An interdisciplinary management of severely resorbed maxillary anterior ridge complicated by traumatic bite using a ridge splitting technique.

Injury to the teeth and alveolar ridge of the maxillary anterior region due to trauma can cause severe alveolar ridge deficiency. Ridge augmentation is a valuable periodontal plastic surgical method for the correction of ridge defects for esthetic purpose. Although ridge augmentation can help to restore the ridge volume, the grafting procedures can significantly increase the patient morbidity, treatment time, and the cost. Among the ridge augmentation techniques, the ridge split procedure demonstrates many benefits such as no need for donor site, the rare risk of damage to underlying anatomical structures, less pain, and swelling. This case report presents a vertical split technique for increasing the bone volume. There was a remarkable healing and significant increase in bone volume. We have followed the case for 6 months.

INTRODUCTION

Alveolar bone loss can occur after tooth extraction or trauma. Furthermore, it can be complicated by the traumatic deep bite which leads to severe alveolar ridge resorption. Atrophy of the alveolar bone may also be seen in congenitally missing teeth, failed implants and advance periodontal disease. These ridge defects are common in conjunction with single or multiple tooth loss. The Prosthodontic treatment with fixed partial denture of surgically uncorrected ridge defects is challenging and leads to several esthetic and functional problems.[1] Numerous techniques have been used to modify the width of a deficient alveolar ridge. These techniques range from guided bone regeneration (GBR), block bone grafting, distraction osteogenesis, ridge splitting etc., For a deficient edentulous maxillary ridge, the localized ridge expansion is a useful technique to provide an increase in ridge width so as to achieve an adequate alveolar crest. The segmented ridge split procedure (SRSP) was originally developed by Simion et al.[2] and Scipioni et al.[3] and later discussed by Nevins and Stein.[4] The indication for ridge augmentation using ridge expansion procedure include an edentulous space with minimal loss of vertical bone height accompanied by an inadequate alveolar bone thickness (<4 mm) in the bucco-palatal direction. This case report is presented with the aim to describe an interdisplinary management of severely resorbed maxillary anterior ridge using a ridge splitting technique.

CASE REPORT

A 19-year-old female patient presented to our University Dental Center with the chief complaint of deficient maxillary anterior edentulous ridge. The patient wanted the esthetic rehabilitation of missing upper front teeth. On clinical examination, there was deficient maxillary anterior edentulous ridge complicated by the traumatic deep bite. After taking initial records [Figure 1], the case was discussed among prosthodontist, periodontist, and orthodontist. After the oral prophylaxis and hygiene maintenance instructions patient was referred to the orthodontist for bite opening. It took 12 months to open the bite [Figure 2]. The patient was then referred to the periodontist for the management of deficient maxillary anterior edentulous ridge. A consultation with prosthodontist involving patient was made before ridge splitting procedure regarding the rehabilitation of edentulous maxillary anterior segment using dental implants or fixed prosthetic bridge. Due to economic conditions patient opted for a fixed bridge in place of dental implants. For achieving an emergence profile of the prosthesis, improvement in the bone height and width was required. Hence, it was decided to perform ridge splitting procedure for improving horizontal and vertical thickness of ridge using bone allograft without implant placement at the time of ridge splitting procedure.

Figure 1

Pretreatment intraoral photograph; (a) Frontal view; and (b) Maxillary occlusal view

Figure 2

Intraoral photograph after the bite opening with orthodontic appliance

Surgical procedure

It is not extremely common to open an edentulous ridge, only to find thin atrophic bone especially when it is traumatized by opposing teeth. In this case, a SRSP was performed to open entire edentulous bony segment like an envelope to receive the bone graft. After routine preparation of the surgical site with a Povidine Iodine solution (5% w/v), the local anesthetic solution (2% adrenaline) was administered. The incision was made with no. 15 Bard Parker blade at midcrestal level and the full thickness mucoperiosteal flap was raised. On reflection of mucoperiosteal flap, it was found that the palatal cortical bone was mostly absent due to traumatic deep bite from mandibular anterior teeth. The sharp bony spicules were rounded off by osteoplasty procedure to provide a smooth blended bone surface. The edentulous alveolar ridge was then splitted vertically by inserting chisel. The chisel was directed towards the palatal side to give the access for the placement and retention of bone graft in the ridge. The decalcified freeze dried bone allograft (DFDBA) was prepared by processing the graft particles into a sterile dappen dish and reconstituted with sterile saline water. Excess sterile saline was removed with a gauge; the graft material was then placed into the surgically prepared site with an amalgam carrier followed by firm pressure with amalgam condenser. The defect was filled to the existing alveolar crest. Primary soft tissue closer was done using 3–0 black braided silk suture by simple interrupted sutures. Periodontal dressing was given for the wound stabilization for 7 days [Figure 3].

Figure 3

Intra-operative photograph of surgical technique; (a) after flap reflection; (b) after bone splitting and bone fill; and (c) after suturing

Postoperatively, the patient was placed on amoxicillin 250 mg and metronidazole 200 mg 8 hourly for 5 days. Ibuprofen 400 mg 8 hourly for 3 days and chlorhexidine gluconate mouth rinse (0.12%) twice daily 10 ml for 2 weeks. The patient was instructed neither to brush the surgical site nor manipulate it in any manner for 10 days. The sutures were removed after a week and the site was debrided with saline water. Splinted porcelain fused to metal bridge was then delivered [Figure 4]. We have followed the case for 6 months.

Figure 4

Posttreatment photograph of the patient; (a) After 1 week; (b and c) After 2 weeks frontal and maxillary occlusal view; and (d) With prosthesis

DISCUSSION

The sufficient bone quantity will be essential prerequisite for esthetic rehabilitation. Several techniques have been described to enhance the bone volume, e.g. bone grafting, GBR, and distraction osteogenesis. Residual ridge widening is another novel method to prepare atrophic ridge for prosthodontic rehabilitation. Bone splitting and widening procedures were first described by Tatum[5] in 1984 as an alternative method in the management of atrophic ridge. The use of this minimally invasive technique has many advantages, e.g. lower risk of damage to the anatomical structures, less pain and less swelling. In this case, DFDBA was used to fill the gap created by a vertical split of the bone. The DFDBA has been shown to induce new bone to enhance periodontal regeneration. The current widespread use of DFDBA is based on the reported osteoinductive ability of bone allograft preparation.[6] Demineralization of the graft exposes the bone inductive protein located in the bone matrix, and in fact may activate them. DFDBA has been shown to induce new bone and enhance the periodontal regeneration.[78] In this case, we have accessed the height and width of the alveolar ridge preoperatively and postoperatively using a digital caliper and measured to the tenth of the millimeters as described by Stepovich.[9] The height and width of the change of alveolar bone were calculated on pretreatment and post treatment models. The study models were measured for the changes in height and width at three points, that is, mid-buccally, right to mid-buccal region and left to mid-buccal region of the edentulous part. The recordings observed are shown in Table 1. We have found significant amount of increase in the width of alveolar bone [Figures 3 and 4]. Caliper is an effective tool in accessing the bone height and width. The resorption of the alveolar bone from palatal aspect due to traumatic deep bite resulting in thinning of alveolar bone. The conventional X-ray being two-dimensional in nature was not preferred instead clinical measurement was made by using Boley gauge.[9] In our setup, we don’t have cone beam computed tomography and we didn’t use the medical computed tomography because of higher unnecessary radiation exposure and expense.

Table 1

The height and width changes of alveolar bone as calculated on the pretreatment and posttreatment study models

CONCLUSION

This report describes the modification of original maxillary ridge expansion technique.[1] Following are the advantages of this procedure:

Good access and flap mobility

Lower risk of complete bone fracture

Improved graft stability

Better maintenance of soft and hard tissue volume

Enhance the emergence profile of the prosthesis.