Advances in Human Biology

: 2018  |  Volume : 8  |  Issue : 2  |  Page : 127--130

Management of compromised anterior maxillary edentulous arch with symphyseal bone graft

Sunil Kumar Mishra, Ramesh Chowdhary, Padmakar S Patil, Srinivasa B Rao 
 Department of Maxillofacial Prosthodontics and Implantology, HKE'S S.N. Institute of Dental Sciences and Research, Kalaburagi, Karnataka, India

Correspondence Address:
Sunil Kumar Mishra
Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh


Achieving optimal aesthetics, function and phonetics with implant-supported restorations depends largely on the amount of bone present at the site where implant has to be placed. Sometimes, patient reports with compromised conditions which makes the implant placement difficult. Today, reconstruction procedures such as autogenous bone graft and guided bone regeneration make the implant placement possible in different ridge deficient cases. This case report describes step-by-step procedure of restoring the missing maxillary right central incisor with implant-supported prostheses. In missing left central incisor region, the alveolar bony defect was corrected by autogenous bone graft obtained from symphysis region, for restoration with implant prostheses.

How to cite this article:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Management of compromised anterior maxillary edentulous arch with symphyseal bone graft.Adv Hum Biol 2018;8:127-130

How to cite this URL:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Management of compromised anterior maxillary edentulous arch with symphyseal bone graft. Adv Hum Biol [serial online] 2018 [cited 2019 Dec 15 ];8:127-130
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Currently, implant treatment is considered as a reliable option for the replacement of missing teeth and widely accepted treatment for improving function and aesthetics.[1] Brånemark et al. had introduced the term osseointegration and it had created a revolution in advanced dental treatment for the rehabilitation of lost missing teeth, with implant-supported prosthesis.[2],[3] In cases where there was a deficiency of soft-tissue and bone, rehabilitation with implant-supported prosthesis to restore single or multiple teeth, especially in aesthetic region, is a great challenge for the implantologist. To preserve or create the natural appearance of the tooth and surrounding structures are quite difficult and challenging for the clinician.[4],[5] The residual alveolar ridge present plays a crucial role in the success of implant rehabilitation. Reconstruction procedures, such as autogenous bone graft and guided bone regeneration, make the implant placement possible in cases where the ridge was deficient.[6]

This case report presents the rehabilitation of a patient with the missing maxillary right central incisor with the help of implant-supported prosthesis. A two-stage implant surgery was done wherein the first surgery was for implant insertion and the second surgery, several months later, was performed for uncovering the implant and attaching a prosthetic abutment. In missing left central incisor region, the alveolar bony defect was corrected by autogenous bone graft obtained from symphysis region.

 Case Report

A 23-year-old, female patient reported to the maxillofacial prosthodontic department of HKE'S S.N. Institute of Dental Sciences, Kalaburagi, Karnataka, India, with the chief complaint of lost right and left front tooth and want it to be replaced [Figure 1]. Intraoral examination showed that there was missing right (11) and left (21) central incisors. Intraoral periapical radiographs (IOPA) and orthopantomogram were taken to make the radiographic investigations. Maxillary and mandibular arch impressions were made to obtain a diagnostic cast. A detail medical history of the patient was taken along with blood investigations to overrule any systemic findings. The available options for the treatment were explained to the patient, and patient chose rehabilitation with dental implant. Bone mapping was done, which revealed the width of labiopalatal cortical bone as 5.5 mm in 11 region and 4.5 mm in 21 region. It was planned to place a implant of size 3.5 mm × 12 mm in 11 region and bone graft to be placed in 21 region with delayed implant placement in that region.{Figure 1}

Under right infraorbital nerve block, the implant surgery was started. An incision in the mid-crestal region was given along with crevicular incisions and mucoperiosteal flap was elevated. The implant site was prepared, and an implant fixture of dimension 3.5 mm × 12 mm (Biohorizon, Birmingham, USA) was placed at the osteotomy site [Figure 2]. The periosteal flap was again sutured back with 4.0 non-resorbable silk sutures. Antibiotics and analgesic were prescribed and instructions were given for the post-operative care to the patient. After 6 months, the patient came back and she agreed for bone graft with 21 region. The receptor site for bone graft was prepared [Figure 3]. Autogenous bone graft taken with trephine from symphysis region [Figure 4] and blended with synthetic bone graft (Periobone G, Top-Notch Health Care Product Pvt., Ltd., India) [Figure 5] and harvested in 21 region [Figure 6]. Flap was sutured back with 4.0 non-resorbable silk sutures. After 1 month, the second stage surgery was done in 11 region and a gingival former of size 3.5 mm × 3 mm was placed [Figure 7]. After 1 week, gingival former was unscrewed and abutment was placed back. An impression with closed tray technique was done. Abutment was positioned back in impression along with implant analog and was poured in dental stone, and later, cast was retrieved. The abutment was milled [Figure 8] at cast and coping was fabricated and try in was done. A porcelain fused metal crown was fabricated and cemented. Occlusion was checked [Figure 9]. Assessment of the complete seating of the abutment on the implant fixture was done with the help of IOPA radiograph. A removable partial denture was given with 21 region for aesthetics [Figure 10] till the time the osseous defect was regenerated with new bone formation and an implant can be placed in that region.{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}


In this case report, two-staged implant surgery was done, as a success rate of 94% was reported in long-term studies for implant rehabilitation with two-stage protocol.[7] Roynesdal et al. stated that it was more desired to place implants in a two-stage protocol, to obtain a favourable emergence profile at the transmucosal portion in cases where coronal part of the implant is at the crestal level.[8]

In 21 region, there was not enough available bone to place implant. In certain clinical situations, the tooth loss was not coinciding with rehabilitation with implant-supported prosthesis and this leads to delay in treatment of the edentulous region.[9] Hence, it was decided to delay the implant placement and to place bone graft in that region. It was decided to take graft from symphysis region. The symphyseal bone graft consists of cortical bone (65%) and cancellous bone (36%) when compared to the ramus region of mandible, which mainly consists of cortical bone.[10] Symphyseal graft was blended with Periobone-G. Periobone-G (hydroxyapatite) material chemically and crystallographically equivalent to the mineral portion of human bone, specifically hydroxyapatite [Ca10(PO4) 6OH2]. There was no systemic or localised toxicity with this material, and it does not produce any inflammatory reaction. This material causes no alteration of normal bone mineralisation process and merges with the natural bone.[11] When grafted with the allogenous and autogenous bone, the study had shown successful results.[12] Research had shown good results when autogenous bone graft was placed inside the membrane in comparison to allograft.[12],[13],[14] A vertical bone formation of 8 mm was obtained when autogenous bone chips were placed along with membrane, but when allograft was placed with membrane, it does not result in a vertical regeneration of more than 5 mm bone.[12]


There is very much variation in amount and quality of bone present in the anterior maxillary region. To obtain a harmonious and successful prosthesis in the area where there was deficient bone is a great challenge to the clinician. A thorough treatment planning for placement of dental implants in maxillary anterior region is required so that good esthetic results can be obtained. As the dentistry advances, it is the job of the clinician to make aware the patient to different treatment options available so that they can choose best among them.

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Conflicts of interest

There are no conflicts of interest.


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