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Article 14

Guided bone regeneration procedure for implant placement in the esthetic zone A Case Report

@Society of Scientific Research and Studies NLM ID: 101716117

Journal home page: www.jamdsr.comdoi: 10.21276/ jamdsr Indian Citation Index (ICI) Index Copernicus value = 91.86

Introduction: In the anterior maxillary region where the bone is porous, clinicians face challenges to place implants. Guided bone regeneration has satisfactorily come to the rescue when dealing with bone in this aesthetic region. Meticulously following the principles of GBR can increase the survival rate of implants by up to 95% in this region. Case Report: A 27 years old male patient with the chief complaint of poor esthetics due to a missing central incisor was rehabilitated with an implant-supported fixed partial denture. Due to a defect in the buccal bone, guided bone regeneration was done using autograft and xenograft. Conclusion: Guided bone regeneration can help the clinician to practice implants in the esthetic zone successfully. One should meticulously follow the principles of guided bone regeneration.

Esthetics concerns have increased over period of time. Edentulism pertaining to the anterior esthetic zone has brought advancements in the field of fixed restorations. Implants successfully rehabilitate form, function, and esthetics while restoring the patient’s confidence.
1  The treatment comprises surgically placing the implant that simulates the root form of the tooth in the first step and then loading the implant once the healing is complete. There are several different loading protocols according to time like immediate, early, and late.2  For successful implant therapy adequate alveolar ridge dimensions and bone quality is essential which can hold the implant and provide good esthetics and proper function. A lack of horizontal and vertical bone at implant sites causes numerous problems, especially in the esthetic zone.3 In the anterior maxillary region, fine trabecular bone is usually overlayed by porous cortical bone.4 This quality of bone often imposes challenges to the clinician with implant placement. Guided bone regeneration has satisfactorily come to the rescue when dealing with bone in this aesthetic region. Meticulously following the principles of GBR i.eprimary wound closure, angiogenesis, space creation/maintenance, and stability of both the initial blood clot and implant fixture (PASS) has increased implant survival to about 95% in this region. 5-7 This case report highlights the implant placement in the anterior maxilla using a minimal guided bone regeneration procedure.

A 27 years old male patient reported to the Department of Prosthodontics with the chief complaint of poor facial appearance on smiling due to a missing maxillary right central incisor. The patient had a history of trauma six months back and a history of fracture with the maxillary right central incisor. Subsequently, extraction was done with the remaining root piece 5 days after trauma. Since then, the patient has been partially edentulous. There were no other relevant dental and medical histories. The patient’s family history was non‑contributory, whereby the confounding environmental and genetic risk factors were deemed absent. Oral prophylaxis was done. Oral hygiene instructions were given to the patient. In subsequent visits oral hygiene and maintenance were satisfactory. On intraoral examination, the gingival and periodontal status of the patient was apparently healthy. The patient was explained the various treatment modalities available along with their advantages and disadvantages. These included removable partial dentures, tooth-supported fixed partial
dentures,s and implant prostheses. Taking into consideration the esthetic demands in the anterior region and the patient’s request, for an implant‑based fixed prosthetic rehabilitation, was planned.

Treatment plan: Diagnostic impressions were made with alginate and impressions were poured into dental stone. Casts were mounted on a semi-adjustable articulator (Hanau wide Avue). CBCT was done with the maxillary arch.
CBCT showed edentulous space in the region of the maxillary right central incisor with a bone width of 5mm corresponding to the level of 2mm below the crest of the ridge. The available vertical height was 13mm. Buccal concavity was seen in the edentulous space region. Bone in the edentulous area was noted to be of D3 type. An implant size of 3*10 mm was decided. Written informed consent was obtained from the patient before the surgical procedure.

The surgical site was anesthetized by local administration of 2% lignocaine hydrochloride (XICAINE, ICPA Healthcare products Ltd.) with 1:80,000 adrenaline. After the patient presented subjective and objective symptoms of anesthesia a conventional mid-crestal incision was made at the edentulous space. A crestal incision was placed slightly on the palatal side and the mucoperiosteal flap was reflected. The bone width was 3.5mm and a labial concavity in the bone was noted.
The lance drill was made using an Osstem taper kit and an intraoral periapical radiograph was taken with paralleling pin placed in the drilled socket to evaluate the parallelism. Sequential drilling was done till 3.00 *10 mm and osteotomy was completed. An implant fixture(Osstem TS 3*10) was placed with an adequate torque of 30N, and the cover screw was placed. Buccal thread hue was visible, hence guided bone regeneration procedure was performed. First, the periosteal releasing incision was given. Autogenous bone was scraped from the adjacent area using a bone scraper which was mixed with xenograft (Ti-Oss manufactured by Chiyewon Co., Ltd., South Korea) and blood and saline were added to hydrate the graft. Decortication was done in the area where grafting was to be done. The membrane (Fix Gide-GTR by SYNERHEAL Pharmaceuticals, Chennai.) was sutured on the palatal flap first for stability. The graft was placed in the defect and over the implant area. Afterward, the membrane was placed over it and periosteal suturing(resorbable) was done to stabilize the membrane. Horizontal mattress suture was given for flap closure, followed by interrupted suturing to achieve water-tight closure.

Amoxycillin and clavulanic acid combination 625 mg and aceclofenac sodium 50 mg were prescribed for 7 days. The patient was advised to do warm saline gargles for the initial 15 days to promote wound healing. The patient was instructed to avoid any undue stresses and forces on the surgical site. The patient experienced minimal post‑operative discomfort and no complications were reported. After 15 days the sutures were removed. Second stage surgery: After the healing period of six months the patient was recalled and an IOPA radiograph was taken. The radiograph showed signs of osseointegration. For the second stage of surgery partial thickness flap technique was used and the cover screw was removed. Osstem healing abutment of size 5*5mm was placed followed by a healing period of 15 days.

After the second stage of surgery healing was found to be excellent and healthy gingival tissue was formed around the healing abutment. An open tray impression coping(Osstem mini) was selected and an open tray impression was made using putty and a light body (Aveu gum by Avue). Impression was poured and the jig was made using the pattern for the jig try-in and evaluated by IOPA radiograph. In subsequent visits metal trial and bisquetrial were done for custom-made abutment evaluated. A cement-retained metal ceramic crown was fabricated and cemented using glass ionomer cement.(GC Fuji Type I)


Fig. 1 Incision given and flap raised. 

Fig. 2 Implant and cover screw placed.


Fig. 3 IOPA of Implant placed.

Fig. 4 Particulate graft placed.


Fig. 5 Resorbable suture placed.

Fig. 6 Post operative surgical site.


Fig. 7 jig trial.

Fig. 8 Metal try in.


Fig. 9 Final restoration.

Fig. 10 Post operative photograph.

In the case of maxillary anterior implants, chances of buccal bone resorption and subsequent mucosal recession are very common. Therefore, it is very important to respect the biology of the surrounding tissue and plan a prosthodontically-driven implant placement.
8  Meticulous preoperative evaluation of the dimension of the residual ridge is very important to develop an appropriate placement strategy and to preserve adjacent anatomical structures. 9
Zang et al in a CBCT-based study reported that the dimension of the alveolar ridge in the anterior maxillary region is approximately 18 ~ 19 mm in height and 8 ~ 9 mm in width for the selected population. Due to the presence of a buccal undercut, the risk of alveolar cortical plate perforation and surgical complications increases manifold. Therefore, an additional grafting procedure should be considered when implant placement in the anterior maxilla is planned.10

Guided bone regeneration (GBR) is a surgical procedure done to increase alveolar bone volume in the edentulous area where the implant is to be placed or around already placed implants. The principle of GBR is based on the principles of guided tissue regeneration. In GBR, Autogenous bone is considered the “gold standard” because of its osteogenic, osteoconductive, and osteoinductive properties. Ease of availability and absence of antigenic properties add on to the benefits of autogenous graft.11 The need for another surgical site to harvest the bone graft has been one of the major reasons that this procedure is not practiced regularly.

Allografts along with xenografts have been successfully used for guided bone regeneration in bone augmentation.12 However, the risk of infectious disease transmissions, such as for human immunodeficiency virus (HIV) and Hepatitis B and C prevail while using them.13 Though tissue processing techniques like sterilization, mechanical debridement, ultrasonic washing, and gamma irradiation can help alleviate these problems.14

Dental implants placed with GBR using deproteinized bovine bone mineral (DBBM) granules have been shown to achieve satisfactory long-term esthetic and functional outcomes.15-18  A study by Chen et al indicated that the thickness of facial hard tissue showed more reduction if thick post-operative grafting was done. This may be due to difficult angiogenesis in thick grafts and thus deficient blood supply. This bone loss was majorly seen in the first nine months postoperatively. However, the major drawback with particulateDBBM may be the unfavorable mechanical properties and poor resistance to collapse.19

It can be concluded from the case that the success of implants placed in the esthetic zone can be increased by guided bone regeneration. If all the principles of grafting are meticul
ously followed, defects in the anterior maxilla and the poor quality of bone can be successfully dealt with to deliver better quality healthcare to patients.






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