Dr. Anjali Chavan 1 ,Dr. Jyoti Nadgere 2Dr. 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.
Rehabilitation of esthetic zone with dental implants in severely atrophic ridges presents as one of the most challenging situations for prosthodontist. Nowadays use of dental implants for replacement of missing teeth is becoming increasingly popular. Several methods are being used for horizontal ridge augmentation around dental implants. Horizontal ridge augmentation using guided bone regeneration combined with soft tissue graft allows prosthetically driven implant placement. This treatment modality gives optimal dental and gingival esthetics. This case report presents novel approach for horizontal guided bone regeneration using collagen membrane in conjunction with combination of particulated autogenous cortical bone and particulated mineralized bovine bone in the anterior maxilla with simultaneous implant placement.
Keywords: Horizontal bone augmentation around implants, Guided bone regeneration, vascular interpositional periosteal-connective tissue graft.
Citations: Chavan A, Nadgere J, Iyer J. Simultaneous Hard and Soft-Tissue Augmentation around Dental Implant in the Esthetic Zone using osseodensification method: A Case Report. J Prosthodont Dent Mater 2022;3(1):72-80.
Clinical outcome of Dental Implant procedure and its survival are directly related to dimensions of available alveolar bone and soft tissue.1 Resorption of alveolar bone occurs three dimensionally within the initial three months after tooth loss or extraction.2 Anterior edentulous maxilla associated with deficient alveolar bone along with soft tissue defects can be challenging for endosseous implant placement and implant esthetics.
There are various surgical techniques for alveolar bone augmentation advocated for treatment of resorbed ridges such as segmental ridge-split procedure, autogenous or allogeneic block bone graft, alveolar distraction osteogenesis, guided bone regeneration (GBR).3 GBR is a validated and standard surgical technique for ridge augmentation. GBR includes placement of various particulate bone graft individually or combined with complementary materials underneath resorbable and nonresorbable membrane.4–6 In addition to alveolar bone augmentation, sufficient soft tissue architecture is essential for functional and esthetic outcome around dental implants. Various techniques have been introduced for reconstruction of 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.<>sup>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.
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.
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.
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). 3.5x11.5 mm implant fixture was placed (Osstem Implant India Pvt. Ltd) (Fig 9).
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 autogenous bone graft harvested from anterior nasal spine was placed over the exposed portion of implant (Fig 11). Xenograft was placed over the autogenous graft (Geistlich Bio-Oss) (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).
4 weeks after temporization, soft tissue architecture was evaluated (Fig 20). Provisional prosthesis was removed and attached to implant analogue
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 gingival contour 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.
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 was done with CAD-CAM high translucent zirconia crown to check the marginal fit, shape and contour of the prosthesis Final torque was given. Final cementation of prosthesis was done with glass ionomer cement (GC Glass Ionomer Luting Cement) (Fig 27, 28)
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 noncutting edges 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.
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
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 anterior area.
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