Alveolar Ridge Augmentation with Autogenous Mental
Block Harvested using Ultrasonic Bone Surgery (USBS)
and Platelet Rich Plasma: A Case Report
Pankaj Chivte, M.D.S., Nisha Patel, M.D.S., Amol Jamkhande, M.D.S.
EXAM #58
ABSTRACT
Background:
Predictable reconstruction of alveolar ridge defects can be obtained by using
autogenous bone block. Ultrasonic bone surgery (USBS) is a fast, precise, and
simple technique for block graft harvesting. It allows for a clean surgical field
with no risk of injury to surrounding neurovascular structures. This article
describes a case of horizontal alveolar ridge defect augmented with mental bone
block harvested using USBS. The defect was overcorrected using bovine derived
xenograft and platelet rich plasma, which is an autologous source of growth factors
that helps in early graft consolidation. Platelet poor plasma (PPP) membrane was
used for graft containment. After six months, on exposure, it was observed that
the block graft was integrated with the alveolar ridge, resulting in increased ridge
width. This was confirmed on dentascan and 3D reconstruction images. Implants
were placed and restored with satisfactory aesthetic and functional outcome.
Keywords:
alveolar ridge augmentation, ultrasonic bone surgery, mental block graft, platelet
rich plasma
bone, as opposed to the mandibular
ramus, which is nearly 100% cortical in
nature.6 The cortico-cancellous nature of
bone harvested from this site facilitates
faster vascular in-growth once the block
has been placed, resulting in more rapid
integration and less potential resorption
during healing.7
Until recently, rotary instruments
were used for autogenous block graft
harvesting. However, accessing the bone
harvesting site with bur or oscillating
saw is a delicate procedure that requires
great technical skills. Furthermore, this
approach is slow, requiring more surgical
time. Ultrasonic bone surgery (USBS)
represents an alternative technique
to perform precise bone surgery. The
principle of USBS is to induce energetic
microvibrations to a metallic saw of a
given design. The vibration frequency
ranges from 20 to 32 KHz, well above
the audible spectrum. The vibrations are
generated by piezoelectric transducer.
When ultrasonic saws are used to cut hard
tissues, soft tissues like the Schneiderian
membrane, vessels and nerves are
preserved from injury because they
vibrate with the tip.8 This makes USBS
very useful and a simpler alternative for
bone surgery.
Recent research has focused on
applying native growth factors to graft
materials to enhance osteogenesis,
increase vascularization, and shorten
healing time for bone maturation. A
high concentrated source of platelets, in
the form of platelet rich plasma (PRP),
has been used for this purpose. Platelets
produce and release multiple growth and
differentiation factors that are critical for
the stimulation and regulation of wound
healing, including platelet-derived growth
factor (PDGF), transforming growth
factor β (TGF-β), and vascular endothelial
growth factor (VEGF).9
Marx et al.,10 demonstrated in
their clinical studies with mandibular
reconstruction that the addition of PRP
resulted in early graft consolidation and
mineralization in half the time compared
to graft without the addition of PRP.
94-2 • Alveolar Ridge Augmentation with Autogenous Mental Block Harvested using Ultrasonic Bone
Surgery (USBS) and Platelet Rich Plasma: A Case Report
Continuing Education Exam #58 |
Introduction
Localized alveolar ridge defects
can be augmented using autogenous
block grafts. Significant alveolar bone
resorption can occur shortly after
dental extractions. In non-grafted
sites, more than 20% of the buccal
plate is lost after 90 days.1 Up to 4mm
of vertical height can be lost in the
first year.2
Various onlay grafts have been
used for placement and successful
integration of endosseous implants
such as autogenous bone, allografts,
xenografts, and alloplastic materials.
However, autogenous bone is
considered to be the gold standard for
grafting hard tissue defects. The use of
intraoral donor sites like mandibular
symphysis and ramus (membranous
bone) have several advantages over
extraoral sites like iliac crest and
tibial plateau (endochondral bone).
Studies have revealed that membranous
bone grafts retained greater than 80%
of their original volume, whereas iliac
bone showed 65% to 88% resorption.3,4
It is readily apparent that the quantity of
bone required is a major factor in donor
site selection. An extraoral donor site is
often required for ridge augmentation in
totally edentulous patients, for example
where ridge resorption may be extreme
and extensive. A popular and reasonably
safe extraoral site is the posterior iliac
crest, which can yield relatively large
bone volumes ranging from 70-140cc.5
Mandibular symphysis and ramus bone
undergo less resorption because of thick
cortical layers and their rigid structure.
Other advantages include conventional
intraoral access, reduced surgical time
and no cutaneous scars.5 The symphysis
offers over 50% larger graft volume
than what can be obtained from the
mandibular ramus, with much easier
surgical access.5 The average symphysis
graft has been found to be composed of
65% cortical bone and 36% cancellous
T
D
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| Continuing Education Exam #58
Bone healing was accelerated
approximately two times that
of autogenous bone grafts
without PRP.
PRP offers many
advantages: it decreases the
frequency of intraoperative
and postoperative bleeding
at the donor and the recipient
sites, facilitates rapid softtissue healing, aids in the
initial stability of the grafted
tissue at the recipient site
(as a result of its cohesive
and adhesive nature), may
promote rapid vascularization
of the healing tissue by
delivering growth factors
and, in combination with
bone replacement materials,
induces regeneration.11
A byproduct of plateletrich plasma production is
platelet-poor plasma, which,
when activated in a similar
manner as platelet-rich
plasma, can be used as a
hemostatic agent.12
PRP can be prepared in an
in-office environment using a
tabletop centrifuge using 10
ml of the patient’s blood.13
The purpose of this case
study was to evaluate the
effectiveness of using an
ultrasonic bone surgery device
to harvest an intraoral cortical
bone graft coupled with PRP
and using PPP as barrier to
augment alveolar ridge defect
for implant placement.
10
Figure 1: Preoperative alveolar ridge defect on
dentascan.
ridge augmentation using
an autogenous bone
block harvested from the
mandibular symphysis using
USBS.
Recipient bed preparation:
The recipient site was
anesthetized using 2%
lidocaine, with 1:100,000
epinephrine given by
infiltration. The maxillary
ridge was accessed using a
horizontal incision 2 mm
palatal to the crest to ensure
better holding of sutures by
thick palatal tissues. Vertical
releasing incisions were
made one tooth away from
the defect on either side. A
full-thickness mucoperiosteal
flap was raised to the
anterior nasal spine, to
obtain adequate release for
passive primary closure.
Perforation of the cortical
plate is recommended to allow
faster revascularization of the
graft.14 This was done after
the graft was harvested and
tried in the defect. (Figures
2 & 3)
Donor site preparation and
graft harvesting:
Figure 2: Recipient site exposure.
Case Report
A twenty-six-year-old
woman presented for dental
implant treatment. She
reported a history of trauma
three years previously which
resulted in loss of teeth 8, 9
and 10. The patient’s medical
history was not remarkable.
Clinical examination revealed
the loss of labial cortical plate
leading to an unaesthetic
facial profile. Subsequent
radiographic imaging using
dentascan showed a narrow alveolar ridge,
however adequate height was present for
implant placement. (Figure 1)
On the basis of diagnostic findings
and after prosthodontic consultation,
the patient was scheduled for alveolar
After adequate anaesthesia
by infiltration, an incision
was made in the attached
mucosa, 0.5 mm above
the mucogingival junction
(from first premolar to the
contralateral premolar) from
canine to canine region. A
full-thickness mucoperiosteal
flap was reflected to the
inferior border, which results
in a degloving of the anterior
mandible and allows for good
visualization of the entire
symphysis. It is important not
to encroach within 5 mm of
the apices of the incisor and
canine teeth and the mental
neurovascular foramina.
The inferior osteotomy was
made no closer than 4 mm
from the inferior border. A
template was used to identify and locate
the shape and location of graft site. The
Journal of the Tennessee Dental Association ­• 94-2
block graft was harvested using the UBS
device (Italia Medica, Milan, Italy). The
UBS works in the 20-32 KHz range, and
the maximum ultra sonic power is 90 W.
Tips are made of titanium alloy. To open
the bony window, a round 2.8 mm tip
was used. To harvest bone from the chin,
angled and straight saw-shaped tips were
implemented. (Figure 4)
The graft was placed in normal saline
before contouring and fixation. The donor
site was then packed with gauze soaked in
platelet-poor plasma. The harvest site was
packed with gelatin sponge to decrease
the dead space and prevent a hematoma.
The incision was closed with 4-0 silk
suture.
Graft adaptation and fixation:
Results
Implant placement:
After six months, the grafted site was
uncovered and screws removed. The block
graft was stable and integrated with the
alveolar ridge resulting in increase in the
ridge width along with the restoration
of lost labial plate. Three implants were
placed at #8, #9, and #10 positions, with
1 mm of bone on both labial and palatal
sides of the implants. (Hi Tec tapered
titanium thread 3.75 X 13 mm, Hi Tec
Implants, Israel) (Figures 9 & 10). The
implants were successfully loaded after
three months with a satisfactory aesthetic
and functional outcome (Figure 11).
Comparison of dentascan:
A comparison of preoperative and
postoperative dentascan, taken after
six months, shows successful alveolar
bone augmentation. The block graft was
integrated with the alveolar ridge which
can be appreciated by the absence of any
radiolucency between the block graft and
the residual ridge (Figures 12 & 13).
On comparison, the increase in ridge
width is as follows #8 (1.1 mm), #9 (1.0
mm) and #10 (1.1 mm). The same can
be appreciated on 3-D, reconstruction
images. (Figures 14 & 15)
Discussion
Alveolar ridge augmentation using
autologous block grafts is a predicatable
method for enhancing deficient alveolar
ridge before implant placement. The
intraoral block graft is the preferred
choice over extraoral sites due to
increased resorption, high cost, and
increased morbidity of the latter.2,3
Autogenous block grafts harvested from
the mandibular symphysis or ramus
undergo less resorption because of thick
cortical layer and their rigid structure.5
Because the greatest stresses of a loaded
implant are located around the neck
and ridge crest, the crestal bone with
increased density can withstand implant
loading in a more favorable biomechanical
manner.17 This is a distinct advantage over
other regenerative techniques, including
guided bone regeneration. Ultrasonic
bone surgery was recently introduced as
a technique for graft harvesting. USBS
offers the following advantages over
rotary instrumentation:8 a clean and blood
free surgical field because of cavitation
and collapsing action of the ultrasound on
blood vessels, better visual access to the
surgical area, and easier access to bone
harvesting sites with no risk of injury to
surrounding neurovascular bundles and
soft tissues.
Platelet-rich plasma (PRP) is an
autologous concentration of platelets
in concentrated plasma, which is used
extensively to promote soft and hard
tissue healing. Preclinical studies18
support that platelets possess growth
factors that stimulate and enhance wound
healing processes, including osseous
regeneration.
Marx et al.,7 have shown a 40%
decrease in the healing time of
autogenous bone grafts when PRP was
incorporated into the site. Their results
along with the case series by Kassolis JD
et al,19 suggest that the use of PRP may
allow for earlier implant placement and/
or loading. The use of PRP facilitated
the clinical handling of graft material.
And added benefit of PRP is its ability to
form a biologic gel that may provide graft
containment, clot stability, and function as
an adhesive. An autologous material that
possesses a high concentration of biologic
mediators improves the rate of wound
healing without the cost of additional
materials. An experimental study20 to
compare the effects of PRP, Platlet Rich
Fibrin (PRF), and PPP showed that PPP is
an effective material for the preservation
of sockets with buccal dehiscence, and
it plays a significant role in the presence
of few osteogenic cells. Therefore, in
present case, maximum benefits of blood
constituents could be obtained from
10 ml of the patient’s blood with use of
both PRP and PPP which assisted in the
procedure of ridge augmentation with a
cortico-cancellous mental block graft.
In the present case, we observed
minimal resorption of cortical block
at six months, as fixation screws were
completely submerged in the vascularized
block graft (Figure 10). It was in
accordance with the resorption rate (020%) observed by various researchers.21
94-2 • Alveolar Ridge Augmentation with Autogenous Mental Block Harvested using Ultrasonic Bone
Surgery (USBS) and Platelet Rich Plasma: A Case Report
Continuing Education Exam #58 |
The block graft was manipulated to
accurately fit the defect. The edges of
the graft must be 1 mm away from the
adjacent roots. Fixation requires lagging
the graft to the recipient site with multiple
screws. This means that the outer hole in
the graft must be larger than the hole in
the recipient site, allowing compression
of the graft, resulting in rapid primary
bone healing with less resorption.15 The
key is to have a passive fit without any
gap or rocking. Otherwise, the graft will
delaminate at the time of reentry due to
poor integration and a fibrous union in
the space between the graft and the host
bone.16 (Figure 5)
The defect was filled and
overcorrected with particulate bovine
xenograft (Bio-Oss® Spongiosa small
granules 0.25-1mm, Geistlich Pharma
AG, Switzerland) mixed with autologous
PRP. In addition to restoring hard tissue
defect, the particulate bone preserves and
augments the lost soft tissue architecture.
(Figure 6)
The grafted site was covered with
a platelet poor plasma membrane.
The membrane was obtained from the
same blood sample and activated in
the same way as platelet rich plasma. It
helps in hemostasis and functions as a
barrier, which especially helps in graft
containment. (Figure 7)
Soft tissue closure should be passive.
To achieve this, a periosteal releasing
incision was made along the base of the
entire flap. Multiple interrupted nonresorbable sutures were placed to achieve
primary closure over the entire surgical
site. (Figure 8)
Post operatively, the patient was
placed on a soft diet and the prosthesis
was adjusted to avoid impingement on
grafted site. The patient was placed on
postoperative antibiotic (penicillin 500
mg three times a day for seven days) and a
chlorhexidine mouthrinse for 2 weeks.
11
Figure 4: Mental block graft harvesting using
USBS.
Figure 5: Graft fixation with screws.
Figure 6: Defect coverage with Bios-oss® and PRP.
Figure 7: PPP covering the grafted site.
Figure 8: Soft tissue closure.
| Continuing Education Exam #58
Figure 3: Decortication of recipient site.
12
Journal of the Tennessee Dental Association ­• 94-2
Figure 9: Grafted site on exposure after six
months.
Figure 10: Implant placement (Hi Tec tapered
3.75mm).
Figure 11: Prosthetic restoration.
Figure 12: Pre-operative cross-sectional
dentascan image.
Figure 13: Post-operative cross-sectional
dentascan image after six months.
Continuing Education Exam #58 |
94-2 • Alveolar Ridge Augmentation with Autogenous Mental Block Harvested using Ultrasonic Bone
Surgery (USBS) and Platelet Rich Plasma: A Case Report
13
Figure 14: Pre-operative 3D Reconstruction
image.
| Continuing Education Exam #58
There was no post-operative morbidity
observed in the present case which is
perhaps the largest concern with this
site.22 Use of USBS helped to obtain the
desired size of the block with precision in
a bloodless field with improved visibility.
It decreased the possibility of injuring
nerves near the teeth or mental foramen.
All these advantages reduced the surgical
time and added to patient comfort.
14
Conclusion
The autogenous intraoral block graft
is a predictable method to correct an
alveolar ridge defect before implant
placement. Use of USBS simplified the
bone harvesting procedure. Autologous
PRP is a rich source of growth factors
which helps in early graft consolidation
and as a barrier for the containment of
particulate graft material. Optimized
aesthetics and function will be obtained
using autologous bone block and PRP.
Figure 15: Post-operative 3D Reconstruction
images after six months.
References:
1. Nevins M, Camelo M, De Paoli S et al. A study of the
fate of the buccal wall of extraction sockets of teeth with
prominent roots. Int J Periodont Restor Dent. 2006;26:
19-29.
2. Bernstein S, Cooke J, Fotek P et al. Vertical bone
augmentation: where are we now? Implant Dent.
2006;15:219-228
3. Smith JD, Abramson M. Membranous vs. endochondral
bone autografts. Arch Orolaryngol. 1974;99:203-205.
4. Zins JE, Whitaker LA. Membranous vs endochondral bone
autografts: Implications for craniofacial reconstruction.
Plast Reconstr Surg 1983;72:778-785.
5. Misch CM. Comparison of intraoral donor sites for onlay
grafting prior to implant placement. Int J Oral Maxillofac
Implants. 1997;12:767-776.
6. Neiva RF, Gapski R, Wang HL. Morphometric analysis of
implant-related anatomy in Caucasian skulls. J Periodontol
2004 Aug;75(8):1061-67.
7. Hammack BL, Enneking WF. Comparative vascularization
of autogenous and homogenous bone transplants. J Bone
Joint Surg 1960;42:811.
8. Blus C, Szmukler-Moncler S, Salama M, et al. Int J
Periodontics Restorative Dent 2008;28:221-229.
9. Pierce GF, Mustoe TA, Altrock BW, et al. Role of platelet
derived growth factor in wound healing. J Cell Biochem
1991;45:319-326.
10.Robert Marx, Eric Carlson, Ralph Eichstaedt, T. Steven
Schimmele, James Strauss, Karen R. Georgeff. PRP:
Growth enhancement factor for bone grafts. Oral Srg, Oral
Med, Oral Pathol Oral Radiol Endod 1998;85:638-646.
11.Tozum TF, Demiralp B. Platelet rich plasma: A promising
innovation in dentistry. J Can Dent Assoc 2003;69(10):664.
Disclosure: The authors did not report
any disclosures.
12.Pietrzak WS, Eppley BL. Platelet rich plasma: biology and
new technology. J Craniofac Surg. 2005;16:1043-1054.
13.Weibrich G, Kleis WK, Kunz-Kostomanolakis M, et al.
Correlation of platelet concentration in platelet-rich plasma
to the extraction method, age, sex, and platelet count of the
donor. Int J Oral Maxillofac Implants 2001;16(5):693-699.
14.Pikos MA. Mandibular block autographs for alveolar ridge
augmentation. Atlas Oral Maxillofacial Surg Clin N Am
2005;13:91-107.
of compression plates. Clin Orthop Relat Res.
1979;138:167- 174.
16.Hassan GM. Vertical and horizontal bone augmentation
with the intraoral autogenous J- graft. Implant Dentistry
2009;18(3):230-235.
17.Bettega G, Schir E. Contribution of platelet concentrates
to oral and maxillo-facial surgery. Rev Stomatol Chir
Maxillofac 2012;113(4):205-11.
18.Wang HL, Pappert TD, Castelli WA, et al. The effects of
platelet derived growth factors on the cellular response of
the periodontium: An autoradiographic study on dogs. J
Periodontol 1994;65:429-436.
19.Kassolis JD, Rosen PS, Reynolds MA. Alveolar ridge
and sinus augmentation utilizing platelet rich plasma in
combination with freeze dried bone allograft: Case series. J
Periodontal 2000;71:1654-1661.
20.The effects of autogenous plasma and platelet released
growth factors in bone regeneration-in vitro and in vivo
study. Int Poster J Dent Oral Med 15 (2013), Osteology
(30.06.2013).
21.Pikos MA. Mandibular block autographs for alveolar ridge
augmentation. Atlas Oral Maxillofacial Surg Clin N Am
2005;13:91-107.
22.Weibull L, Widmark G, Ivanoff CJ, Borg E, Rasmusson
L. Morbidity after chin bone harvesting--a retrospective
long-term follow-up study. Clin Implant Dent Relat Res
2009;11(2):149-57
Dr. Pankaj Chivte (MDS), Associate
Professor, Department of Periodontology, SD
Dental College, Parbhani. India.
Dr. Nisha Patel (MDS), Assistant
Professor, Department of Periodontology,
Aditya Dental College, Beed. India.
Dr.Amol Jamkhande (MDS), Associate
Professor, Department of Public Health
Dentistry, Bharati Vidyapeeth University
Dental College & Hospital, KatrajDhankawadi Campus Pune. India. Contact
Dr. Jamkhande at dr.amolj@gmail.com
15.Nunamaker DM, Perren SM. A radiological and
histological analysis of fracture healing using prebending
Journal of the Tennessee Dental Association ­• 94-2
Questions for Continuing Education Article - CE Exam #58
Publication date: Fall/Winter 2014. Expiration date: Fall/Winter 2017.
This exam is also available online. If you take the exam online, you can pay with a credit card and print out your
certificate in a matter of minutes. Visit the TDAs website at www.tenndental.org
1. Which bone grafting is considered to be Gold Standard
for grafting hard tissue defects:
a. Allograft
b. Xenograft
c. Autogenous
d. Alloplast
2. Why is the mandibular symphysis the most preferred as
intraoral donor site:
a. Less resorption
b. Conventional access
c. Reduced surgical time
d. All of the above
3. USBS provides a precise bone surgery because:
a. Cuts only hard tissues
b. Soft tissues, nerves and vessels are preserved from
injury
c. Simpler to use
d. All of the above
4. PRP is preferred to be used instead of a membrane due
to:
a. Decreases the frequency of intraoperative and
postoperative bleeding at the donor and the recipient
sites
b. Promotes rapid vascularization of the healing tissue
and facilitates rapid soft-tissue healing
c. Aids in the initial stability of the grafted tissue at the
recipient site due to its cohesive and adhesive nature
d. All of the above
5. Advantages of USBS over rotary instrumentation are:
a. A clean and blood free surgical field because of
cavitation and collapsing action of the ultrasound on
blood vessels
b. Better visual access to the surgical area
c. Easier access to bone harvesting sites with no risk of
injury to surrounding neurovascular bundles and soft
tissues
d. All of the above
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94-2 • Alveolar Ridge Augmentation with Autogenous Mental Block Harvested using Ultrasonic Bone
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Journal of the Tennessee Dental Association ­• 94-2