BIOBRIEF

Horizontal Ridge Augmentation in the Posterior Mandible of a 90-Year-Old Female

Dr. Kim Rocky Mount Perio
Dr. John Kim

THE SITUATION

A 90-year-old female presented requesting dental implants be placed in the left mandibular posterior region. Her chief complaint was increased drooling and difficulty chewing on only one side. She lost her bridge one year prior to her visit and firmly stated that she did not want to wear a partial denture. The clinical exam and CBCT showed that there was a horizontal alveolar ridge deficiency that precluded the implants from being placed in a restoratively desirably position. Therefore, a horizontal ridge augmentation was done using multiple layers of Geistlich Bio-Gide® Compressed over a 1:1 ratio of autogenous bone and Geistlich Bio-Oss® xenograft.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
Note: Very limited range of opening
watch video download pdf

THE APPROACH

The treatment goal was to gain adequate horizontal bone dimension to allow for prosthetically-driven implant placement. Guided bone regeneration was performed in which autogenous bone was mixed with Geistlich Bio-Oss® xenograft in a 1:1 ratio. PRF was used to create “sticky bone” and was covered by multiple layers of Geistlich Bio-Gide® Compressed. The membrane was stabilized with periosteal biting stabilizing sutures. Tension-free primary closure was achieved and the grafted site was allowed to heal for 8 months prior to the implant surgery for #19 and #20.

Pre-operative situation showing the horizontal ridge deficiency (left). Buccal bone concavity evident after full thickness flap elevation (middle). There is insufficient bone to place implants in an ideal restorative position (right).
It is important to locate the mental foramen. Intramarrow penetrations were done to allow for improved blood supply to the bone graft.
The clinical cocktail used for guided bone regeneration: 1) 50/50 mixture of autogenous bone chips, collected with Geistlich SafeScraper TWIST, and Geistlich Bio-Oss®, and 2) Geistlich Bio-Gide® Compressed 20 x 30 mm and 13 x 25 mm.
“Sticky bone”, created by combining PRF with the bone graft, adapted well to the site of the defect. Periosteal biting sutures were used for stabilization of the multiple layers of Geistlich Bio-Gide® Compressed and underlying bone graft.
Geistlich Bio-Gide® Compressed was carefully trimmed to be mindful of the mental nerve.
Tension-free primary closure achieved with horizontal mattress sutures and simple interrupted sutures.
Re-entry and CBCT scan at 8 months showing a significant increase in horizonal bone dimension.
Sufficient regenerated bone to allow for implant therapy (left). Implants #19 and #20 placed. Vital bone from guided bone regeneration as evidenced by the bleeding bone (middle). Tension-free primary closure achieved using 5-0 glycolon sutures.

“A predictable ridge augmentation procedure was needed to help our 90-year-old patient avoid having nutritional deficiencies due to lack of proper chewing ability and also to improve her quality of life.”

THE OUTCOME

The horizontal ridge augmentation procedure resulted in adequate bone for implant therapy as evidenced by the CBCT scan and re-entry surgery. With a sufficient quantity of good quality regenerated bone, implants for #19 and #20 were placed using a surgical guide based on a diagnostic wax up. Our 90-year-old patient is very happy to be able to chew efficiently again.

Stabilizing Geistlich Bio-Gide® Compressed and the underlying particulate graft allows for predictable ridge augmentation across multiple edentulous sites.”

Dr. John Kim
Dr. Kim Rocky Mount Perio

Dr. John Kim

Dr. Kim, originally from Fairfax, VA, received his DMD from Harvard School of Dental Medicine. He completed his residency and received his M.S. in Periodontics at UNC School of Dentistry at Chapel Hill. Dr. Kim is a Diplomate of the American Board of Periodontology and actively speaks as an expert on guided bone regeneration, implant therapy, soft tissue grafting, and managing complications domestically and internationally. He is also an adjunct faculty at UNC Adams School of Dentistry.

BIOBRIEF

Horizontal Ridge Augmentation in the Esthetic Zone

Dr. Justin Kang

THE SITUATION

An adult female patient presented with a long history of edentulism at site #9. Patient was interested in replacing her missing tooth with a dental implant, and was wearing a Nesbit appliance. The irritation from the ill-fitting Nesbit appliance resulted in irregular and friable soft-tissue at site #9.

Pre-operative CBCT demonstrated a hard-tissue concavity apical to the crest of the bone. The primary goal of therapy was to regain horizontal dimension of hard and soft-tissue to achieve prosthetically-driven placement of a dental implant to replace the patient‘s left central incisor.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
Note: Lack of mutually protected occlusion on the patient‘s left side due to wear from parafunctional habit.
watch video download pdf

THE APPROACH

The treatment goal was to regain the horizontal dimension of hard and soft-tissue through guided bone regeneration. In coordination with the restoring dentist, a diagnostic wax up was completed to determine the ideal tooth position and to regain mutually protected occlusion on the patient’s left side. The combination of Geistlich Bio-Oss® and autologous bone chips was used along with Geistlich Bio-Gide® to regenerate the horizontal dimension for prosthetically-driven implant placement.

Baseline: compromised soft-tissue architecture at site #9 due to ill-fitting Nesbit appliance.
Sulcular and paracrestal incision for full thickness flap elevation with single vertical incision distal to the site.
Presence of horizontal tissue deficiency clearly visible following flap elevation.
Application of 50:50 mixture of Geistlich Bio-Oss® and autologous bone chips harvested using Geistlich SafeScraper Twist.
Geistlich Bio-Gide® stabilized using fixation pins and covering the graft material.
Tension-free primary closure achieved using 4-0 PTFE sutures.
Soft-tissue contour at 4-month healing. Fixed provisional in place for soft-tissue contouring.
Occlusal view demonstrating gain in horizontal dimension for prosthetically guided implant placement.

“Patient with a long history of partial edentulism was seeking a long-term, predictable restorative option to replace her missing left central incisor.”

THE OUTCOME

Adequate hard and soft-tissue architecture was restored with the use of Geistlich Bio-Oss® and Geistlich Bio-Gide® for predictable, prosthetically-driven implant placement. The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.

Decortication allows for improved blood supply and nutrients to the bone graft.”

Dr. Justin Kang

This case demonstrates the importance of meticulous incision design, flap advancement, and suturing technique to ensure adequate blood supply and nutrients to the graft material and to maintain primary closure throughout the course of healing.”

Dr. Justin Kang

The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.”

Dr. Justin Kang

Dr. Justin Kang

Dr. Justin Kang received his Doctor of Dental Medicine degree from University of Pennsylvania School of Dental Medicine. He completed his residency and received his Masters of Science in Periodontics at Columbia University College of Dental Medicine. Dr. Kang is a Diplomate of the American Board of Periodontology and a member of numerous professional associations including the Academy of Osseointegration, American Dental Association and the New Jersey Dental Association.

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