the technique seems simple, it is highly technique-sensitive and is recommended only for experienced implantologists. Until there are more published data, the surgeon, the prosthodontist, and the patient must be aware of potential complications. Treatment alternatives should be thoroughly emphasized to the patient. Further clinical and histologic studies are necessary to promote routine clinical application of this technique.


  Conclusion Top


Successful implant placement can be achieved in atrophied maxillary anterior region by using block autografts taken from mandibular symphysis region. Long term cohort studies would however be required in order to guarantee the success of implant therapy in such atrophied regions.


  Acknowledgment Top


I would like to thank profusely who directly or indirectly helped me in this study.

 
  References Top

1.Wiens JP. The use of osseointegrated implants in the treatment of patients with trauma. J Prosthet Dent 1992;67:670-8.  Back to cited text no. 1
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2.Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: A preliminary procedural report. Int J Oral Maxillofac Implants 1992;7:360-6.  Back to cited text no. 2
[PUBMED]    
3.Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. 1. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent 1993;13:29-45.  Back to cited text no. 3
    
4.Palmer RM, Floyd PD, Palmer PJ, Smith BJ, Johansson CB, Albrektsson T. Healing of implant dehiscence defects with and without expanded polytetrafluoroethylene membranes: A controlled clinical and histological study. Clin Oral Implants Res 1994;5:98-104.  Back to cited text no. 4
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5.Stevenson S, Li XQ, Davy DT, Klein L, Goldberg VM. Critical biological determinants of incorporation on non-vascularized cortical bone grafts. Quantification of a complex process and structure. J Bone Joint Surg Am 1997;79:1-16.  Back to cited text no. 5
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6.Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing two techniques of bone augmentation: Onlay graft alone or associated with a membrane. Clin Oral Implants Res 2001;12:632-9.  Back to cited text no. 6
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7.Matsui Y, Ohta M, Ohno K, Nagumo M. Alveolar bone graft for patients with cleft lip/palate using bone particles and titanium mesh: A quantitative study. J Oral Maxillofac Surg 2006;64:1540-5.  Back to cited text no. 7
[PUBMED]    
8.Romanos GE. Immediate loading of endosseous implants in the posterior area of the mandible: Animal and clinical studies. In: Romanos GE, (ed). Berlin: Quintessence; 2005.  Back to cited text no. 8
    
9.Schwartz-Arad D, Levin L. Symphysis revisited: Clinical and histologic evaluation of newly formed bone and reharvesting potential of previously used symphysial donor sites for onlay bone grafting. J Periodontol 2009;80:865-9.  Back to cited text no. 9
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10.Leonetti JA, Koup R. Localized maxillary ridge augmentation with a block allograft for dental implant placement: Case reports. Implant Dent 2003;12:217-26.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
Acknowledgment
References
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