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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 70-75

Surgical procedure for guided bone regeneration using resorbable membrane barrier for ridge augmentation in successful implant placement


1 Department of Periodontics, Faculty of Medical Technology, Derna, Libya
2 Technical Colleges, NB for the Technical and Vocational Education, Tripoli, Libya
3 Department of Prosthodontics, Faculty of Medical Technology, Derna, Libya

Date of Web Publication2-Mar-2016

Correspondence Address:
Raghavendra Nagappa
'SAROJA', Plot No. 2, 9th Cross Rightside, Kappagal Road, Ballri - 583 101, Karnataka
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-3019.177931

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  Abstract 

Objectives: Guided bone regeneration (GBR) is a widely used technique to augment alveolar ridge defects to allow implant placement and improve the final aesthetic outcomes of implant-supported restorations. Since the introduction of GBR, which is based on the theory of guided tissue regeneration, scientific evidence has demonstrated its effectiveness in regenerating lost bone. A biologically based technique must be used for clinical success and to avoid the occurrence of complications. This article will discuss a step-by-step surgical procedure for GBR using absorbable membrane barrier for ridge augmentation in implants. Materials and Methods: A full-thickness midcrestal incision is made between the teeth preserving the interdental papilla. The required osteotomy is then prepared, the 4.1 × 10 SLA Straumann implant is placed, and good primary stability is achieved. Following implant placement, GBR procedures are performed. A resorbable collagen membrane is then cut to the same shape as the template and placed over the surgical site. Results: The GBR using absorbable membrane barrier for ridge augmentation produces a dense bone, resulting in minimal or no bone loss when implants are placed into this bone. Conclusions: This GBR using absorbable barrier membrane for ridge augmentation in implants had several advantages over other techniques. One advantage is preserving the interdental papilla and providing sufficient advancement of the flap, which are very important for the success of GBR and for the success of implants placed. The second advantage is avoiding of second surgery for the removal of membrane even though the complications using resorbable membrane barrier may have been multifactorial. Therefore, meticulous surgical and restorative procedures are necessary to reduce the prevalence of complications.

Keywords: Absorbable membrane barrier, guided bone regeneration (GBR), implant placement


How to cite this article:
Nagappa R, Elzer AS, Younis SF, Doddagoudar M. Surgical procedure for guided bone regeneration using resorbable membrane barrier for ridge augmentation in successful implant placement. J Indian Acad Dent Spec Res 2015;2:70-5

How to cite this URL:
Nagappa R, Elzer AS, Younis SF, Doddagoudar M. Surgical procedure for guided bone regeneration using resorbable membrane barrier for ridge augmentation in successful implant placement. J Indian Acad Dent Spec Res [serial online] 2015 [cited 2019 Mar 18];2:70-5. Available from: http://www.jiadsr.org/text.asp?2015/2/2/70/177931


  Introduction Top


Guided bone regeneration (GBR) is a well-documented and versatile procedure for regenerating bone, thereby allowing successful implant placement. [1]

The surgical procedure consists of placing of an occlusive physical barrier between the connective tissue and the bone defect to prevent the migration of the epithelial and connective tissue cells into the defect and to stabilize the blood clot and graft. This allows the slower migrating osteogenic cells to proliferate and form new bone, thereby selectively repopulating the wound with osteoblasts prior to the migration of connective tissue and epithelial cells. [2]

This article will discuss a step-by-step surgical procedure for GBR using absorbable membrane barrier for ridge augmentation in implants.

Procedure

Step 1: The flap is designed in accordance with the following five principles.

  1. Access to the bone defect
  2. Maintenance of the blood supply of the elevated flap and the neighboring tissues
  3. Preserving the interdental papilla
  4. Providing the sufficient advancement of the flap
  5. Allowing for tension-free primary closure


A full-thickness midcrestal incision is made between the teeth preserving the interdental papilla. Two full-thickness vertical incisions are made down to the bone on either side, starting in the area of the base of the vestibule and continuing coronally in one continuous cut to meet the crestal incision [Figure 1]. The vertical incisions are made trapezoidal with the base, widening apically to ensure an adequate blood supply and an easy coronal repositioning of the flap after augmentation with the graft material [3] [Figure 2].
Figure 1: Incision design: Vertical incision is connected to the midcrestal incision, preserving the interdental papilla

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Figure 2: A full-thickness flap is elevated, allowing access to the buccal bone

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The required osteotomy is then prepared, the 4.1 × 10 SLA Straumann implant is placed and good primary stability is achieved [Figure 3]. Following implant placement, GBR procedures are performed when the facial bone shows a concave morphology or the presence of dehiscence as shown in [Figure 4].
Figure 3: Implant placement

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Figure 4: Buccal view after implant placement with a bony
defect on the buccal surface of the implant


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Step 2: Recipient site preparation

The bony defect is debrided of granulation tissue and tissue tags, using curettes and back-action chisels. Cortical perforations (decortications) are then made with a #1 or #2 round bur using high speed with copious irrigation to create bleeding at the surgical site. The decortications are designed to increase the blood supply and osteogenic progenitor cell migration from the bone marrow to the site of augmentation [4] [Figure 5].
Figure 5: Decortications of the surgical site to create bleeding

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Step 3: Releasing incisions

Periosteal releasing incisions are made with a sharp 15 C blade on the inner apical portion of the flap, creating a 2-3 mm split-thickness dissection [Figure 6] and [Figure 7]. These releasing incisions allow for better flap release and subsequent advancement of flap closure. Making these periosteal incisions allow easy access to the apical periosteum for stabilizing sutures [Figure 8]. This exposed apical periosteum will be used as anchorage for the membrane-stabilizing sutures [Figure 9].
Figure 6: Periosteal releasing incisions creating a 2-3 mm split-thickness dissection using a new surgical blade

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Figure 7: Split-thickness periosteal dissection

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Figure 8: Split-thickness periosteal dissection helps advance the flap coronally without tension

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Figure 9: The exposed periosteum is used as an anchorage for the membrane stabilizing sutures

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Step 4: Graft materials and membrane placement

An autoclaved tinfoil is used as a template, fitted and trimmed to the ideal shape [Figure 10]. A resorbable collagen membrane is then cut to the same shape as the template and placed over the surgical site [Figure 11]. Once the membrane is in the correct position, it is then adjusted to extend 2-3 mm beyond the augmented area.
Figure 10: A sterilize tinfoil template is trimmed to the correct dimension and tried on the defect. A resorbable collagen membrane is then adjusted accordingly as shown in the fi gure

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Figure 11: Membrane is brought to the surgical site

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The demineralized allograft bone (porous bone graft) is placed and condensed to fill the bone defect, ensure proper space maintenance and bone contact, and support the membrane [Figure 12].
Figure 12: Bone graft material is placed under the membrane and condensed

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Step 5: Stabilization of graft material and barrier membrane

Stabilization of the membrane and the underlying graft material is achieved by using horizontal mattress sutures extending from the apical portion of the facial periosteum to the palatal aspect of the flap [Figure 11]. To minimize the risk of irritation and infection on the palatal aspect, the suture knot is positioned and stabilized inside the flap and only 2-3 mm of suture is exposed palatally. Chromic gut suture is the material of choice as it is strong enough to stabilize flap, [5] absorbs in 10-14 days, and its monofilament structure limits plaque accumulation [Figure 13].
Figure 13: Membrane is secured, tightened, and the knot is positioned inside the flap with membrane stabilizing sutures

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Step 5: Suturing to advance the flap coronally

To coronally advance the flap, a horizontal mattress suture is used to connect the inner middle portion of the buccal flap to the inner aspect of the palatal flap. On the facial aspect, the suture is placed to the depth of the tissue while not completely perforating through the flap. The periosteum is then coronally advanced together with the flap, allowing passive tension-free closure of the flaps [Figure 14].
Figure 14: Flap is adjusted for tension-free primary closure

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Step 6: Suturing to ensure primary closure

Final tissue adaptation is achieved by means of multiple interrupted 4-0 chromic gut sutures, regularly spaced to close the incisions [Figure 15].
Figure 15: Final closure of fl ap after horizontal mattress suture is placed

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A provisional prosthesis is used when necessary to provide aesthetics and function for the patient and to protect the augmented site during healing. The healing phase of hard tissue augmentation procedures requires that no transmucosal pressure be placed on the grafted and/or regenerated ridge tissues or the implants themselves. A fixed provisional restoration is recommended. However, in some cases a clasp partial removable denture can be used if it is properly adjusted to ensure no contact with the augmented area. A vacuum-formed shell can also be used and the missing teeth filled with acrylic or resin composite. The patient should be shown how to insert, remove, and clean any removable prosthesis.


  Results Top


The case has been evaluated after the procedure at 3 months [Figure 16], 6 months, and 9 months. It was found that GBR using absorbable membrane barrier for ridge augmentation produces a dense bone, resulting in minimal or no bone loss when implants are placed into this bone.
Figure 16: Buccal view after 12 weeks

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  Conclusion Top


Understanding and utilization of proper incision design and flap advancement, releasing incisions, bone decortications, stabilization of the graft and membrane, tension-free primary closure of the flap, and postoperative patient compliance are crucial factors in obtaining predictable outcomes. This GBR using absorbable barrier membrane for ridge augmentation in implants had several advantages over other techniques. [3]

One advantage was preserving the interdental papilla and providing sufficient advancement of the flap, which are very important for the success of GBR and for the success of implants placed.

The second advantage was avoiding of second surgery for the removal of membrane. In addition, complications such as membrane exposure, infection, graft particle leakage, collapse of grafted site, and excessive bleeding complications were minimal in this surgical technique even though complications using resorbable membrane barrier may have been multifactorial. Therefore, meticulous surgical and restorative procedures are necessary to reduce the prevalence of complications. [6],[7],[8],[9]

The GBR using absorbable membrane barrier for ridge augmentation produces a dense bone, resulting in minimal or no bone loss when implants are placed into this bone. The graft materials used in this procedure provide osteogenicity, osteoinductivity, and osteoconductivity. This can be absorbed as new bone formation occurs. [3]

One can perform this technique in most of the implant cases. The technique will likely evolve over time so that different sized cortical bone pins and cortical bone chips are available for different situations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dahlin C, Lindhe A, Gottlow J, Nyman S. Healing of bone defects by guided bone tissue regeneration. Plast Reconstr Surg 1988;81:672-6.  Back to cited text no. 1
    
2.
Nyman S. Bone regeneration using the principle of guided tissue regeneration. J Periodontal 1991;18:494-8.  Back to cited text no. 2
    
3.
Stuart J. Froum, Sang-Choon Cho, Leon Pariente. A surgical protocol for guided bone regeneration procedures using absorbable membranes to minimize and treat complications. Dental Learning 2012;6:3-13.  Back to cited text no. 3
    
4.
Greenstein G, Greenstein B, Cavallaro J, Tarnow D. The role of bone decortication in enhancing the results of guided bone regeneration: A literature review. J Periodontol 2009;80:175-89.  Back to cited text no. 4
    
5.
Vasanthan A, Satheesh K, Hoopes W, Lucaci P, Williams K, Rapley J. Comparing suturing strengths for clinical applications: A novel invitro study. J Periodontal 2009;80:618-24.   Back to cited text no. 5
    
6.
Retzepi M, Donos N. Guided bone regeneration: Biological principle and therapeutic applications. Clin Oral Implants Res 2010;21:567-76.  Back to cited text no. 6
    
7.
McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol 2007;78:377-96.  Back to cited text no. 7
    
8.
Fu JH, Wang HL. Horizontal bone augmentation: The decision tree. Int J Periodontics Restorative Dent 2011;31:428-36.  Back to cited text no. 8
    
9.
Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing two techniques of bone augmentation: Onlay graft alone or associated with a membrane. Clin Oral Implants Res 2001;12:632-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]



 

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