Journal of Dental Implants
   About JDI | Search | Ahead of print | Current Issue | Archives | Instructions | SubscribeLogin 
Users Online: 167  Wide layoutNarrow layoutFull screen layout Home Print this page  Email this page Small font size Default font size Increase font size


 
 
Table of Contents
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 61-65

Ridge augmentation using allograft bone block: A case report with 5-year follow-up


Consultant Implantologist, Private Practice, Delhi, India

Date of Web Publication17-Dec-2018

Correspondence Address:
Dr. Vikrant Jain
4734, Pahari Dhiraj, New Delhi - 110 006
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_18_17

Rights and Permissions
   Abstract 

Allograft bone blocks are tried and tested procedure to gain bone width so that an implant can be placed in cases with deficient bone width. It is a simple and easy technique. This article presents a case with deficient bone width in the anterior maxilla and the technique that was used to gain the desired bone width with successful placement and loading of dental implant.

Keywords: Autogenous bone, demineralized freeze-dried bone allograft, fixation screws, maxilla, platelet-rich fibrin


How to cite this article:
Jain V, Jain A. Ridge augmentation using allograft bone block: A case report with 5-year follow-up. J Dent Implant 2018;8:61-5

How to cite this URL:
Jain V, Jain A. Ridge augmentation using allograft bone block: A case report with 5-year follow-up. J Dent Implant [serial online] 2018 [cited 2019 Jan 21];8:61-5. Available from: http://www.jdionline.org/text.asp?2018/8/2/61/247583


   Introduction Top


Deficient bone width in anterior maxillae is a common finding, especially in cases where tooth loss is due to periodontal problems or with big periapical pathology.

Buccal cortical plates in anterior maxillary zone (include premolar area) are usually very thin, and they easily give away in case of traumatic extractions thus reducing the overall bone width. Therefore, to gain bone width, it is very important and is indicated to deliver prosthesis with favorable biomechanics, esthetics, and thus, long-term results.[1]

Various techniques and materials have been used to gain the bone width over the years such as guided bone regeneration, ridge expansion, ridge distraction techniques, pouch technique, and onlay grafts using autogenous or allogeneic bone blocks.[2]

Allograft bone blocks (cortical or cancellous) are among one of the most predictable procedures.[3],[4],[5],[6],[7],[8],[9],[10],[11]

They can also be used in patients with congenitally missing tooth who may present with underdeveloped alveolar ridges.[12]

They have advantages as follows:

  • They do not require a second surgery for autogenous bone block
  • Quantity of bone block is not limited like in autogenous blocks
  • Discomfort and morbidity to the donor site are avoided.


Therefore, it can be used as an alternative to autogenous bone which requires another surgery to harvest the graft and thus long chairside time.[13]

Materials

Allogeneic bone block, demineralized freeze-dried bone allograft (DFDBA) particulate, platelet-rich fibrin (PRF), and titanium fixation screws.


   Case Report Top


A 30-year-old female presented with a chief complaint of fracture tooth in the upper right front region.

Radiographic examination revealed root canal treated tooth and almost loss of entire crown [Figure 1].
Figure 1: Preoperative X-ray

Click here to view


Clinically, tooth showed crown fracture with mobility, and tooth root was palpable through facial gingiva indicating buccal bone loss and thus insufficient bone width.

DFDBA bone block technique was planned to regain the bone volume, following the extraction and curettage of infected socket once the soft tissue healing of the extracted socket takes place.

Method

Extraction of tooth no. 12 was done under local anesthetic, and thorough debridement of extraction socket is done. Immediate interim restoration was done using composites for esthetic purpose.

Adequate healing time was given for complete soft-tissue formation at extraction site.

Surgical procedure

Two percent lignocaine with adrenaline 1:80000 (Lignox 2% A, Indoco Remedies Ltd, Mumbai, India) was used to anesthetize the surgical site.

Incision placement

An incision was placed from mesial of central incisor to the distal of canine using no. 15 blade, releasing incisions were made at mesial line angle of central incisor and distal line angle of canine which were extended beyond mucogingival junction to achieve tension-free flap. The base was kept broad for good blood supply and to gain desired access to the surgical site. The bone was accessed and was found deficient in width [Figure 2].
Figure 2: Inadequate bone width to place implant in accordance with the esthetic requirements

Click here to view


Preparation of natural bone

Once the natural bone of the patient was accessed, it was prepared to receive the DFDBA bone block. The facial bone surface was smoothened using tapered fissure bur with copious irrigation, and a round bur was used to drill numerous small holes through the buccal cortical plate for good blood supply to the DFDBA bone block.

Once the site is prepared to receive DFDBA bone block (Rocky Mountain Tissue Bank, Aurora, Colorado 80014), the pack containing the bone block (10 mm × 10 mm × 5 mm) is opened and the bone block is now prepared and adapted according to the size of recipient site using tapered fissure bur with copious irrigation. It was made sure that the block is seated properly to the recipient bone without any rocking movement and is having intimate contact with natural bone. Sharp edges if any were rounded off.

Titanium fixation screws (Ortho Max Mfg Co. Pvt. Ltd., Baroda, India) of 2-mm diameter and 8-mm length were then used to fix the bone block with the natural bone. Drill holes were made on two selected sites through the bone block into the natural bone, and the fixation screws were lagged to hold the block on natural bone without any mobility [Figure 3] and [Figure 4].
Figure 3: Allograft bone block secured with fixation screw

Click here to view
Figure 4: Onlay block with fixation screw

Click here to view


Once the fixation of block was done, it was again checked for any sharp edges that might tear the soft tissue.

Meanwhile, the patient's blood is withdrawn and was centrifuged to make PRF out of it.

The periosteum is further released using no. 15 B.P. blade so that flap can be closed properly without any tension, and few minutes were given so that the hemostasis is reached. Once the bleeding stopped, the particulate graft DFDBA (Tata Memorial Hospital Tissue Bank, Mumbai, India) and synthetic graft-HA + Beta TCP (Equinox Medical Technologies BV, Netherland) were mixed with growth factors that were obtained during the making of PRF. This bone graft was used to cover the block from all its side.

All this graft material was covered with PRF membrane, and six interrupted sutures were given using 3-0 nonabsorbable sutures (Johnson and Johnson).

Healing period

Sutures were removed after 8 days of the surgery, and the patient was provided with a fixed composite provisional prosthesis that would not place any pressure on the bone graft or the ridge to prevent any kind of resorption or displacement of the bone graft.

Implant placement

This surgery was performed after a healing period of 9 months. The surgical site was anesthetized, and an incision was placed from mesial of central incisor to the distal of canine using no. 15 blade, releasing incisions at the second-stage surgery were made at distal line angle of canine only. Flap was reflected enough only to remove the titanium fixation screws.

Once the fixation screws were removed, the implant osteotomy was performed, and implant of size 3.75 × 11.5 (ADIN Dental Implant Systems Ltd, Israel) was placed [Figure 5] and [Figure 6].
Figure 5: Implant in position with cover screw

Click here to view
Figure 6: Postoperative X-ray

Click here to view


Interrupted sutures were placed and removed after 10 days. Immediate fixed composite provisional prosthesis was delivered to the patient on the same date.

Second-stage surgery

The implant was exposed after 3 months under local anesthetic.

Implant-level impression for final prosthesis was taken, and a healing abutment was placed to contour the soft tissues. Meanwhile, again a temporary restoration was delivered. Necessary metal coping and bisque try-in were done to check for the fit of the prosthesis and esthetics, also to determine if any other soft-tissue procedure is needed.

Delivery of final prosthesis

Once the patient was satisfied with prosthesis, the final prosthesis was delivered with the necessary instructions [Figure 7].
Figure 7: Final crown in position with desired esthetics

Click here to view



   Discussion Top


The main advantage of the allogeneic bone block is its readily available in various sizes.

No secondary surgery is required for donor site.

One can also use customized allogenic bone blocks for vertical and/or horizontal bone defect augmentations so that block of desired size and shape as per the requirement of recipient site can be prepared preoperatively, thus reducing the chairside surgical time and postoperative complications.[14],[15],[16]

Allograft bone block has both osteoinductive and osteoconductive properties, but lack osteogenic properties as they do not have viable cells which are there in autogenous bone blocks.

However, both allograft and autogenous bones act similar and do not challenge the immune system significantly.[17] Furthermore, the red blood cells and white blood cell balance does not get impaired with both allograft and autograft bone augmentation.[18]

Some amount of graft resorption during or after healing of the augmented site is always a possibility with any bone block grafting procedures.

Success with immediate nonfunctional loading following DFDBA augmentation is also achievable.[19]

However, there is risk of nerve and vascular injury at donor site with autogenous bone graft harvesting.


   Conclusion Top


Dental implant placement in the anterior esthetic zone is a challenge with insufficient bone width (volume). This problem can easily be overcome by bone block technique using allogeneic bone.[20]

This case report shows successful and long-term results [Figure 8] with the use of DFDBA bone block along with the use of PRF and successful placement of the dental implant in newly formed bone and delivery of a final restoration on it [Figure 9].
Figure 8: Postoperative X-rays with final prosthesis

Click here to view
Figure 9: Postoperative photographs

Click here to view


Complications

Apart from the common complications that can occur during any dental surgical procedures such as infection and incision dehiscence, there can be membrane exposure, mucosa perforation, exposure of fixation screws during the healing procedure; and partial or full failure of graft can take place.[21]

Complications in maxillae are often less as compared to mandible.[22]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Viswambaran M, Arora V, Tripathi RC, Dhiman RK. Clinical evaluation of immediate implants using different types of bone augmentation materials. Med J Armed Forces India 2014;70:154-62.  Back to cited text no. 1
    
2.
Araújo PP, Oliveira KP, Montenegro SC, Carreiro AF, Silva JS, Germano AR, et al. Block allograft for reconstruction of alveolar bone ridge in implantology: A systematic review. Implant Dent 2013;22:304-8.  Back to cited text no. 2
    
3.
Novell J, Novell-Costa F, Ivorra C, Fariñas O, Munilla A, Martinez C, et al. Five-year results of implants inserted into freeze-dried block allografts. Implant Dent 2012;21:129-35.  Back to cited text no. 3
    
4.
Nissan J, Marilena V, Gross O, Mardinger O, Chaushu G. Histomorphometric analysis following augmentation of the anterior atrophic maxilla with cancellous bone block allograft. Int J Oral Maxillofac Implants 2012;27:84-9.  Back to cited text no. 4
    
5.
Acocella A, Bertolai R, Ellis E 3rd, Nissan J, Sacco R. Maxillary alveolar ridge reconstruction with monocortical fresh-frozen bone blocks: A clinical, histological and histomorphometric study. J Craniomaxillofac Surg 2012;40:525-33.  Back to cited text no. 5
    
6.
Nissan J, Gross O, Mardinger O, Ghelfan O, Sacco R, Chaushu G, et al. Post-traumatic implant-supported restoration of the anterior maxillary teeth using cancellous bone block allografts. J Oral Maxillofac Surg 2011;69:e513-8.  Back to cited text no. 6
    
7.
Wallace S, Gellin R. Clinical evaluation of freeze-dried cancellous block allografts for ridge augmentation and implant placement in the maxilla. Implant Dent 2010;19:272-9.  Back to cited text no. 7
    
8.
Nissan J, Mardinger O, Calderon S, Romanos GE, Chaushu G. Cancellous bone block allografts for the augmentation of the anterior atrophic maxilla. Clin Implant Dent Relat Res 2011;13:104-11.  Back to cited text no. 8
    
9.
Barone A, Varanini P, Orlando B, Tonelli P, Covani U. Deep-frozen allogeneic onlay bone grafts for reconstruction of atrophic maxillary alveolar ridges: A preliminary study. J Oral Maxillofac Surg 2009;67:1300-6.  Back to cited text no. 9
    
10.
Wallace S, Gellin R. Clinical evaluation of a cancellous block allograft for ridge augmentation and implant placement: A case report. Implant Dent 2008;17:151-8.  Back to cited text no. 10
    
11.
Keith JD Jr. Localized ridge augmentation with a block allograft followed by secondary implant placement: A case report. Int J Periodontics Restorative Dent 2004;24:11-7.  Back to cited text no. 11
    
12.
Nissan J, Mardinger O, Strauss M, Peleg M, Sacco R, Chaushu G, et al. Implant-supported restoration of congenitally missing teeth using cancellous bone block-allografts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:286-91.  Back to cited text no. 12
    
13.
Contar CM, Sarot JR, Bordini J Jr., Galvão GH, Nicolau GV, Machado MA, et al. Maxillary ridge augmentation with fresh-frozen bone allografts. J Oral Maxillofac Surg 2009;67:1280-5.  Back to cited text no. 13
    
14.
Schlee M, Rothamel D. Ridge augmentation using customized allogenic bone blocks: Proof of concept and histological findings. Implant Dent 2013;22:212-8.  Back to cited text no. 14
    
15.
Jacotti M. Simplified onlay grafting with a 3-dimensional block technique: A technical note. Int J Oral Maxillofac Implants 2006;21:635-9.  Back to cited text no. 15
    
16.
Jacotti M, Wang HL, Fu JH, Zamboni G, Bernardello F. Ridge augmentation with mineralized block allografts: Clinical and histological evaluation of 8 cases treated with the 3-dimensional block technique. Implant Dent 2012;21:444-8.  Back to cited text no. 16
    
17.
Spin-Neto R, Stavropoulos A, de Freitas RM, Pereira LA, Carlos IZ, Marcantonio E Jr. Immunological aspects of fresh-frozen allogeneic bone grafting for lateral ridge augmentation. Clin Oral Implants Res 2013;24:963-8.  Back to cited text no. 17
    
18.
Spin Neto R, Felipe Leite C, Pereira LA, Marcantonio E, Marcantonio E Jr. Is peripheral blood cell balanced altered by the use of fresh frozen bone block allografts in lateral maxillary ridge augmentation? Clin Implant Dent Relat Res 2013;15:262-70.  Back to cited text no. 18
    
19.
Nissan J, Romanos GE, Mardinger O, Chaushu G. Immediate nonfunctional loading of single-tooth implants in the anterior maxilla following augmentation with freeze-dried cancellous block allograft: A case series. Int J Oral Maxillofac Implants 2008;23:709-16.  Back to cited text no. 19
    
20.
Jo JH, Kim SG, Oh JS. Bone graft using block allograft as a treatment of failed implant sites: Clinical case reports. Implant Dent 2013;22:219-23.  Back to cited text no. 20
    
21.
Pereira E, Messias A, Dias R, Judas F, Salvoni A, Guerra F. Horizontal resorption of fresh-frozen corticocancellous bone blocks in the reconstruction of the atrophic maxilla at 5 months. Clin Implant Dent Relat Res 2015;17 Suppl 2:e444-58.  Back to cited text no. 21
    
22.
Chaushu G, Mardinger O, Peleg M, Ghelfan O, Nissan J. Analysis of complications following augmentation with cancellous block allografts. J Periodontol 2010;81:1759-64.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed979    
    Printed20    
    Emailed0    
    PDF Downloaded36    
    Comments [Add]    

Recommend this journal