![ Combination approach is useful in treating
severe defects involving multiple missing
teeth
Individual approaches alone may not be
sufficient to achieve desired results [Table 1].](https://image.slidesharecdn.com/verticalandhorizontalridge-250815165637-5a95cadc/85/Vertical-and-horizontal-ridge-augmentation-in-anterior-maxilla-22-320.jpg)
Vertical and horizontal ridge augmentation in anterior maxilla
- 1. Vertical and horizontal ridge augmentation in anterior maxilla using autograft, xenograft and titanium mesh with simultaneous placement of endosseous implants Sudhendra Deshpande, Jeevanand Deshmukh, Sumeet Deshpande, Richa Khatri, Shubha Deshpande Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014
- 2. Introduction Advanced alveolar bone loss (>7 mm) may result in esthetically and functionally compromised dental prosthesis like removable and fixed partial dentures and ideal implant placement in prosthetically driven position. Augmentation of bone is often necessary for functional harmony with adjacent natural dentition.
- 3. Different methods of bone augmentation Particulate and block grafting materials Guided Bone Regeneration with or without growth and differentiation factors Ridge splitting, expansion Distraction osteogenesis, either alone or in combination. These techniques may be used for horizontal/vertical ridge augmentation, socket preservation and sinus augmentation
- 4. A unique case of vertical and horizontal ridge augmentation in anterior maxilla using autograft, xenograft and titanium mesh with simultaneous placement of endosseous implants, where autograft was obtained from the same site avoiding second surgical site
- 5. CASE REPORT 45 year male patient reported Missing front teeth. Four anteriors and a premolar was lost at the age of 25 years in a road traffic accident Wears removable partial denture for missing teeth Desire to restore with a permanent fixed prosthesis.
- 6. Clinical and radiographic examination severe vertical ridge resorption in maxillary anterior region Highest resorption in left lateral incisor region, leading to reversal of architecture Drooping of lips was evident on left side
- 7. Decrease in horizontal width of alveolar ridge was evident from left central incisor to left first premolar region inadequate bone for implant supported bridge.
- 8. Treatment plan Vertical and horizontal alveolar bone augmentation Simultaneous placement of endoosseous implants in right and left central incisor and left premolar Vertical bone augmentation in 22 region - Autograft from 23 region since patient not willing for secondary surgical site. For Horizontal bone augmentation- Bio‑oss, a xenograft, and Titanium mesh Soft tissue augmentation for esthetics (patient was not willing).
- 9. Surgical procedure Preoperative decontamination of oral cavity Chlorhexidine 0.2% mouthrinse for 1 min Perioral skin disinfection 5% povidone‑iodine solution Under LA, full thickness flap was reflected. A knife edge type ridge was seen Bleeding points were created on the recipient bed. A rectangular corticocancellous block graft was harvested from the canine region of the same site using trephine bur
- 10. Graft is shaped, positioned firmly in the lateral incisor area and then anchored with the help of titanium screws. Three endosseous implants ( Osstem, GS system, South Korea) were placed with cover screw [ Bio-oss was used to cover the entire area contained in titanium mesh Mesh was stabilized with three fixation screws to prevent any micromovement during the healing phase. Surgical site was closed with the flap and primary wound closure was obtained by horizontal mattress and interrupted sutures The area was covered with the periodontal dressing to protect it and
- 11. Chemical plaque control with chlorhexidine 0.2% (1 min mouthrinse, 3 times a day) for 2 weeks Diclofenac 50 mg, 3 times a day for 3 days and Amoxicillin 500 mg, 3 times a day for 10 days. Sutures were removed after 10 days. Reviewed weekly for the first 4 weeks; and then 1 every month. Exposure of titanium mesh in the central incisor was noticed in 3rd month review Patient was asked to maintain the area using 1% Chlorhexidine gel application twice a day
- 12. After 6 months Reflection of full thickness flap Titanium mesh was removed Newly formed bone was seen with implants embedded Appreciable increase in vertical height and horizontal width of bone Screw caps were removed and transfer abutments were placed
- 13. A 5 unit metal ceramic bridge was cemented Lip drooping on left side was completely eliminated IOPA of left central incisor region revealed bone regeneration
- 14. After 1 yr , partial filling of black triangles in the interdental areas was evident due to creeping attachment.
- 15. Discussion Overall the survival rates of implants placed in augmented ridges is 87% (range from 60% to 100%) Breine and Branemark first reported use of corticocancellous bone grafts for ridge augmentation in implant dentistry Revascularization of corticocancellous block grafts takes place at a much faster rate than in cortical bone autografts. Revascularization of block grafts enables maintenance of their vitality, and, hence, reduces chances of graft infection and necrosis. Autograft is considered as the Gold Standard for bone transplantation. It is osteogenic, osteoconductive and osteoinductive.
- 16. Auto grafts Sources Extraoral source (iliac crest, ribs) Intraoral source (chin, ramus). Used in block or particulate form. Preference - Corticocancellous block grafts Enhanced revascularization of the cancellous portion, Mechanical support and rigidity of the cortical portion Healing is described as‘‘creeping substitution’’ Viable bone replaces the necrotic bone within the graft and is highly dependent on graft angiogenesis and revascularization.
- 17. Advantages No risk of rejection or adverse immunological reaction Risks Donor site morbidity Limited bone availability Size mismatch Drooping of chin Nerve damage Tooth devitalization Gingival recession Increased postoperative discomfort, infection and blood loss.
- 18. Advantages of this case Autogenous coticocancellous block graft from canine region of same surgical site Avoided secondary site morbidity and used it for vertical ridge augmentation in left lateral incisor area. Bleeding points created on recipient bed, which increases rate of revascularization, the availability of osteoprogenitor cells and the rate of remodeling. Block graft was stabilized using titanium screws to avoid movement. Elimination of graft mobility and dead space between the graft and host bone.
- 19. Xenografts Reported in 1889 by Senn for bone grafting Derived from another species Biocompatible and osteoconductive. Bovine bone well tolerated in intraoral procedures. Better results in maxillary bone (D3, D4 type) Bovine bone correct defects adjacent to implants as well as in sinus lift and alveolar ridge augmentation procedures. Undergoes remodelling at a very slow rate In this case, Bio‑oss for horizontal ridge augmentation provided excellent results after 6 months
- 20. Titanium micromesh Introduced by Von Arx et al in 1996 in implant surgeries Excellent biocompatibility and handling for 3 D reconstruction of defects Most common - 0.2 mm thick mesh which gives the flap sufficient retention to prevent dehiscence. Acts as a protective matrix to contain graft material, maintain space and facilitate bone in growth, but is not cell occlusive. Recent studies with different types of grafts are reliable. Advantages Porous nature increases rate of revascularization than conventional techniques
- 21. Disadvantages Titanium mesh is very technique sensitive Mesh exposure rates reported from 20% to 40%. Managment of Mesh exposure complications Small exposure - plaque removal at the exposed portion of the mesh and local application of 0.12% chlorhexidine. No obvious infection - mesh removal can be delayed as done in the present case Primary wound coverage necessary for bone regeneration Degree of regeneration directly correlates with the adequacy of soft tissue coverage and surface area of the vascularized bony walls.
- 22. Combination approach is useful in treating severe defects involving multiple missing teeth Individual approaches alone may not be sufficient to achieve desired results [Table 1].
- 23. CONCLUSION Combination of autogenous graft, bovine bone material and titanium mesh for horizontal and vertical augmentation with simultaneous placement of implants resulted in better functional and esthetic restorations. Autogenous bone grafts from same surgical site can be used for augmentation of smaller defects, but may not be feasible for larger areas.