|Year : 2018 | Volume
| Issue : 2 | Page : 61-65
Ridge augmentation using allograft bone block: A case report with 5-year follow-up
Vikrant Jain, Aparna Jain
Consultant Implantologist, Private Practice, Delhi, India
|Date of Web Publication||17-Dec-2018|
Dr. Vikrant Jain
4734, Pahari Dhiraj, New Delhi - 110 006
Source of Support: None, Conflict of Interest: None
| 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
| Introduction|| |
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.
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.
Allograft bone blocks (cortical or cancellous) are among one of the most predictable procedures.,,,,,,,,
They can also be used in patients with congenitally missing tooth who may present with underdeveloped alveolar ridges.
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.
Allogeneic bone block, demineralized freeze-dried bone allograft (DFDBA) particulate, platelet-rich fibrin (PRF), and titanium fixation screws.
| Case Report|| |
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].
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.
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.
Two percent lignocaine with adrenaline 1:80000 (Lignox 2% A, Indoco Remedies Ltd, Mumbai, India) was used to anesthetize the surgical site.
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].
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).
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.
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].
Interrupted sutures were placed and removed after 10 days. Immediate fixed composite provisional prosthesis was delivered to the patient on the same date.
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].
| Discussion|| |
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.,,
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. Furthermore, the red blood cells and white blood cell balance does not get impaired with both allograft and autograft bone augmentation.
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.
However, there is risk of nerve and vascular injury at donor site with autogenous bone graft harvesting.
| Conclusion|| |
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.
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].
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.
Complications in maxillae are often less as compared to mandible.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]