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 Table of Contents  
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 127-130

Management of compromised anterior maxillary edentulous arch with symphyseal bone graft

Department of Maxillofacial Prosthodontics and Implantology, HKE'S S.N. Institute of Dental Sciences and Research, Kalaburagi, Karnataka, India

Date of Web Publication8-May-2018

Correspondence Address:
Sunil Kumar Mishra
Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AIHB.AIHB_23_17

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Achieving optimal aesthetics, function and phonetics with implant-supported restorations depends largely on the amount of bone present at the site where implant has to be placed. Sometimes, patient reports with compromised conditions which makes the implant placement difficult. Today, reconstruction procedures such as autogenous bone graft and guided bone regeneration make the implant placement possible in different ridge deficient cases. This case report describes step-by-step procedure of restoring the missing maxillary right central incisor with implant-supported prostheses. In missing left central incisor region, the alveolar bony defect was corrected by autogenous bone graft obtained from symphysis region, for restoration with implant prostheses.

Keywords: Anterior maxilla, autogenous graft, bone graft, dental implant, osseous defects, symphysis

How to cite this article:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Management of compromised anterior maxillary edentulous arch with symphyseal bone graft. Adv Hum Biol 2018;8:127-30

How to cite this URL:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Management of compromised anterior maxillary edentulous arch with symphyseal bone graft. Adv Hum Biol [serial online] 2018 [cited 2022 Aug 15];8:127-30. Available from: https://www.aihbonline.com/text.asp?2018/8/2/127/232018

  Introduction Top

Currently, implant treatment is considered as a reliable option for the replacement of missing teeth and widely accepted treatment for improving function and aesthetics.[1] Brånemark et al. had introduced the term osseointegration and it had created a revolution in advanced dental treatment for the rehabilitation of lost missing teeth, with implant-supported prosthesis.[2],[3] In cases where there was a deficiency of soft-tissue and bone, rehabilitation with implant-supported prosthesis to restore single or multiple teeth, especially in aesthetic region, is a great challenge for the implantologist. To preserve or create the natural appearance of the tooth and surrounding structures are quite difficult and challenging for the clinician.[4],[5] The residual alveolar ridge present plays a crucial role in the success of implant rehabilitation. Reconstruction procedures, such as autogenous bone graft and guided bone regeneration, make the implant placement possible in cases where the ridge was deficient.[6]

This case report presents the rehabilitation of a patient with the missing maxillary right central incisor with the help of implant-supported prosthesis. A two-stage implant surgery was done wherein the first surgery was for implant insertion and the second surgery, several months later, was performed for uncovering the implant and attaching a prosthetic abutment. In missing left central incisor region, the alveolar bony defect was corrected by autogenous bone graft obtained from symphysis region.

  Case Report Top

A 23-year-old, female patient reported to the maxillofacial prosthodontic department of HKE'S S.N. Institute of Dental Sciences, Kalaburagi, Karnataka, India, with the chief complaint of lost right and left front tooth and want it to be replaced [Figure 1]. Intraoral examination showed that there was missing right (11) and left (21) central incisors. Intraoral periapical radiographs (IOPA) and orthopantomogram were taken to make the radiographic investigations. Maxillary and mandibular arch impressions were made to obtain a diagnostic cast. A detail medical history of the patient was taken along with blood investigations to overrule any systemic findings. The available options for the treatment were explained to the patient, and patient chose rehabilitation with dental implant. Bone mapping was done, which revealed the width of labiopalatal cortical bone as 5.5 mm in 11 region and 4.5 mm in 21 region. It was planned to place a implant of size 3.5 mm × 12 mm in 11 region and bone graft to be placed in 21 region with delayed implant placement in that region.
Figure 1: Missing right and left central incisors.

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Under right infraorbital nerve block, the implant surgery was started. An incision in the mid-crestal region was given along with crevicular incisions and mucoperiosteal flap was elevated. The implant site was prepared, and an implant fixture of dimension 3.5 mm × 12 mm (Biohorizon, Birmingham, USA) was placed at the osteotomy site [Figure 2]. The periosteal flap was again sutured back with 4.0 non-resorbable silk sutures. Antibiotics and analgesic were prescribed and instructions were given for the post-operative care to the patient. After 6 months, the patient came back and she agreed for bone graft with 21 region. The receptor site for bone graft was prepared [Figure 3]. Autogenous bone graft taken with trephine from symphysis region [Figure 4] and blended with synthetic bone graft (Periobone G, Top-Notch Health Care Product Pvt., Ltd., India) [Figure 5] and harvested in 21 region [Figure 6]. Flap was sutured back with 4.0 non-resorbable silk sutures. After 1 month, the second stage surgery was done in 11 region and a gingival former of size 3.5 mm × 3 mm was placed [Figure 7]. After 1 week, gingival former was unscrewed and abutment was placed back. An impression with closed tray technique was done. Abutment was positioned back in impression along with implant analog and was poured in dental stone, and later, cast was retrieved. The abutment was milled [Figure 8] at cast and coping was fabricated and try in was done. A porcelain fused metal crown was fabricated and cemented. Occlusion was checked [Figure 9]. Assessment of the complete seating of the abutment on the implant fixture was done with the help of IOPA radiograph. A removable partial denture was given with 21 region for aesthetics [Figure 10] till the time the osseous defect was regenerated with new bone formation and an implant can be placed in that region.
Figure 2: Intraoral periapical radiograph showing implant in missing right central incisor region.

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Figure 3: Receptor site for bone graft.

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Figure 4: Autogenous graft taken from mandibular symphyseal region.

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Figure 5: Autogenous bone blended with alloplastic bone.

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Figure 6: Blended bone graft placed at receptor site.

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Figure 7: Gingival former placed.

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Figure 8: Milling of abutment on cast.

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Figure 9: Cement retained prostheses.

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Figure 10: Removable partial denture given with missing left central incisor.

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  Discussion Top

In this case report, two-staged implant surgery was done, as a success rate of 94% was reported in long-term studies for implant rehabilitation with two-stage protocol.[7] Roynesdal et al. stated that it was more desired to place implants in a two-stage protocol, to obtain a favourable emergence profile at the transmucosal portion in cases where coronal part of the implant is at the crestal level.[8]

In 21 region, there was not enough available bone to place implant. In certain clinical situations, the tooth loss was not coinciding with rehabilitation with implant-supported prosthesis and this leads to delay in treatment of the edentulous region.[9] Hence, it was decided to delay the implant placement and to place bone graft in that region. It was decided to take graft from symphysis region. The symphyseal bone graft consists of cortical bone (65%) and cancellous bone (36%) when compared to the ramus region of mandible, which mainly consists of cortical bone.[10] Symphyseal graft was blended with Periobone-G. Periobone-G (hydroxyapatite) material chemically and crystallographically equivalent to the mineral portion of human bone, specifically hydroxyapatite [Ca10(PO4) 6OH2]. There was no systemic or localised toxicity with this material, and it does not produce any inflammatory reaction. This material causes no alteration of normal bone mineralisation process and merges with the natural bone.[11] When grafted with the allogenous and autogenous bone, the study had shown successful results.[12] Research had shown good results when autogenous bone graft was placed inside the membrane in comparison to allograft.[12],[13],[14] A vertical bone formation of 8 mm was obtained when autogenous bone chips were placed along with membrane, but when allograft was placed with membrane, it does not result in a vertical regeneration of more than 5 mm bone.[12]

  Conclusion Top

There is very much variation in amount and quality of bone present in the anterior maxillary region. To obtain a harmonious and successful prosthesis in the area where there was deficient bone is a great challenge to the clinician. A thorough treatment planning for placement of dental implants in maxillary anterior region is required so that good esthetic results can be obtained. As the dentistry advances, it is the job of the clinician to make aware the patient to different treatment options available so that they can choose best among them.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla – A systematic review. Int J Oral Maxillofac Implants 2014;29 Suppl:186-215.  Back to cited text no. 1
Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A, et al. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.  Back to cited text no. 2
Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416.  Back to cited text no. 3
Magne P, Magne M, Belser U. Natural and restorative oral esthetics. Part I: Rationale and basic strategies for successful esthetic rehabilitations. J Esthet Dent 1993;5:161-73.  Back to cited text no. 4
Magne P, Magne M, Belser U. Natural and restorative oral esthetics. Part II: Esthetic treatment modalities. J Esthet Dent 1993;5:239-46.  Back to cited text no. 5
Yeh HC, Hsu KW. Guided bone regeneration for fenestration defects in dental implants. Chang Gung Med J 2003;26:684-9.  Back to cited text no. 6
Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11-25.  Back to cited text no. 7
Røynesdal AK, Ambjørnsen E, Haanaes HR. A comparison of 3 different endosseous nonsubmerged implants in edentulous mandibles: A clinical report. Int J Oral Maxillofac Implants 1999;14:543-8.  Back to cited text no. 8
Toscano N, Shumaker N, Holtzclaw D. The art of block grafting. A review of the surgical protocol for reconstruction of alveolar ridge deficiency. J Implant Adv Clin Dent 2010:2:45-66.  Back to cited text no. 9
Neiva RF, Gapski R, Wang HL. Morphometric analysis of implant-related anatomy in Caucasian skulls. J Periodontol 2004;75:1061-7.  Back to cited text no. 10
Gupta S, Vandana KL. Evaluation of hydroxyapatite (Periobone-G) as a bone graft material and calcium sulfate barrier (Capset) in treatment of interproximal vertical defects: A clinical and radiologic study. J Indian Soc Periodontol 2013;17:96-103.  Back to cited text no. 11
[PUBMED]  [Full text]  
Simion M, Jovanovic SA, Trisi P, Scarano A, Piattelli A. Vertical ridge augmentation around dental implants using a membrane technique and autogenous bone or allografts in humans. Int J Periodontics Restorative Dent 1998;18:8-23.  Back to cited text no. 12
Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994;14:496-511.  Back to cited text no. 13
Tinti C, Parma-Benfenati S, Polizzi G. Vertical ridge augmentation: What is the limit? Int J Periodontics Restorative Dent 1996;16:220-9.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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