CASE PRESENTATION 4 Symphyseal Grafting.pptx

A CASE PRESENTATION ON PARASYMPHYSIS GRAFTING AND DENTAL IMPLANT PLACEMENT

1. CASE PRESENTATION 5: Alveolar Ridge Augmention Using Mandibular Symphyseal Grafting With Implant Placement. MODERATED BY: DR ASHISH SHARMA. DR HIMANSHU BHUTANI. PRESENTED BY: DR BIKRAM RANA.

2. CASE HISTORY: DEMOGRAPHIC DATA NAME: Mr. Vimal Kumar AGE : 22 Years GENDER: Male CR NO: 20230613719 MARITAL STATUS: Umarried ADDRESS: Gamma Phase 1Gautam Budh Nagar.

3. CHIEF COMPLAINT: Patient complained of missing tooth with respect to upper front region since last 2 years . Patient was apparently asymptomatic 2 years prior. Since then he gave a history of trauma due to the impact of cricket ball hitting his lower face region. At that time of the injury, there was instantaneous pain, swelling and bleeding from mouth with fracture and loosening of upper front tooth which were later removed. The incident was not associated with bleeding from ear or nose and patient was conscious with respect to time, place and person. HISTORY OF PRESENT ILLNESS

4. Patient visited a local dental clinic for extraction of his mobile teeth after a few days but did not plan any replacement for it. He reported to the ITS Dental College & Hospital on 18 th August 2023 for replacement of his upper anterior teeth and a comprehensive treatment plan was formulated for him addressing his complaint both functionally and aesthetically.

5. DENTAL HISTORY: No relevant history reported. MEDICAL & SURGICAL HISTORY: No relevant history reported. FAMILY HISTORY: No relevant history reported. HISTORY OF ALLERGY TO DRUGS & FOOD MATERIALS: No relevant history. PERSONAL HISTORY: Brushing Habits : Once daily Apetite : Normal Sleep Pattern : Normal Areca nut chewing : No habits reported. Tobacco : No habits reported. Alcohol : No habits reported

6. GENERAL PHYSICAL EXAMINATION BUILT AND STATE OF NUTRITION :- Sthenic , Ectomorphic ● GCS Score : 15 ASA GRADE : 1 ● GAIT: Normal ● Vitals : ○ Pulse: 88 beats/ min ○ SpO2 : 99 % ○ Temperature : 99.7 degree F ○ Blood pressure : 132/80 mm hg ○ RBS : 99 mg/dl PALLOR: ICTERUS: CLUBBING: CYANOSIS: KOILONYCHIA: ABSENT

7. EXTRA-ORAL EXAMINATION: INSPECTION : No swelling, rigor or gross facial asymmetry was noticed. Lips: Competent Mouth opening : 35mm (More than 3 fingers of the patient, with no deviation of jaw while opening mouth. PALPATION: TMJ: No Crepitus or Pain, S mooth Bicondylar TMJ movements. Lymph Nodes: Level 1- Non-tender and non palpable

8. INTRA ORAL EXAMINATION : 1.Number of teeth present : 30 2.No sinus tract, rigor or swelling observed wrt upper front teeth seen. 3. Missing : 11 and 21. 4.Vestibule: Depth is normal, no vestibular obliteration noted wrt upper front tooth region. 5.Caries - none. 6.Stains / Calculus : Grade 1. 8.Mobility : Absent. 9.Occlusion: Angle’s class 1 molar relation. INSPECTION:

9. INTRA ORAL EXAMINATION: PALPATION: No tenderness on palpation was present wrt alveolar mucosa 11, 21. No tenderness on soft tissue palpation wrt vestibule of left upper front tooth region. No signs of pus discharge wrt upper front teeth region.

10. PROVISIONAL DIAGNOSIS: Partially Edentulous wrt 11,21

11. INVESTIGATIONS: A CBCT SCAN FOR BOTH ARCHES WAS ADVISED TO THE PATIENT.

12. CBCT SLICES

13. CBCT REPORT

14. DIFFERENTIAL DIAGNOSIS : Partially Edentulous wrt 11,21. FINAL DIAGNOSIS : Partially Edentulous wrt 11,21. TREATMENT PLAN: PROSTHETIC REHABILITATION OF 11 and 21 rerion with endosteal Dental Implants followed by augmentation of the RAR and Labial Cortical Bone with Mandibular Symphyseal Graft.

15. PRE-OPTERATIVE INVESTIGATIONS

16. Patient came to department on 21 st August and was informed about the planned treatment, the benefits and potential risks and complications related to the procedure and administration of local anaesthesia. A written consent was then obtained from the patient after describing the complete procedure. PRE OPERATIVE STEPS INFORMED CONSENT

17. CBCT SIMULATION

18. SUMMARY OF OPERATIVE STEPS: Harvesting of Mandibular Symphyseal Graft Block. Trimming and Contouring of the harvested graft. Placement of Dental Implants wrt 11, 21. Adapatation of the Symphyseal Graft to the RAR of 11,21. Placement of GTR Membrane. Augmentation of the Ridge with Alloplastic Novabone putty. Closure.

19. OPERATIVE STEPS Surgical site was prepared with 5% povidine iodine and patient was draped under strict aseptic condition. LOCAL ANAESTHESIA- 2% Lignocaine hydrochloride with Adrenaline (1:80,000 units) was used and the patient’s left Inferior Alveolar Nerve was block bilaterally and with Labial infiltration of the Symphysis region. Mucosal Incisions were given using a No 15 Bard parkers Blade. The Superior Horizontal Incision was given 2mm below the FGM from Distal of 43 to Distal of 33.

20. The Vertical Incisions release incisions were given were given bilaterally at the disto -labial line angle of the lower canines perpendicular to the horizontal incisionsconnecting the superior and inferior horizontal cuts. A full thickness mucoperiosteal flap was raised and as such a rectangular shaped flap was reflected, the periosteal attachments were severed to expose the clear bone.

21. Radiographs were taken to visualize and confirm the area of the donor site and it proximity to roots of the mandibular anterior teeth.

22. A reciprocating surgical saw was used to make the bony cuts at 40,000 RPM The bony cuts were given in accordance to “ Misch’s Criteria ”. The Superior Horizontal cut was given 5 mm below the root apices from Distal of 42 to Distal of 32 . The Inferior Horizontal cut was given 5mm above the lower border of the mandible, the bilateral extent remaining the same as the superior incision . The Vertical cuts were given 5mm away from the mental foramen bilaterally at the disto -labial line angle of the lower lateral incisors connecting the superior and inferior horizontal cuts.

23. A rectangular bony window created with margins of 1.5 mm length and 1mm in height. The segment was mobilized by deepening the cuts using a no 4 Epker type Straight osteotome and mallet .

24. The mobilized bony block was removed with periosteal elevator and the exposed donor site was flused with normal saline and examined.

25. The graft site was examined and Collaplug was used as a local haemostatic agent to control bleeding.

26. The patient’s infraorbital nerve was blocked bilaterally. Crestal incision was given along the RAR of 11 and 21 and continued around the crevicle bilaterally till the distal of 13 and 23. Bilateral release incisions were given along the disto -labial line angle of 13,23.

27. Implant sizes were chosen according to the bone height available. Osteotomy was done using a spade drill followed by a 2mm pilot drill incrementally increasing the depth finishing with the drill width 3.2mm. The final depth was evaluated using the depth gauge and a 10mm length was confirmed.

28. Endosteal Dental implants of sizes 3.3x10 ( Adin Swell) was placed @ 11 and 3.5x10mm ( Adin Touareg -S). Primary Stability was checked by noting the value of the grading on the torque rachet at initial torque value 35Ncm.

29. The harvested graft was collected and assembled. Held out using a allis tissue holding forcep and sectioned saggitally into two segments of even thickness and length. Sectioning was done using a Ultrasonic Piezo Osteotomy tip.

30. The harvested graft section was trimmed, assembled and adapted to the deficient labial cortical plate. The graft sections were fixed with 2mm screws to the residual labial plate.

31. Fixation was cross examined with a IOPAR.

32. ‘ Colo -Guide’ GTR Membrane was cut and adapted over the grafting site labially and fixed using silk sutures.

33. Alloplastic Bone graft, ‘ Novabone Putty’ was applied in the space between of block graft and the GTR membrane labially . Closure of the site was done using 3’0 silk Sutures.

34. The implant site was sutured using 5’0 proline sutures The Symphyseal graft donor site was closed using 5’0 proline sutures

35. FOLLOWUP The patient was recalled after a week and was evalauted . The sutures were removed and IOPAR was done to evaluate the implanted and donor sites.

36. 1 st week FOLLOWUP RADIOGRAPH

37. CONCLUSION

38. Implants that do not have an adequate amount of bone covering them in all aspects (at least 1.5 mm bone buccal and lingual to the implant shoulder or about 2 mm in aesthetic zones) are at high risk for crestal bone loss. This in turn results in soft-tissue recession eventually failure of the implant.  When deciding to augment, there are multiple sources of bone-augmentation materials ranging from autogenous , allogenic , xenogenic and synthetic materials . The maxilla consists for the most part of cancellous bone with a thin cortex layer, whereas the mandible has more cortical bone and is denser.

39. The maxillary alveolar bone resorbs from the labial plate inwards and the mandibular alveolar bone from the lingual plate outwards . Classification of bone quality and bone quantity as described by Lekholm and Zarb , 1985.

40. PHASES OF BONE REMODELLING

41. Osteogenic grafts  provide a source of new bone formation by the osteoblasts that are present in the graft material. This can only be seen in the cases of autogenous bone grafts. Osteoinduction  is defined as the mechanism whereby a bone-substitute material induces bone formation by stimulating undifferentiated mesenchymal cells to turn into osteoblasts , ex- BMP. Osteoconduction  is the mechanism whereby bone formation is enhanced by providing a scaffold for osteogenic cells that are present in the local environment of the host. Classification Of Bone Grafts Based On The Mechanism Of Action

42. Regarding the influence of the grafted material used, it has been shown that particulated autogenous bone has the advantage of relatively fast incorporation in comparison with autogenous bone blocks . P articulate bone lacks structural stability and is prone to resorption . In contrast, autogenous bone blocks provide structural stability leading to better dimensional stability . However, block grafting requires a longer healing period of at least 6 months with about 50% (half the initial augmented volume) resorption at the end of the healing period.

43. CASE PICTURES GUIDED BONE REGERATION

44. ONLAY GRAFTING