Alveolar Ridge Augmentation using a Double-Layer Technique
A Case Presentation
Markus B. Hürzeler, Prof. Dr. med. dent.
This study describes a two-barrier technique for guided bone regeneration associated with implant placement. Upon reviewing this study, the reader should:
- Understand the importance of the alveolar ridge to successful implant aesthetics.
- Recognize the clinical benefits associated with two different types of collagen membranes.
Endosseous implants have been documented to be a successful treatment option for restoring missing or failing teeth. Implant success, as measured through fixture osseointegration and restoration of function, has been reported to be high and stable over time. The predictability of implant procedures and the maintenance of long-term implant stability in function are directly related to the quality and quantity of the available osseous tissue for implant placement. Implantation of endosseous devices in areas where the dimensions of the alveolar bone are equal to or less than those of the implant results in parts of the implant surfaces and/or threads not being covered by bone. In the dental literature, it is still unclear whether exposed implant threads hamper the long-term prognosis of endosseous implants.
With respect to dental aesthetics, uncovered implant threads may be seen in concordance with the observations made following facial displacement of a tooth and can lead to soft tissue recession, which is subsequently followed by an aesthetic failure of the fixture. For an optimal outcome, several authors recommend at least 2 mm of bone structure on the buccal aspect of the implant shoulder. In the aesthetic zone, however, the anterior alveolar ridge is often devoid of this amount of bone structure. Therefore, in many instances, the bone structure on the buccal aspect of the implant shoulder has to be created using augmentation procedures.
The most widely used technique to increase the alveolar ridge width is to exclude the invasion of nonosteogenetic soft tissue cells by guided bone regeneration (GBR). The efficacy of the GBR technique both in rebuilding the atrophic alveolar bone prior to implant placement and around exposed implant surfaces has been well established in the literature.
This case presentation demonstrates a modification of the conventional GBR concept. The modifications involve the application of two different kinds of bioresorbable collagen membranes in combination with a xenogenous bone substitute. As the biodegradation of the membrane might be regarded as too rapid for bone regeneration, a long-lasting osseous membrane with a biodegradation of up to six months was mounted above the bone substitute, but beneath the membrane. With this concept, the ideal behaviour of the membrane towards soft tissue and the lasting durability of the osseous membrane can be combined.
*Clinical Associate Professor, Department of Operative Dentistry and Periodontology, Albert Ludwigs University, Freidburg, Germany; Clinical Associate Professor, University of Texas, Dental Branch, Houston, TX; private practice, Munich, Germany.
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- Albrektsson T, Zarb G, Worthington P, Eriksson A. The long-term efficacy of currently used dental implants: A review and proposed criteria for success. Int J Oral Maxillofac Impl 1986;1:11-25.
- Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567-572.
- Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: A Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Impl 2006;21:696-710.
- Wennström J. Lack of association between width of attached gingiva and development of soft tissue recession. A 5-year longitudinal study. J Clin Periodontol 1987;14:181-184.
- Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal bone response: Stage 1 placement through stage 2 uncovering. Ann Periodontol / American Academy of Periodontology 2000;5:119-128.
- Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodont Rest Dent 2005;25:113-119.
- Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: A clinical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996;54:420-432.
- Buser D, Dula K, Belser UC, et al. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int J Periodont Rest Dent 1995;15:10-29.
- Becker W, Dahlin C, Lekholm U, et al. Five-year evaluation of implants placed at extraction and with dehiscences and fenestration defects augmented with ePTFE membranes: Results from a prospective multicenter study. Clin Impl Dent Relat Res 1999;1:27-32.
- Caffesse RG, Nasjleti CE, Morrison EC, Sanchez R. Guided tissue regeneration: Comparison of bioabsorbable and non-bioabsorbable membranes. Histologic and histometric study in dogs. J Periodontol 1994;65:583-591.
- Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration around titanium dental implants in dehisced defect sites: A clinical study. Int J Oral Maxillofac Impl 1992;7:233-245.
- Fiorellini J, Nevins M. Localized ridge augmentation/preservation. A systematic review. Ann Periodontol 2003;8:321-327.
- Fugazzotto PA. Report of 302 consecutive ridge augmentation procedures: Technical considerations and clinical results. Int J Oral Maxillofac Impl 1998;13:358-368.
- Simion M, Baldoni M, Rossi P, Zaffe D. A comparative study of the effectiveness of e-PTFE membranes with and without early exposure during the healing period. Int J Periodont Rest Dent 1994;14:166-180.
- Hutmacher D, Hürzeler MB, Schliephake H. A review of material properties of biodegradable and bioresorbable polymers and devices for GTR and GBR applications. Int J Oral Maxillofac Impl 1996;11:667-678.
- Bunyaratavej P, Wang HL. Collagen membranes. A review. J Periodontol 2001;72:215-229.
- Hürzeler MB, Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodont Rest Dent 1999;19:279-287.
- Hürzeler MB, von Mohrenschildt S, Zuhr O. Second stage implant surgery in the esthetic zone--A new technique. A case report. Int J Periodont Rest Dent 2007;accepted for publication.
- Sevor JJ, Meffert RM, Cassingham RJ. Regeneration of dehisced alveolar bone adjacent to endosseous dental implants utilizing a resorbable collagen membrane: Clinical and histological results. Int J Periodont Rest Dent 1993;13:71-83.
- Kohal RJ, Trejo PM, Wirsching C, et al. Comparison of bioabsorbable and bioinert membranes for guided bone regeneration around non-submerged implants. An experimental study in the mongrel dog. Clin Oral Impl Res 1999;10:226-237.
- Kohal RJ, Hürzeler MB. [Bioresorbable barrier membranes for guided bone regeneration around dental implants]. Schweiz Monatsschr Zahnmed 2002;112:1222-1229.
- Colangelo P, Piattelli A, Barrucci S, et al. Bone regeneration guided by resorbable collagen membranes in rabbits: A pilot study. Implant Dent 1993;2:101-105.
- von Arx T, Broggini N, Jensen SS, et al. Membrane durability and tissue response of different bioresorbable barrier membranes: A histologic study in the rabbit calvarium. Int J Oral Maxillofac Impl 2005;20:843-853.
- Rothamel D, Schwarz F, Sager M, et al. Biodegradation of differently cross-linked collagen membranes: An experimental study in the rat. Clin Oral Impl Res 2005;16:369-378.
- Iglhaut J, Aukhil I, Simpson DM, et al. Progenitor cell kinetics during guided tissue regeneration in experimental periodontal wounds. J Periodontal Res 1988;23:107-117.
- Buser D, Dula K, Hess D, et al. Localized ridge augmentation with autografts and barrier membranes. Periodontol 2000 1999;19:151-163.
- Hutmacher DW, Kirsch A, Ackermann KL, Hürzeler MB. A tissue engineered cell-occlusive device for hard tissue regeneration--A preliminary report. Int J Periodont Rest Dent 2001;21:49-59.
- Friedmann A, Strietzel FP, Maretzki B, et al. Observations on a new collagen barrier membrane in 16 consecutively treated patients. Clinical and histological findings. J Periodontol 2001;72:1616-1623.