Dr Selvaraj Balaji presents an advanced case that required both vertical and horizontal soft and hard tissue augmentation to achieve an aesthetic and functional long-term result.
A female patient presented with concerns about her smile aesthetics due to her failed upper bridge. She was getting married the following year and was worried that her lack of confidence smiling in front of people would have a negative impact on her big day. Upon initial assessment, it was revealed that she had an anterior bridge, which had been in place for about 10-15 years and no longer looked right in the smile. The patient had approached other dentists enquiring about dental implants, but had only been offered a new bridge due to the amount of bone and soft tissue loss.
Assessment and planning
A comprehensive clinical assessment was conducted, including clinical photographs, a radiograph, and evaluation of the oral hygiene, smile line and all other relevant aspects. The patient was referred to a colleague to assess the health and stability of the UR1 and UL3, which were the teeth supporting the bridge. It was important to establish the long-term prognosis of these teeth before making any further decisions about treatment. The professional recommendation was that these teeth would likely remain stable for the foreseeable future.
When the patient returned to the practice, the bridge was removed and a CT scan was taken to assess the bone level. This confirmed that the patient had both horizontal and vertical hard and soft tissue defects. As such, bone and soft tissue augmentation were indicated as part of the restoration process, to ensure sufficient tissue for the successful placement of the dental implants.
The CT scan and impressions were used to plan the treatment, identifying the ideal position, angle and depth for the implants with respect to the final restoration. It was necessary to plan vertical bone augmentation using non a resorbable PTFE membrane. A combination of autogenous bone mixed with xenograft would be used.
All of this, including the potential benefits, risks and limitations of treatment were described in detail to the patient. The importance of long-term oral hygiene was also emphasised to the patient, who gave fully informed consent to proceed.
Bone augmentation
On the day of surgery, the area was sufficiently numbed and a very wide flap was raised, otherwise known as a safety flap. An autogenous bone block was harvested from the lower left ramus of the mandible using a Master-Core trephine bur and safe scraper to collect the cortical bone. The bone block was particulated to facilitate early vascularisation of the graft material for enhanced healing. It is also easy to shape the graft in this form in order to properly accommodate the shape and depth of the defect.
A mixture of 60% autogenous bone and 40% xenograft was created. The PTFE membrane was shaped according to the defect size and shape, placed and stabilised in the palatal bone with master pins.
The graft material was then applied to the defect. The membrane was folded buccally and stabilised with further master pins. It is important, at this stage, to ensure that the membrane adaptation is both stable and tight enough to hold the graft material in place. Any movement of the membrane or the graft material will lead to bone loss and could impact the treatment outcome.
Soft tissue handling is also crucial. Closure of the defect is paramount to avoid exposure of the membrane and the complications associated with this. For this case, the flap was released by using three separate techniques; the first was a mucoperio elastic technique, the second a perioplasty, and the third was orbicularis oris muscle extension. This clinical approach allowed the release of the buccal flap to safely and effectively accommodate both the hard and soft tissue grafts.
The site was closed with PTFE sutures using a bi-layer closure, where connective tissue meets connective tissue. The patient was given standard post-operative oral hygiene instructions and the site was left to heal for around eight months.
Implant placement, soft tissue grafting and restorations
Healing after the first phase of treatment was uneventful. The patient returned for the implant placement appointment as planned, during which the graft was exposed and the membrane removed. Good, solid bone was revealed, confirming this an appropriate time for implant surgery.
Following the original treatment plan, two implants (3.6 x 11mm) were placed in the UL1 and UL2 positions. The soft tissue graft was performed simultaneously, using what I call the wedding cake technique. This involves placing a thick layer of soft tissue, followed by a thinner layer of tissue on the top. This approach increases the thickness of the soft tissue around the implant crown, optimising healing and aesthetics.
The site was once again closed tension-free sing PTFE sutures. Another three months were allowed for healing, before the implants were exposed and restored with screw-retained temporary implant crowns designed to contour the papillae. When ready for the final restorations, the patient received implant crowns on the UL1 and UL2, and standard crowns were placed on the UR1, 2 and 3 to complete the smile.
Discussion
The bone grafting technique described in this case report was chosen because it offers predictable results when implemented effectively. With the right amount of autogenous bone and careful management of the flap closure before and after implant placement, we were able to optimise both the functional and aesthetic outcome. Exposure of the membrane is a very common complication associated with this type of surgery, and it usually occurs because the soft tissue or flap closure has not been correctly managed. The soft tissue graft is also important in order to increase the gingival thickness around the implant crown – this should involve both horizontal and vertical grafting for the best results. As can be seen from the eight-year follow up photos, meticulously implementing these techniques deliver long-term stable results.
Case images
Fig 1 Patient presentation
Fig 2a Radiographic assessment
Fig 2b Radiographic assessment
Fig 2c Radiographic assessment
Fig 3 Bridge removal
Fig 4 Bridge removed occlusal view
Fig 5 Safety flap raised exposing vertical bone defect
Fig 6 Horizontal bone defect revealed, avoiding vital structures during surgery
Fig 7a Bone harvest site at left lower ramus of the mandible
Fig 7b Harvesting cortical bone
Fig 8 – Mixture of autogenous bone and xenograft placed
Fig 9 – Bone graft held in place with a PTFE membrane secured with master pins
Fig 10 – Flap closed without tension
Fig 11 – Site healed
Fig 12 Site reopened after hard tissue augmentation healing
Fig 13 Implants placed in UL1 and UL2 potisions according to the plan
Fig 14a Soft tissue grafting with wedding cake technique
Fig 14b Soft tissue grafting with wedding cake technique
Fig 15 Soft tissue contour post healing after temporary crown
Fig 16 Implant-retained crowns placed on UL1 and UL2, with standard crowns on UR1, 2 and 3
Dr Balaji provides industry-leading training courses on both hard and soft tissue management around dental implants with the ASHA Club.
For more information about how you could elevate your skills with the support of experts, please visit www.ashaclub.co.uk or call 07974 304269
Author bio:
Dr Selvaraj Balaji: BDS, MFDS RCPS(Gla), MFD SRCS(Ed), LDS RCS(Eng)
Since he obtained the BDS Degree, Dr Balaji has worked in Maxillo-facial units in the UK for several years and gained substantial experience in surgical dentistry. He is the principal dentist of The Gallery Dental Group which is made up of Meadow Walk Dental Practice and The Gallery Dental & Implant Centre. Dr Balaji is also the founder of the Academy of Soft and Hard Tissue Augmentation (ASHA) and runs courses, lectures and study clubs in the UK and around Europe for aspiring implantologists.
