Deficient Ridges Research Articles

Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix

Patient wanted to restore her lost teeth with implants in the lower left first molar and second premolar region. Cone beam computerized tomography (CBCT) revealed inadequate bone width and height around future implant sites. The extraction socket of second premolar area revealed inadequate socket healing with sparse bone fill after 4 months of extraction. To evaluate the clinical feasibility of using a collagen physical resorbable barrier made of human pericardium (HP) to augment localized alveolar ridge defects for the subsequent placement of dental implants. Ridge augmentation was done in the compromised area using Puros® demineralized bone matrix (DBM) Putty with chips and an HP allograft membrane. Horizontal (width) and vertical hard tissue measurements with CBCT were recorded on the day of ridge augmentation surgery, 4 month and 7 months follow-up. Intra oral periapical taken 1 year after implant installation showed minimal crestal bone loss. Bone volume achieved through guided bone regeneration was a gain of 4.8 mm horizontally (width) and 6.8 mm vertically in the deficient ridge within a period of 7 months following the procedure. The results suggested that HP Allograft membrane may be a suitable component for augmentation of localized alveolar ridge defects in conjunction with DBM with bone chips.

Reconstruction of the Narrow Ridge Using Combined Ridge Split and Guided Bone Regeneration with rhPDGF-BB Growth Factor–Enhanced Allograft

In clinical situations where the presence of severe horizontal ridge deficiencies precludes simultaneous implant placement and bone augmentation, a staged approach may be desirable to allow optimal implant placement. Numerous therapeutic options are available for the treatment of the horizontally deficient ridge. With advances in tissue engineering, the use of growth factors can significantly improve wound healing with more rapid bone formation and maturation. These case reports demonstrate a technique that enhances the predictability of horizontal bone gain with reduced surgical trauma and postoperative complications. Recombinant human platelet-derived growth factor BB (rhPDGF-BB) in combination with particulate allograft is used to stimulate the proliferation and migration of osteogenic cells. A ridge split technique with vertical bone incisions allows expansion and mobilization of the buccal plate, creating a space that will contain the particulate graft material. Decortication of the mobilized buccal plate will create pathways to allow cellular and vascular access for enhanced maturation. Additional graft material is placed lateral to the mobilized buccal plate to increase apical ridge width. The use of piezoelectric surgery enables a precise crestal bony incision in severely deficient ridge widths and aids in faster wound healing. This study discusses the technique and the recommended therapeutic considerations to ensure predictable regeneration of adequate bone for optimal implant placement in horizontally deficient ridges.

Localised Ridge Augmentation with Autogenous Block Bone Graft for the Restoration of Maxillary Anterior Teeth

Resorption of alveolar ridge is a common sequel of tooth loss. It is even more if trauma occurs. In such cases it becomes a challenge for the dentist to restore esthetics and function. Therefore augmentation of alveolar ridge is an important aspect of dental implant therapy. Here is a case of step by step procedure of restoration of localized maxillary ridge deficiency successfully treated with symphyseal block bone graft.

Maintaining space in localized ridge augmentation using guided bone regeneration with tenting screw technology

Prosthetic guided implant surgery requires adequate ridge dimensions for proper implant placement. Various surgical procedures can be used to augment deficient alveolar ridges. Studies have examined new bone formation on deficient ridges, utilizing numerous surgical techniques and biomaterials. The goal is to develop time efficient techniques, which have low morbidity. A crucial factor for successful bone grafting procedures is space maintenance. The article discusses space maintenance tenting screws, used in conjunction with bone allografts and resorbable barrier membranes, to ensure uneventful guided bone regeneration (GBR) enabling optimal implant positioning. The technique utilized has been described in the literature to treat severely resorbed alveolar ridges and additionally can be considered in restoring the vertical and horizontal component of deficient extraction sites. Three cases are presented to illustrate the utilization and effectiveness of tenting screw technology in the treatment of atrophic extraction sockets and for deficient ridges.

Vertical Ridge Augmentation with a Collagen Membrane, Bovine Bone Mineral and Fibrin Sealer: Clinical and Histologic Findings

This study evaluated the treatment of alveolar bone deficiencies combined with dental implant placement. Thirty-five endosseous implants were inserted into 20 patients. After implant placement, the mean height of the supracrestal bone defects measured 4.25 ± 1.34 mm. Bone regeneration procedures were performed using a combination of a bovine bone-derived mineral stabilized with a fibrin-fibronectin sealing system and covered with a bilayered porcine collagen membrane. Healing was uneventful in all instances with maintenance of primary closure throughout the healing period. Stage-two surgery was performed after 6 months, and a hard bonelike tissue was detectable at the defect sites. Histologic examination confirmed the presence of newly formed bone with residual particles of xenograft. The mean bone gain was 3.95 ± 1.47 mm. The positive outcomes in terms of bone regeneration and low complication rate demonstrated the potential of this technique for the treatment of supracrestal ridge deficiencies. Bovine bone mineral combined with a fibrin sealer and protected by a collagen membrane should be considered as an alternative in the treatment of vertical peri-implant bone defects.

Growth Factor–Mediated Vertical Mandibular Ridge Augmentation: A Case Report

Posterior vertical alveolar ridge deficiencies are challenging defects to treat predictably and often require autogenous bone-harvesting procedures. Traditional treatment modalities, eg, guided bone regeneration, distraction osteogenesis, and autogenous grafts, present with a number of potential complications and limited success when used to restore vertical ridge height. Recent advances in recombinant growth factor technology may provide viable, alternative therapies for the treatment of significant alveolar ridge deficiencies. This proof-of-principle case report examines the utility and effectiveness of using a composite graft of freeze-dried bone allograft and recombinant human platelet-derived growth factor BB in conjunction with an overlying titanium mesh to regenerate well-vascularized bone in a significant posterior mandibular ridge defect prior to implant placement. The important role of the overlying periosteum as a possible key source of osteogenic cells during growth factor-enhanced regenerative procedures is emphasized.

Posterior maxillary segmental osteotomy for the implant reconstruction of a vertically deficient ridge: A 3-year clinical report

A vertically deficient posterior maxillary edentulous ridge in conjunction with sinus pneumatization or extensive horizontal bone resorption presents significant challenges for implant placement and restoration with an implant-supported fixed prosthesis. Various surgical techniques have been reported for the reconstruction of the vertically deficient posterior maxilla: guided bone regeneration, sinus elevation, block and/or particulate grafting with barrier membranes, and distraction osteogenesis. This clinical report describes the technique, the management of intrasurgical complications, and the 3-year follow-up results of augmenting the vertically deficient posterior maxilla with a segmental osteotomy prior to rehabilitation with an implant-supported fixed prosthesis.

Immediate Distraction Osteogenesis

The goal of this study was to demonstrate the technique and effectiveness of incorporating recombinant human bone morphogenetic protein-2 (rhBMP-2) to the established sandwich osteotomy technique. Although the success of the sandwich osteotomy procedure has been well documented, we hope to show that the addition of rhBMP-2 will enhance bone formation.We performed a sandwich osteotomy technique in patients who had been treated initially by grafting with suboptimal results. Only defects involving the anterior maxilla (3 patients) or the anterior mandible (1 patient) were included. There were 4 patients, 2 men and 2 women, with an age range of 19 to 62 years. The causes of the ridge deficiencies ranged from pathology to trauma. The height (distance) of distracted transport bone segment was measured. The amount of relapse was measured 6 months after the surgery.All patients exhibited a significant increase in bone height. The amount distracted was 6.75 mm (range, 5-11 mm). The amount of relapse was 8.5% (range, 0%-18%). Dental implants were placed in the reconstructed ridges in all patients. There were no instances of permanent paresthesia. Two patients had exposure of a portion of the hardware, which healed uneventfully.The sandwich osteotomy technique has proven to be an effective method for augmenting deficient alveolar ridges. The addition of rhBMP-2 may aid in its success rate by promoting osteogenesis at the osteotomy site, especially in multiple-operated patients where other traditional techniques have failed to gain the desired ridge height.

The Bone Lamina Technique: A Novel Approach for Lateral Ridge Augmentation—A Case Series

The goal of this case series is to present a novel treatment approach for lateral ridge augmentation. Four systemically healthy patients (aged 48 to 59 years) with inadequate dental alveolar ridge widths were selected for inclusion. All ridge defects were augmented using a xenogeneic cortical bone shield in combination with particulated bone substitutes and a thin collagen barrier. At baseline and after 6 months, digital cone beam computed tomography scans were performed. Biopsy specimens were harvested at reentry surgery and processed for histologic analysis. The results revealed a sufficient amount of bone structure for implant placement without additional augmentation procedures. The histologic analysis demonstrated that new bone formation had taken place and the bone shield had resorbed entirely. This case series indicates that the bone lamina technique has the biologic and mechanical properties to successfully achieve hard tissue augmentation of deficient ridges.

Human histological analysis between an autograft symphysis block and an allograft J block with PRGF in a maxillary anterior ridge augmentation

An autogenous symphysis block graft and an allogeneic J block graft were obtained and simultaneously grafted into a bilateral maxillary anterior ridge deficiency using platelet rich growth factor (PRGF) as a bioactive modifier. PRGF is a biological system of a complex bioactive proteins (transforming growth factor-B1, platelet-derived growth factor, and insulin-like growth factor). The augmented sites were allowed to heal for 6 months before obtaining core biopsy samples for histologic analysis. The purpose of this case study was to compare the histologic findings of an allograft and autograft block using a bioactive modifier, PRGF. The histologic findings from this study indicated bone remodeling with comparable amounts of viable woven and lamellar bone in each sample obtained.

Reconstruction of large soft tissue chin defects with a combination of z-plasty and inferior submental advancement flaps

Autogenous block grafting has long been a modality of treatment to create adequate bone volume in larger osseous deficient ridges prior to dental implant placement. With some autogenous donor sites being unfavorable anatomically to harvest from, clinicians have turned to using allogenic block materials. With the development of allogenic corticocancellous J blocks, it has allowed the clinician to seek other options of grafting when our gold standard, autogenous blocking, is unavailable.

Evaluation of horizontal ridge augmentation using beta tricalcium phosphate and demineralized bone matrix: A comparative study

Objectives: To evaluate the effectiveness of beta tricalcium phosphate (β-TCP) alone compared to β-TCP and Demineralized Bone Matrix (DBM) in regenerating localized horizontal maxillary alveolar ridge deficiencies prior to implant placement. Study Design: The study included 20 patients with horizontal maxillary ridge deficiencies limited to one or more neighbouring teeth and initial ridge width of ≤ 5mmm. Patients were divided equally into two equal groups. Ridge augmentation was performed using Guided Bone Regeneration (GBR) principals. In group I GBR was performed using β-TCP only, while in group II both β-TCP and DBM were used. Following a 6 months healing period, bone cores from both groups were retrieved and implants were inserted. Specimens were examined histologically to calculate percentage of mineralized bone. Apical and crestal changes in ridge dimensions were calculated by digital subtraction using Cone Beam Computed Tomography (CBCT) immediately after graft placement and six months later. Results: There was a statistically significant difference between the mean area percentage of mineralized bone between both groups where it was 40.1 % (range: 27.76-% 66.29 %) for group I and 68.96 % (range: 60.07 % - 87.33 %) for group II. Radiograpically, the mean ridge width in group I increased crestally to 4.66 mm (range:3.5-5mm) and apically to 6.12 mm (range: 4.1-6.7 mm). In group II the mean ridge width increased crestally to 5.2 mm (range 4.9-5.4mm) and apically to 6.9 mm (range 6.0-7.8 mm). Group II showed more bone gain with a mean of 1.37 mm crestally and 2.44 mm apically. This difference however was not statistically significant Conclusion: Within the limitations of this study the combination of DBM and β-TCP can be used effectively in cases exhibiting minimal alveolar ridge defects. Key words:Guided bone regeneration, equine bone, alloplast, bone graft.

Reconstruction of localized maxillary ridge defect with autogenous mandibular ramus block bone graft for dental implant placement

Severely resorbed alveolar ridge in aesthetic zone of maxilla can compromise the successful implant placement and aesthetic outcome. This study reports a case of severely deficient maxillary alveolar ridge being only 1.2 mm of bone width and implant site requires a hard tissue base foundation: To fulfill this requirement, mandibular ramus block bone is used to improve bone width. After 5 months of the graft surgery, 6.8 mm gain in bone width was noticed, implant was placed and till now it was fighting fit in terms of function and aesthetics.

Esthetic Dentistry in Patients with Bilaterally Missing Maxillary Lateral Incisors: A Multidisciplinary Case Report

Congenitally missing maxillary lateral incisors pose a difficult esthetic and treatment planning problem for clinicians. Age, location, space limitations, alveolar ridge deficiencies, uneven gingival margins, occlusion and periodontal factors often necessitate an interdisciplinary approach. Over the last several decades, dentistry has focused various treatment modalities for replacement of missing teeth. Treatment plans for patients with missing maxillary lateral incisors have traditionally included either space closure or space reopening. To remove healthy tooth structure of adjacent teeth to replace a tooth, for some patients and dentists, is a very aggressive treatment option which eliminates the option of three unit bridges. Removable partial dentures are also not preferred for its bulkiness and reduced esthetics. Presently, the single implant supported crown is a predictable method of tooth replacement in adolescents. The aim of this case report is to provide a conservative method for the management of bilateral missing lateral incisor.

Socket Preservation at Molar Site using Platelet Rich Fibrin and Bioceramics for Implant Site Development

ABSTRACTBackgroundThe extraction socket preservation technique conserves the alveolar architecture and prevents hard and soft tissue collapse that minimizes the necessity for future augmentation procedures. Also, considerable interest has recently emerged over the potential benefits of using platelet rich fibrin (PRF), a highly concentrated form of platelets power packed with growth factors encased in a leukocyte rich matrix that enhances osteogenic differentiation and bone repair. This article describes the currently improved technique utilizing alloplasts with autologous PRF to be implemented for preserving a future implant site.Materials and MethodsFollowing the atraumatic extraction of the periodontally compromised tooth, the socket bony walls were debrided and decorticated to facilitate regional acceleratory phenomenon. Venous blood was drawn from the antecubital fossa of the patient and was centrifuged according to Choukroun's method to yield autologous PRF that was minced into uniformly sized bits. Except for 2 to 3 mm of the coronal aspect of the socket, the rest was filled with particles of a slowly resorbing bone substitute material mixed homogeneously with minced PRF. A collagen membrane was used to seal the coronal end of the socket and was stabilized using 3-0 black braided silk sutures.ResultsClinically and radiographically satisfactory and successful regeneration of the deficient ridge's hard and soft tissues was demonstrated after 6 months post therapy.ConclusionSocket preservation surgery utilizing bioceramics and PRF is an effective procedure for posterior socket preservation coupled with rapid healing and aids in providing sound bone quality for successful implant placement.How to cite this articleGupta HS, Chowdhary KY, Pathak TS, Kini VV, Pereira R, Mistry A. Socket Preservation at Molar Site using Platelet Rich Fibrin and Bioceramics for Implant Site Development. J Contemp Dent 2013;3(2):102-107.

Subapical osteotomy to correct dental implant malpositioning and vertical ridge deficiency: A clinical report

This clinical report describes a subapical osteotomy to correct vertical ridge deficiency and malpositioned maxillary anterior implants. A 37-year-old woman with a noncontributory medical history presented with the chief complaint of an unesthetic implant-supported prosthesis. The maxillary left central and lateral incisors were restored with metal ceramic restorations. Gingiva-colored porcelain was fabricated to compensate for severe vertical and horizontal soft tissue deficiency. The patient was dissatisfied with the esthetics associated with the restorations and soft tissues since she presented with a high smile line and gingival display. Under general anesthesia, a subapical osteotomy was performed. The implant and ridge segment was coronally repositioned to correct the ridge deficiency. The surgical procedure and postoperative healing were uneventful. The surgical outcome was stable for a follow-up period of 3 years. The subapical osteotomy provided a satisfactory clinical outcome in managing a severely deficient residual ridge and malpositioned maxillary anterior implants as an alternative treatment to other surgical approaches.

Poster 72: A Canine Model for In Vivo Tissue Engineering and Alveolar Vertical Ridge Augmentation: Using rhBMP-2/ACS Versus Autogenous Bone With Titanium Mesh

This study was designed to develop an animal model for invivo evaluation of tissue engineering (TE) therapies, and application of TE for reconstruction of vertical posterior mandibular ridge deficiency. A 2-stage canine posterior alveolar ridge defect was chosen as a model chamber for assessment of bone regeneration therapies including space-maintenance devices, growth/differentiation factors, constructs, and tissue-device interfaces. Specifically, defects covered by titanium mesh were used to study bone regeneration with no graft, absorbable collagen sponge (ACS)/buffer, autogenous bone, and rhBMP-2/ACS.

The Sandwich Bone Augmentation Technique

Introduction: Horizontal ridge width reduction after tooth extraction is a common clinical scenario. As such, when implant‐supported restorations are planned for tooth replacement, it is a challenge to regenerate adequate bone width to house the dental implant and ensure its long‐term stability. Several horizontal ridge augmentation techniques, e.g. guided bone regeneration, ridge splitting, and block grafts, have been tested and proven to predictably augment bone width. Although these techniques are successful, treatment time is significantly increased and patients need to endure additional surgical procedures. Therefore, this case report aims at illustrating the ease and success of the sandwich bone augmentation technique when performed with dental implant placement.Case Presentation: A clinical case with a horizontally deficient ridge was selected. A buccal dehiscence was observed after placement of the dental implant in a prosthetically driven position. Autogenous bone graft harvested from the osteotomy site was placed on the exposed implant surface. Mineralized cancellous bone allograft was layered on, followed by a layer of mineralized cortical bone allograft. A collagen membrane was trimmed and used to contain the bone grafts as well as to exclude unwanted cells, such as epithelial cells and connective tissue fibroblasts. Tension‐free primary closure was subsequently obtained. Six months later, mature regenerated bone was found on the buccal surface of the implant at surgical reentry.Conclusion: Simultaneous implant placement with the sandwich bone augmentation technique predictably regenerated bone on implant buccal dehiscence defects.

New Crestal Approach for Lifting Sinus in the Extremely Atrophic Upper Maxillae

Introduction: Sinus augmentation, when performed with simultaneous or delayed implant placement, is a predictable procedure in augmenting deficient ridges. Traditionally, sinus augmentation was performed with either the lateral window or crestal osteotome approaches. In this case series, a new sinus floor elevation technique is proposed to treat specific cases of extremely atrophic maxillae.Case Series: In this technique, a window is opened from the ridge crest instead of the lateral wall. Particulate bone graft is subsequently packed through the crestal window to elevate the Schneiderian membrane. Primary closure is achieved and implant placement is performed after healing is completed.Conclusion: This new crestal sinus elevation technique combines direct visualization of the Schneiderian membrane with minimal flap reflection in the augmentation of severely atrophic maxillae in preparation for subsequent implant placement.

The Art of Block Grafting in the Preparation of Site for an Implant

Currently implants in dentistry have become a successful treatment option for replacement of missing teeth or tooth. However, sufficient width and height of maxillary or mandibular alveolar ridge is a must for implant placement. Deficient ridge may occur due to trauma, other local pathologies or periodontal diseases. Retention and success of implants in insufficient ridge height becomes questionable. A correct diagnosis of the deficient ridge especially in the maxillary posterior region, whether due to pneumatization of the maxillary sinus or due to periodontal disease, needs to be made prior to deciding the treatment protocol. Surgical reconstruction of such alveolar ridge using autologous bone grafts allows implant fixation in an esthetic and functional manner. For repair of most localized alveolar defects, block bone grafts from the symphysis offer advantages over iliac crest grafts, like close proximity of donor and recipient sites, convenient surgical access, decreased donor site morbidity, decreased cost and hidden scar. We hereby present a case of deficient alveolar height in the maxillary posterior region which was reconstructed with intraoral symphysis graft from the mandible before implant placement.