Dr. Anjali Chavan 1
, Dr. Jyoti Nadgere 2
, Dr. Janani Iyer 3
1 Post Graduate Student, 2 HOD & Professor, 3 Associate Professor,
Dept. of Prosthodontics and Crown & Bridge
Mahatma Gandhi Mission Dental College, Navi Mumbai.
Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022 73
deficient soft tissue in which onlay or inlay-type soft tissue grafts have been successfully used to gain
esthetic results.7 Soft tissue augmentation in the maxillary anterior region by vascularized interpositional
periosteal-connective tissue (VIP-CT) grafts have been used. This pedicle autograft provides excellent
blood supply, less morbidity, primary closure of donor and recipient bed.7,8
The aim of this case report is to describe a simultaneous soft and hard tissue augmentations associated with
implant placement in esthetic zone.
CASE REPORT
A 20-year-old male patient reported with the chief complaint of unpleasant smile due to missing tooth
in the upper front teeth region for the past 4 months and wants to replace it (Fig 1). The tooth was lost
due to carious involvement. He was healthy without any systemic disease. The patient opted for implant
supported prosthesis for replacement of missing tooth (Fig 2). A comprehensive case history and
preoperative impressions, photographs, and radiographs were evaluated. On intraoral examination,
maxillary right central incisor was missing and horizontal atrophy of an edentulous area was noticed
(Fig 3). Angle’s Class I malocclusion was present. Papillary frenal attachment was seen in maxillary
labial frenum.Then investigations including routine blood screening, periapical radiograph, and cone
beam computed tomography (CBCT) of the anterior maxilla were done. (Fig 4).
CBCT image showed ridge width as 3.5 mm, while ridge height was adequate that would
preclude the prosthetically driven implant placement. Frenectomy and Implant placement with
simultaneous GBR and VIP-CT flap technique was planned. Scaling and polishing were done and the
patient was instructed to follow strict oral hygiene protocol.
Fig 1. Preoperative Extraoral Fig 2. Preoperative intraoral
Fig 3. Resorbed edentulous region Fig 4. Periapical radiograph and CBCT with
11 showing available bone
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Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
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SURGICAL PROCEDURE
Maxillary labial frenectomy by conventional technique was followed under local anesthesia 2%
lidocaine with 1:100,000 epinephrine (LOX 2% Adrenaline; Neon) (Fig 5). Implant placement using
osseodensification technique was performed along with guided bone regeneration and connective
tissue grafting 2 weeks post frenectomy.
Fig 5. Maxillary Labial Frenectomy Fig 6. Mucoperiosteal flap elevation
Fig 7. Mucoperiosteal flap elevation Fig 8. Osteotomy after osseodensisfication
Fig 9. Implant placed with 11 Fig 10. Decortication
After administration of local anesthesia (2% lignocaine with 1:200,000 adrenaline), a crestal
incision and two vertical incisions were given distal to mesiolabial line angles of right canine and left
lateral incisor. A mucoperiosteal flap was elevated (Fig 6). Tooth supported surgical stent was made
by using autopolymerising resin and placed in the surgically planned region. Lance drill was used
through surgical stent (Fig 7). Osseodensification was done by using Densah burs (Versah, India) (Fig
8). 3.5×11.5 mm implant fixture was placed (Osstem Implant India Pvt. Ltd) (Fig 9).
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Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022
Fig 11. Autogenous bone graft
Fig 13. Collagen membrane secured labially
Fig 15. Suturing after surgery
Implant fixture had primary stability of 25 N/cm. Implant dehiscence was present with 3-4 threads
exposed on the labial surface. Decortication was done on the labial aspect (Fig 10). GBR was followed
by Sandwich technique for hard tissue augmentation and resorbable collagen membrane was secured
palatally with bone tac. Then autogenousbone graft harvested from anterior nasal spine was placed over
the exposed portion of implant (Fig 11). Xenograft was placed over the autogenous graft (Geistlich BioOss) (Fig 12) and other free end of collagen membrane was secured labially after ensuring appropriate
closure of underlying bone graft (Fig 13). Then VIP-CT graft from palatal region extended upto right
second premolar region. VIP-CT graft was then rotated labially over resorbable membrane and secured
apically with suture (Fig 14). Tension free primary closure achieved with 4-0 suture (Fig 15)
(MONOCRYL 4-0). Intraoral periapical radiograph was taken after surgery (Fig 16).
SECOND STAGE SURGERY
After 4 months of implant placement, second stage surgery was planned (Fig 17). Mid crestal incision
was placed at 11 implant regions. PEEK engaging abutment was used as a temporary abutment. PEEK
temporary abutment was engaged to implant and modified intraorally (Fig 18). Temporization of PEEK
abutment was done with composite resin (Protem, 3M ESPE). Screw retained provisional prosthesis was
given (Fig 19).
Fig 12. Xenograft placed
over autogenous bone graft.
Fig 14. Vascular interpositional connective
tissue periosteal graft
Fig 16. Periapical radiograph after surgery
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Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022
Fig 19. Screw retained provisional prosthesis
FINAL PROSTHESIS
4 weeks after temporization, soft tissue architecture was evaluated (Fig 20). Provisional prosthesis was
removed and attached to implant analogue
Fig 20 Soft tissue architecture after previsualization
Fig 21. Silicone index of provisional crown
Fig 17. Periapical radiograph after 4 months Fig 18. Peek abutment modified intraorally
Fig 22. Customized impression coping
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Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022
Index of cervical contour of provisional crown was made in addition silicone (GC LEXCEED)
(Fig 21). Provisional crown was removed from implant analogue and open tray impression coping
was attached to implant analogue. Impression coping was customized with composite resin (3M
ESPE) (Fig 22). Customized Open tray Impression copings to replicate gingivalcontour was screwed
to implant. IOPA was taken to check the fit of customized impression coping. Customized open tray
final impression was made with addition silicone (GC FLEXCEED) (Fig 23).Impression was poured
in type IV gypsum product (Kallabhai) and dies were prepared.
. Fig 24. Shade selection
Shade selection was done using vita shade guide (Fig 24). Implant level jig trial was done.
Final cast was scanned. SMART abutment was uniquely made for the patient, which is a computer
aided designed and manufactured abutment (Fig 25). Smart abutment trial was done (Fig 26). Final
cement retained prosthesis with high translucent zirconia crown was planned. Bisque try in wasdone
with CAD-CAM high translucent zirconia crown to check the marginal fit, shape and contour ofthe
prosthesis Final torque was given. Final cementation of prosthesis was done with glass ionomer cement
(GC Glass Ionomer Luting Cement) (Fig 27, 28)
Fig 23. Pick up impression
with elastomeric impression
Fig 25. labial view of Smart abutment Fig 26a. Periapical radiograph showing
fit of abutmment
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Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022
Fig 26b. Abutment jig trail intraorally Fig 27a. Intraoral view of cement retained prosthesis
Fig 27 b Periapical radiograph postoperative Fig 28. Postoperative Extraoral
DISCUSSION
Several augmentation techniques have been proposed to enhance the outcomes of atrophic jaw
reconstruction. However, the recipient site features as well as the type of bone deficiency might have
an impact on the outcome of these procedures.2 Abrams et al. showed 91% prevalence of the anterior
ridge deformity in the mandibular and maxillary arches of partially edentulous patients. Class III
defects showed prevalence of about 55.8%, followed by Class I defect, which was 32.8% and Class II
defects, which were 2.9%.9 In this case report, osseeodensification followed by guided bone
regeneration and connective tissue grafting was done for ridge augmentation procedure.
Osteotomy was done by using Densah burs. Osseodensification osteotomy preparation
technique developed by Salah Huwais in 2013.10 This bone preservation technique is made possible
with a specially designed bur that has many lands with a large negative rake angle, which work as
noncuttingedges to increase the density of the bone as they expand an osteotomy.11 Densifying burs
are designed to have a cutting chisel edge and a tapered shank, so as they enter deeper into the
osteotomy and also they have a progressively increasing diameter that controls the expansion process.
The osseous densification preparation technique preserves bone bulk in two ways: compaction of
cancellous bone due to viscoelastic and plastic deformation, and compaction autografting of bone
particles along the length and at the apex of the osteotomy. These burs are used with a standard surgical
engine and can densify bone by rotating in the noncutting direction (counterclockwise at 800–1,200
rotations per minute) or drill bone by rotating in the cutting direction (clockwise at 800–1,200 rotations
per minute). 11
This new technique’s proposed method of bone compaction is through the application of
controlled deformation due to rolling and sliding contact along the inner surface of the osteotomy with
the rotating lands of the densifying bur.
Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022 79
The bone deformation occurs through viscoelastic and plastic mechanisms when the load is controlled
beneath the ultimate strength of bone. 12 Copious amounts of irrigation fluid during this procedure
provide lubrication between the bur and bone surfaces and eliminate overheating. A recommended
technique is for the surgeon to utilize a bouncing motion of the bur in and out of the osteotomy, which
will induce a pressure wave ahead of the point of contact. The irrigation fluid that is then forced into
the osteotomy may also facilitate autografting of bone particles along the inner surface of the
osteotomy. Osteotomy diameters were found to be smaller than conventional due to the springy nature
and elastic strain of bone.12 This increased the percent of bone available at the implant site by about
three times and increases the primary stability.10,13
The challenge is that hard and soft tissue augmentation is necessary to achieve a successful
result. In this case report, GBR and VIP-CT soft tissue augmentation was done. Bone grafts are
believed to be essential for osseous regeneration. The GBR approach including barrier membranes
has emerged as another method to promote alveolar bone repair.14 The difficulty with GBR
techniques is membrane exposure during the healing process.15,16 The wound site is compromised
when the overlying tissue is thin, and inadequate flap release compromises the vasculature, resulting
in membrane exposure.1,5,17
In VIPCT flap technique, the amount of tissue gain is more and the pedicled blood supply
is derived from the connective tissue periosteal plexus within the flap that provides the biological
basis for predictable coverage.7,8 Vascularized interpositional connective tissue grafts for ridge
augmentation preserve the color match and characteristics of overlying mucosa resulting in a better
esthetics because the flap is covered with buccal flap resulting in maintaining natural coloration
and texture thereby reducing the need for secondary procedures. The donor site is near the surgical
field and has minor morbidity.7,8,18
CONCLUSION
Many novel techniques and biomaterials have been described in the literature that clinicians
may use to reconstruct bone deficiencies. The GBR and soft tissue augmentation technique can be
effectively used in delayed implant placement. Prosthetic-driven augmentation is recommended for
a better outcome. If the clinician focuses only on ridge augmentation techniques to solve bone
deficiency problems, he or she may overlook other treatment options that may have lower risks and
less morbidity, such as using short, narrow, or tilted implants. It is a versatile technique that is
useful in the simultaneous augmentation of hard and soft tissues in advanced defects in the
maxillary anteriorarea.
REFERENCES:
- Kirmani M, Zia A, Ahad A, Bey A. Hard-and soft-tissue augmentation around dental implant
using ridge split and connective tissue graft for esthetic rehabilitation of atrophic anterior
maxilla. Journal of Indian Society of Periodontology. 2018 Nov;22(6):555. - La Monaca G, Pranno N, Pompa G, Annibali S, Vozza I, Cristalli MP. Vertical Guided Bone
Regeneration with Mineralized Cancellous Bone Allograft in a Severe Anterior Maxillary
Defect: A Clinical Report with 14-Year Follow-Up. Case Reports in Dentistry. 2019 Nov
18;2019. - ResnikRR.In thisissue: GuidedBoneRegeneration: 8 Stepsto Successful Ridge Augmentation
(1 ceu ) step 1 : evaluate the bony defect. 2020;(2):1-16. - Khojasteh A, Kheiri L, Motamedian SR, Khoshkam V. Guided bone regeneration for the
reconstruction of alveolar bone defects. Annals of maxillofacial surgery. 2017 Jul;7(2):263.
Chavan A. et al: Simultaneous Hard and Soft-Tissue Augmentation osseodensification method: A Case Report
The JPDM I Vol 3 I Issue 1 I 2022