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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 115-119

Ridge augmentation and endosseous implant placement with a staged approach


1 Department of Periodontics, Nair Hospital and Dental College, Mumbai, Maharashtra, India
2 Department of Prosthodontics, Government Dental College and Hospital, Mumbai, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Manish A Ashtankar
233, New Balaji Nagar, Manewada Road, Nagpur - 440 027, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmd.ijmd_13_18

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  Abstract 


Rehabilitation of edentulous site in the maxillary anterior area is always associated with esthetic consideration as a primary factor, especially in female patients. Simultaneously, sufficient bone quantity and quality is required for survival of endosseous implant. Hence, it is prudent to do ridge augmentation for a horizontal defect in the anterior maxillary area. Insufficient bone volume can be augmented by different methods, including particulate and block grafting materials, guided bone regeneration with or without growth and differentiation factors, ridge splitting, and expansion and distraction osteogenesis, either alone or in combination. These techniques may be used for horizontal/vertical ridge augmentation, socket preservation, and sinus augmentation. Here, we present a case of horizontal ridge augmentation achieved with allograft material and staged implant placement.

Keywords: Allograft; endosseous implant; esthetics; ridge augmentation


How to cite this article:
Ashtankar MA, Shangonda CR. Ridge augmentation and endosseous implant placement with a staged approach. Indian J Multidiscip Dent 2018;8:115-9

How to cite this URL:
Ashtankar MA, Shangonda CR. Ridge augmentation and endosseous implant placement with a staged approach. Indian J Multidiscip Dent [serial online] 2018 [cited 2019 Jul 22];8:115-9. Available from: http://www.ijmdent.com/text.asp?2018/8/2/115/249111




  Introduction Top


Rehabilitation of edentulous site in the maxillary anterior area is always associated with esthetic consideration as a primary factor, especially in female patients. Simultaneously, sufficient bone quantity and quality is required for survival of endosseous implant. Physiological stimulation is a prime factor for maintenance of the alveolar bone.[1],[2] Advanced alveolar bone loss (>7 mm) may result in esthetically and functionally compromised ideal dental implant placement in prosthetically driven position.[3]

Insufficient bone volume can be difficult to augment without growth and differentiation factors and autogenous bone graft. Autogenous bone graft is also considered the gold standard.[4] Here, we present a case of horizontal ridge augmentation achieved with allograft material and staged implant placement.


  Case Report Top


A 34-year-old female patient referred from the department of prosthodontics for augmentation of ridge defect before Fixed partial denture. The patient's chief complaint was need of replacement of missing tooth esthetically.

Intraoral examination showed edentulous maxillary canine region on the left side with a history of traumatic extraction 1 year back. Edentulous area presented with a horizontal bony defect. The interocclusal distance was sufficient [Figure 1]. Insufficient bone was found for implant placement, so horizontal ridge augmentation was planned with an onlay bone graft.
Figure 1: Edentulous area presented with a horizontal bony defect

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Surgical procedure

Preoperative preparation: Surgery was performed in a sterile environment. The patient's mouth was rinsed with 0.2% chlorhexidine for 1 min to reduce the bacterial count. Perioral skin area was scrubbed with 5% povidone-iodine solution for disinfection. Surgical area was anesthetized with 2% lignocaine with 1:200,000 adrenaline.

The horizontal incision on the alveolar crest and two vertical releasing incisions were given, and a full-thickness flap was reflected. A horizontal defect of 8 × 6 × 4mm was evident on exposure [Figure 2] and [Figure 3]. Bleeding points were created (decortication) on the recipient bed to increase the graft acceptance [Figure 4]. Demineralized freeze-dried bone allograft (DFDBA) corticocancellous bone block (Tata Memorial Hospital, Mumbai) was used as an onlay graft material as the patient was not ready for autogenous bone graft and second surgical site [Figure 5]. Block graft was shaped according to the defect and positioned firmly in the canine region and then anchored with the help of a titanium screw [Figure 6]. Particulate DFDBA bone graft was placed to fill the remaining defect [Figure 7] and was closed with chorion membrane to cover the particulate bone graft material [Figure 8]. Mucoperiosteal flap was then closed with interrupted suture to obtain primary wound closure [Figure 9]. The area was covered with the periodontal dressing (Coe Pak, GC America Inc., IL, USA) to protect it and facilitate healing [Figure 10]. Postoperatively, antibiotic capsule amoxicillin (500 mg) thrice a day for 3 days and nonsteroidal anti-inflammatory drug tablet diclomol (50 mg) thrice a day for 3 days were prescribed to prevent postoperative infection and pain. The patient was recalled after 10 days for suture removal. Follow-up was done after the 1st and 3rd months. In the 5th month, screw exposure was happened which was removed and the patient was instructed to apply chlorhexidine gluconate 1% w/w topically on wound site.
Figure 2: A horizontal defect of 8 × 6× 4 was evident on exposure

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Figure 3: A horizontal defect of 8 × 6 ×4 was evident on exposure

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Figure 4: Decortication

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Figure 5: Demineralized freeze-dried bone allograft corticocancellous bone block

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Figure 6: Block graft anchored with the help of titanium screw

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Figure 7: Particulate demineralized freeze-dried bone allograft bone graft was placed to fill the remaining defect

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Figure 8: Chorion membrane to cover particulate bone graft material

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Figure 9: Interrupted suture with 4-0 Vicryl to obtain primary wound closure

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Figure 10: Periodontal dressing

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Staged approach

After 6 months, the site was reentered with a full-thickness flap for implant placement. 3.75 D, 10 L endosseous implant was placed by following proper protocol [Figure 11]. Intraoral periapical showed properly placed an implant in the maxillary canine region [Figure 12]. Immediate acrylic temporization done with maxillary canine as esthetic was a concern [Figure 13]. Final functional loading was done after achieving sufficient osseointegration at the 4th month [Figure 14].
Figure 11: 3.75 D, 10 L endosseous implant was placed

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Figure 12: IOPA showed properly placed an implant in the maxillary canine region

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Figure 13: Immediate acrylic temporization

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Figure 14: Final functional loading was done after achieving sufficient osseointegration at 4 months

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  Discussion Top


Many patients consider their maxillary anterior teeth as their most important esthetic facial features, whether a high or low smile line.[5],[6] Traumatic tooth loss or periodontal or endodontic disease results in tissue deficiency in the anterior maxilla. Tissue deficiencies may include deficits of soft tissue (alveolar mucosa) and/or hard tissue (alveolar bone). Bone deficiencies of the alveolar process may be categorized as vertical or horizontal deficits or combinations thereof. Hard- and soft-tissue defects may lead to functional, structural, or esthetic compromises in the final prosthesis.[3]

According to the classification of bony defect,[7] this case had Class 4 ridge defect, i.e., horizontal defect. We decided to follow onlay grafting to fill the defect. Onlay grafting can either be block onlay grafting or be particulate onlay grafting. The latter can further be categorized as subperiosteal tunnel grafting or direct particulate onlay grafting.[8] Both studies[9],[10] indicate that a particulate graft may not have the same potential for staged ridge augmentation compared to a block graft, as has been documented previously in other clinical studies.[11],[12],[13],[14],[15]

Block onlay grafting is indicated for horizontal or vertical deficiency or combined horizontal and vertical deficiency. The recipient sites with three-walled and four-walled defect morphology with an apical stop are considered to be best amenable to direct particulate onlay grafting.[8]

Allogenic graft material, i.e., DFDBA, was used as corticocancellous bone block and particulate graft. Its use for ridge augmentation in implant dentistry was first reported by Breine and Brånemark.[16] The revascularization of corticocancellous block grafts takes place at a much faster rate than in cortical bone autografts.[4]

Autograft is considered as the gold standard for bone transplantation.[4] It is osteogenic, osteoconductive, and osteoinductive. The healing of autogenous block grafts has been described as “creeping substitution” where viable bone replaces the necrotic bone within the graft and is highly dependent on graft angiogenesis and revascularization.[4] There is no risk of rejection or adverse immunological reaction with autogenous bone grafts. They are highly advantageous, but are associated with risks, such as donor site morbidity and limited bone availability.[17]

Allografts

The grafts are harvested from the same species, but from a different donor (genetically heterogeneous).[18] Essentially, allografts are osteoconductive with the exception being DFDBA, which may possess some osteoinductive potential. This is possibly because of the exposed organic content (might be growth factors) after demineralization. The mechanism of incorporation of allografts involves creeping substitution similar to autogenous cortical grafts.[18] FDBA undergoes faster replacement and osseointegration compared to DFDBA and thus enables earlier implant placement.[18]

We had followed staged implant placement along with ridge augmentation in this case. Systematic reviews by Kuchler and von Arx) showed that staged and simultaneous augmentation procedures in the anterior maxilla are both associated with high implant success and survival rates. The level of evidence, however, is better for the staged approach than for the simultaneous one.[19]


  Conclusion Top


Guided bone regeneration is the most predictable technique, as evidence suggests. The use of corticocancellous allogenic bone graft material with staged endosseous implant placement can give better functional and esthetic restoration of the edentulous area. The autogenous bone graft can be avoided for a larger defect if the patient is concerned about the second surgical site.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.  Back to cited text no. 1
    
2.
Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res 2012;23 Suppl 5:1-21.  Back to cited text no. 2
    
3.
Wang HL, Al-Shammari K. HVC ridge deficiency classification: A therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22:335-43.  Back to cited text no. 3
    
4.
McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol 2007;78:377-96.  Back to cited text no. 4
    
5.
Dong JK, Jin TH, Cho HW, Oh SC. The esthetics of the smile: A review of some recent studies. Int J Prosthodont 1999;12:9-19.  Back to cited text no. 5
    
6.
Henson ST, Lindauer SJ, Gardner WG, Shroff B, Tufekci E, Best AM. Influence of dental esthetics on social perceptions of adolescents judged by peers. Am J Orthod Dentofacial Orthop 2011;140:389-95.  Back to cited text no. 6
    
7.
Benic GI, Hämmerle CH. Horizontal bone augmentation by means of guided bone regeneration. Periodontol 2000 2014;66:13-40.  Back to cited text no. 7
    
8.
Goyal M, Mittal N, Gupta GK, Singhal M. Ridge augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112.  Back to cited text no. 8
  [Full text]  
9.
Hämmerle CH, Jung RE, Yaman D, Lang NP. Ridge augmentation by applying bioresorbable membranes and deproteinized bovine bone mineral: A report of twelve consecutive cases. Clin Oral Implants Res 2008;19:19-25.  Back to cited text no. 9
    
10.
Meijndert L, Raghoebar GM, Meijer HJ, Vissink A. Clinical and radiographic characteristics of single-tooth replacements preceded by local ridge augmentation: A prospective randomized clinical trial. Clin Oral Implants Res 2008;19:1295-303.  Back to cited text no. 10
    
11.
ten Bruggenkate CM, Kraaijenhagen HA, van der Kwast WA, Krekeler G, Oosterbeek HS. Autogenous maxillary bone grafts in conjunction with placement of I.T.I. Endosseous implants. A preliminary report. Int J Oral Maxillofac Surg 1992;21:81-4.  Back to cited text no. 11
    
12.
Chiapasco M, Abati S, Romeo E, Vogel G. Clinical outcome of autogenous bone blocks or guided bone regeneration with e-PTFE membranes for the reconstruction of narrow edentulous ridges. Clin Oral Implants Res 1999;10:278-88.  Back to cited text no. 12
    
13.
Simon BI, Von Hagen S, Deasy MJ, Faldu M, Resnansky D. Changes in alveolar bone height and width following ridge augmentation using bone graft and membranes. J Periodontol 2000;71:1774-91.  Back to cited text no. 13
    
14.
Knapp CI, Feuille F, Cochran DL, Mellonig JT. Clinical and histologic evaluation of bone-replacement grafts in the treatment of localized alveolar ridge defects. Part 2: Bioactive glass particulate. Int J Periodontics Restorative Dent 2003;23:129-37.  Back to cited text no. 14
    
15.
Meijndert L, Raghoebar GM, Schüpbach P, Meijer HJ, Vissink A. Bone quality at the implant site after reconstruction of a local defect of the maxillary anterior ridge with chin bone or deproteinised cancellous bovine bone. Int J Oral Maxillofac Surg 2005;34:877-84.  Back to cited text no. 15
    
16.
Breine U, Brånemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;14:23-48.  Back to cited text no. 16
    
17.
Fu JH, Wang HL. Horizontal bone augmentation: The decision tree. Int J Periodontics Restorative Dent 2011;31:429-36.  Back to cited text no. 17
    
18.
Jamjoom A, Cohen RE. Grafts for ridge preservation. J Funct Biomater 2015;6:833-48.  Back to cited text no. 18
    
19.
Kuchler U, von Arx T. Horizontal ridge augmentation in conjunction with or prior to implant placement in the anterior maxilla: A systematic review. Int J Oral Maxillofac Implants 2014;29:14-24.  Back to cited text no. 19
    


    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], [Figure 13], [Figure 14]



 

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