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CONTINUING EDUCATION
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CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
height and hide the prosthetic transition area under the lip.4 augmentation.7 Computed tomography (CT) is extremely useful
The need for lip support may also be a concern when multiple in assessing the maxillary anatomy, ridge deficiency, and
teeth are missing. This is more significant when a fixed volume of bone augmentation required.8,9 Many surgeons have
prosthesis, without a flange, is planned. A diagnostic try-in CBCT machines in their offices (CS 9000 3D System [Carestream
without a flange can be used to assess the need for lip support.5 Dental]). CBCT exposes the patient to less radiation and allows
The soft tissue in the edentulous span and around the an immediate assessment of the patients condition. A radio-
adjacent teeth should be evaluated, including the amount of graphic template fabricated from a diagnostic setup of the
keratinized tissue, gingival biotype, and mucosal thickness. planned tooth positions is worn during the scan. A radiopaque
Thin tissue may be more prone to graft perforation, titanium medium, such as barium sulfate, is mixed into the acrylic or
mesh exposure, or gingival recession around adjacent teeth painted on the tooth areas of the template. Radiopaque denture
from flap elevation. Thin tissue may also contribute to teeth can also be set for a wax try-in (SR VivoTAC [Ivoclar
recession defects on bordering teeth and marginal bone loss Vivadent]). The patient wears the template during the CT scan,
around implants.6 It is often better to plan the correction of allowing the clinician to evaluate the prosthetic tooth position
soft-tissue deficiencies prior to bone augmentation. This may in relationship to the atrophic ridge.7 The high can also be
help reduce soft-tissue complications (ie, wound dehiscence) identified in the scan by inclusion of a wire that outlines the
and improve graft incorporation. Autogenous-free gingival inferior border of the lip. The CBCT scan can also be used to
grafts from the palate may be used to increase the amount of produce a stereolithographic model of the maxilla (Anatomodel
keratinized tissue along the ridge and adjacent teeth. Con- [Anatomage Dental]). The 3-D model is helpful for patient
nective tissue grafts from the palate can also be used to correct education and surgical planning for the reconstruction. The
dental recession defects and enhance mucosal thickness in the model can also be sterilized and used during surgery to aid in
edentulous span, enhancing the graft coverage. Allogeneic fitting bone blocks, titanium mesh, or Teflon membranes.
dermis may also be considered for this purpose (Alloderm Additionally, dental implant planning software can be used with
[BioHorizons] or Perioderm [DENTSPLY Implants]). Soft-tissue the CT scan to precisely evaluate implant sizes and positions as
corrective surgery should be performed at least 8 weeks prior well as the augmentation needs of the patient (SimPlant
to bone augmentation. This allows the vascular network [Materialise Dental]).8,9
within the tissues to re-establish. Vertical bone augmentation However, the actual implant surgery is staged after healing
will require a periosteal release incision at the base of the facial of the bone graft. Guided surgery for dental implant placement
flap to allow tension-free closure. The surgeon should be aware into the grafted site may also be considered.10 This is especially
that facial flap advancement over a bone graft will move the helpful in cases where implants need to be placed to avoid the
mucogingival junction more palatal. The keratinized gingiva transition zone of the prosthesis.
can be repositioned during subsequent surgical procedures or It is difficult to provide absolute guidelines for the number
connective tissue grafting can be performed. and distribution of implants to support the fixed prosthesis.
The teeth adjacent to the edentulous span should also be Some generalizations may be made based on biomechanical
evaluated prior to grafting. The marginal bone height on the support and the vertical dimensions of soft tissue around
roots bordering the ridge defect will determine the level that implants.11 When there are 2 missing adjacent teeth, the
may be achieved with vertical bone augmentation. In some clinician must decide on placing 2 implants for individual
cases, it may be prudent to remove teeth with marginal bone crowns or one implant for a cantilevered bridge. The soft-tissue
loss to improve the ability to reconstruct the ridge. It is usually profile around the implants may guide this decision. The
preferred to extract compromised teeth 8 weeks prior to the average papilla height between 2 adjacent implants is
bone graft surgery and allow soft-tissue healing over the site. approximately 3.5 mm.12 As the average papilla height between
natural teeth is 4.5 mm, a shorter papilla between 2 implants
Prosthetic Planning may create an overall asymmetry in the soft-tissue profile. This
It is important to define the prosthetic goals prior to the problem can be avoided if one implant is used to support a
maxillary reconstruction. The design of the final prosthesis cantilevered pontic. However, there are mechanical risks of
determines the number of implants required and their ideal cantilevering, and the patients occlusion must be evaluated to
positions. If there is inadequate available bone for implant consider this type of prosthesis.13 When more than 2 teeth are
placement in the desired locations, then bone augmentation is missing, an implant bridge is often preferred rather than
considered. This concept has been termed prosthetic guided bone individual implant crowns. If the plan is to surgically
2
CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
reconstruct the defect back to normal anatomy, then
CASE 1
pontic sites can be planned between the implants in an
attempt to provide more soft-tissue height. The vertical
soft tissue of an implant next to a pontic can approach
5.5 mm.4 This greater soft-tissue thickness can create
the illusion of interdental papilla. If the plan is to
replace the missing hard and soft tissue with the
prosthesis, then biomechanical support overrules the
need for soft-tissue height. In this scenario, implant
Figure 1. Preoperative view of patient Figure 2. Diagnostic denture tooth
positioning in relation to the teeth is less critical and
following traumatic tooth loss from a try-in.
the number of implants is determined by prosthetic
support. It is imperative to prevent loading of the car accident.
grafted site during healing. A fixed provisional
prosthesis is preferred over a temporary removable
partial denture.
Small-diameter temporary, or transitional,
implants can also be utilized for provisional bridge
support. The transitional implants should be placed in
native bone and not within the bone graft. A removable
vacuum-formed or Essix retainer (DENTSPLY Raintree
Figure 3. Radiopaque denture teeth Figure 4. The 3-D reconstruction from
Essix) is another excellent option for cosmetic tooth
replacement during graft healing, as it is supported by used for radiographic template. the CBCT.
the teeth and does not place any pressure on the site.
Another option is a removable prosthesis that fits over
the remaining maxillary teeth with pontics in the
edentulous span (Snap-On Smile [DenMat]). A special
dental resin is processed over a cast of the dentition so
the prosthesis is retained by the teeth and prevents soft-
tissue loading in the edentulous area.
Prosthetic replacement of the missing tissues can
Figure 5. The 3-D model fabricated Figure 6. Reconstruction of the
be accomplished with gingival colored porcelain,
from the CBCT. maxillary defect with a corticocancellous
acrylic, composite (GRADIA [GC America]), or
zirconium silicate microceramic (Ceramage [Shofu block graft from the iliac crest.
Dental]). Composite application can be accomplished
chairside and customized to the patient but requires
periodic maintenance and reapplication. Dental
ceramics offer a more durable solution, but the
aesthetics are often determined by the skill of the
dental technician.
3
CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
CASE 2
Figure 9. Preoperative view of maxillary defect Figure 10. Preoperative view of the full
from a horse kicking accident. smile. Note the occlusal cant following a
mandible fracture malunion.
Figure 12. Denture tooth set up to plan Figure 13. 3-D model fabricated from the Figure 14. The maxillary defect is
for maxillary reconstruction and prosthetic CBCT. reconstructed with rhBMP-2/mineralized
correction. bone allograft in a titanium mesh.
Figure 15. Dental implants are placed into the Figure 16. Final screw-retained PFM fixed Figure 17. Full smile with the final implant
BMP graft after 6 months healing. implant prosthesis (Dr. Katherine Misch, prosthesis.
Advantage Dental Design, Tallahassee, Fla).
walls. As such, the morphology of a bone defect should influence require materials and/or techniques that offer greater biologic
the choice of material or technique. Sites with fewer surrounding activity and regenerative capacity. As a general rule, vertical onlay
osseous walls and greater jaw atrophy are more demanding and bone augmentation is more biologically and clinically challenging
4
CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
than horizontal bone augmentation. In addition, vertical bone de- multiple missing teeth and a large vertical bone defect in the
fects inside the bony contour (intrabony) are much easier to right anterior maxilla (Figure 1). Although her lip covered the
reconstruct than onlay augmentations required outside the area, she desired reconstruction and prosthetic replacement
osseous contour (extrabony). Explanations for this difference without artificial gingiva. A diagnostic denture tooth setup was
would include fewer osseous walls and more difficulty obtaining used to assess the tooth position and maxillary defect
graft stability, soft-tissue coverage, and space maintenance during (Figure 2). Radiopaque denture teeth were used to fabricate a
healing. In addition to bone repair, soft-tissue augmentation is radiographic template worn during the CBCT (Figure 3). The CT
often needed in the aesthetic zone. Soft-tissue grafting can be used scan template is visible in the 3-D reconstruction from the
to improve the gingival biotype, thicken the soft-tissue flap, and/or CBCT (Figure 4). A printed 3-D model was fabricated to aid in
improve the soft-tissue profile around teeth, implants, and pontics. planning the bone augmentation (Figure 5). The maxillary
Although there are no studies to document that one technique defect was reconstructed with a corticocancellous bone graft
is superior for vertical bone augmentation, the surgeon should from the iliac crest (Figure 6). The patient wore an Essix retainer
strive to select a method that offers predictable results for the during healing of the bone graft. Following a 4-month healing
presenting clinical situation.14 Depending on the degree of period, 4 dental implants were inserted (Figure 7). Upon
atrophy, some techniques offer a greater amount of bone integration of the implants, she was restored with a cement-
regeneration than others. Extrabony vertical defects measuring retained PFM fixed implant bridge (Figure 8).
greater than 5.0 mm are more biologically and clinically
demanding. If guided bone regeneration is used, then a titanium- Case 2
reinforced Teflon membrane should be considered. The particulate A 53-year-old female was referred to our office following a facial
graft used with the barrier membrane should either contain injury suffered from a horse kick. She fractured her mandible and
particulated autogenous bone and/or a growth factor with the bone lost several maxillary and mandibular teeth (Figure 9). She
substitute to enhance bone formation. Autogenous block bone presented with a malunion of the mandible fracture that resulted
grafts have proven to be another predictable method for in development of an occlusal deviation (Figures 10 and 11). A
reconstruction of vertical defects. The iliac crest is often utilized, denture tooth setup was used to plan the maxillary
as this donor site provides the amount and quality of bone needed reconstruction (Figure 12). A CBCT scan of the maxilla was
for larger defects.15 Titanium mesh grafting is another technique obtained and a 3-D model was fabricated to aid in planning the
that may be considered for vertical augmentation. The mesh surgery (Figure 13). The vertical defect was so severe that an
provides a scaffold to protect the graft and provide space implant prosthesis with artificial gingiva was planned. The
maintenance during healing. In the past, autogenous cancellous maxillary defect was reconstructed with rhBMP-2 mixed with
bone was traditionally used as the graft. More recently, mineralized bone allograft and platelet concentrate in a titanium
recombinant bone morphogenetic protein-2 (rhBMP-2) has been mesh (Figure 14). Following a 6-month graft healing period, the
utilized with titanium mesh as an alternative to bone harvest mesh was removed and 4 implants were inserted (Figure 15).
(Infuse Bone Graft [Medtronic]). This growth factor is chemotactic Upon integration of the implants, the patient was restored with
for mesenchymal stem cells and induces their proliferation and a screw-retained fixed implant prosthesis. Gingival-colored
differentiation into osteoblasts. The growth factor is applied to a porcelain was used for prosthetic replacement of the missing
collagen sponge as the carrier and mixed with mineralized bone hard and soft tissues (Figures 16 and 17).
allograft as a matrix for bone replacement (MinerOss [BioHori-
zons]). The composite graft mixture is placed within the titanium CONCLUSION
mesh and fixated to the maxilla with screws (Salvin Dental). The decision to graft or not to graft the deficient anterior maxilla
Significant vertical bone gains have been found with this is contingent upon a thorough diagnostic evaluation of the
approach.16 Dental implants are placed after the bone graft has patient. The clinician must also consult the patient on his or her
incorporated. A staged approach to implant placement allows for preferences as well as educate the patient on the advantages and
graft remodeling and assessment of graft incorporation. limitations of surgical versus prosthetic solutions. Proper
planning can help the team attain the patients aesthetic goals
CASE REPORTS and better manage this challenging problem.!
Case 1
A 22-year-old female was referred to our office following an References
ejection injury suffered in an automobile accident. She had 1. Vera C, De Kok IJ, Reinhold D, et al. Evaluation of buccal alveolar
5
CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
bone dimension of maxillary anterior and premolar teeth: a cone 9. Tischler M, Ganz SD. The CT/CBCT-based team approach to
beam computed tomography investigation. Int J Oral Maxillofac care. Part I: Identifying the implant patient and prosthetic
Implants. 2012;27:1514-1519. options. Dent Today. 2012;31:74-79.
2. Tallgren A. The continuing reduction of the residual alveolar 10. Pikos MA, Magyar CW, Llop DR. Guided full-arch immediate-function
ridges in complete denture wearers: a mixed-longitudinal study treatment modality for the edentulous and terminal dentition
covering 25 years. J Prosthet Dent. 2003;89:427-435. patient. Compend Contin Educ Dent. 2015;36:116-128.
3. Coachman C, Salama M, Garber D, et al. Prosthetic gingival 11. Misch CE. Treatment planning: force factors related to patient
reconstruction in a fixed partial restoration. Part 1: introduction conditions. In: Misch CE, ed. Contemporary Implant Dentistry.
to artificial gingiva as an alternative therapy. Int J Periodontics 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:105-129.
Restorative Dent. 2009;29:471-477. 12. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the
4. Salama M, Coachman C, Garber D, et al. Prosthetic gingival crest of bone to the height of the interproximal papilla between
reconstruction in a fixed partial restoration. Part 2: diagnosis adjacent implants. J Periodontol. 2003;74:1785-1788.
and treatment planning. Int J Periodontics Restorative Dent. 13. Kim P, Ivanovski S, Latcham N, et al. The impact of cantilevers
2009;29:573-581. on biological and technical success outcomes of implant-
5. Misch CE, Misch-Dietsh F. Preimplant prosthodontics: overall supported fixed partial dentures. A retrospective cohort study.
evaluation, specific criteria, and pretreatment prostheses. In: Clin Oral Implants Res. 2014;25:175-184.
Misch CE, ed. Contemporary Implant Dentistry. 3rd ed. St. 14. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation
Louis, MO: Mosby Elsevier; 2008:233-275. procedures in implant dentistry. Int J Oral Maxillofac Implants.
6. Linkevicius T, Apse P, Grybauskas S, et al. The influence of soft 2009;24(suppl):237-259.
tissue thickness on crestal bone changes around implants: a 1- 15. Misch CM. Maxillary autogenous bone grafting. Dent Clin North
year prospective controlled clinical trial. Int J Oral Maxillofac Am. 2011;55:697-713.
Implants. 2009;24:712-719. 16. Misch CM, Jensen OT, Pikos MA, et al. Vertical bone
7. Misch CM. Use of a surgical template for autologous bone augmentation using recombinant bone morphogenetic protein,
grafting of alveolar defects. J Prosthodont. 1999;8:47-52. mineralized bone allograft, and titanium mesh: a retrospective
8. Ganz SD. Cone beam computed tomography-assisted treatment cone beam computed tomography study. Int J Oral Maxillofac
planning concepts. Dent Clin North Am. 2011;55:515-536, viii. Implants. 2015;30:202-207.
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CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
a. True b. False
This CE activity was not developed in accordance with AGD
PACE or ADA CERP standards. CEUs for this activity will not 5. Thin tissue may contribute to recession defects on
be accepted by the AGD for MAGD/FAGD credit. bordering teeth and marginal bone loss around
implants.
a. True b. False
6. If there is inadequate available bone for implant
POST EXAMINATION QUESTIONS
1. Surgical shortcomings, such as missing papilla or placement in the desired locations, then bone
residual vertical deficiencies, can create difficult augmentation is considered. This concept has been
prosthetic dilemmas and poor outcomes. termed prosthetic guided bone augmentation.
a. True b. False a. True b. False
2. The facial cortex over the maxillary incisors is quite 7. As the average papilla height between natural teeth is
thick, averaging approximately 2.5 mm. 2.0 mm, a longer papilla between 2 implants may
create an overall asymmetry in the soft-tissue profile.
a. True b. False
a. True b. False
3. The use of a soft-tissue borne removable prosthesis
can cause continued ridge resorption throughout time 8. Autogenous block bone grafts have proven to be
and additional loss of vertical bone height. another predictable method for reconstruction of
vertical defects. The iliac crest is often utilized as this
a. True b. False
donor site provides the amount and quality of bone
4. When skillful surgeons obtain a successful repair of needed for larger defects.
the defect, the restoring dentist and patient never find
a. True b. False
aesthetic shortcomings in the final result.
7
CONTINUING EDUCATION
To Graft or Not To Graft? Treating Vertical Bone Defects in the Aesthetic Zone
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