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475
Int. J. Med. Surg. Sci.,
2(2)
:475-479, 2015.
Sandwich Osteotomy With Interposition Of A
Bovine Block Bone Graft for Vertical Ridge
Augmentation
Osteotomía en Sandwich con Interposición de Injerto Óseo
Bovino en Bloque para Aumento Vertical de Reborde
Claudio Ferreira Nóia*,**; Rafael Ortega-Lopes***; Bruno Costa Martins de Sá**; Claudinei
Ferreira Nóia**; Fábio Augusto Coelho de Oliveira** & Sergio Olate****,*****
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S.
Sandwich osteotomy with interposition of a bovine block bone graft for vertical ridge augmentation.
Int. J.
Med. Surg. Sci., 2(2)
:475-479, 2015.
SUMMARY: The aim of the present study was to report the clinical case of a patient with a vertical
defect of the alveolar ridge, which prevented the installation of dental implants without first treating the
defect in question. A 32-year old female patient with a height defect of approximately 6 mm in the region of
the missing absent teeth (13 and 14). The patient was treated using the sandwich osteotomy technique,
with the interposition of a block bone graft of bovine origin. No complications were reported in the post-
operative period. After seven months, two dental implants were installed in the relevant region. The bovine
bone graft was incorporated into the relevant area. The bovine bone block graft used in this clinical case was
shown to be a viable option for interposition between bone segments that have been osteotomized via
sandwich osteotomy.
KEY WORDS: Alveolar ridge augmentation; Bone graft; Dental implants.
INTRODUCTION
The treatment of vertical bone defects of
the alveolar ridge, for the subsequent
installation of dental implants, remains a great
challenge for dental surgeons today (Nóia
et
al
., 2012; Laviv
et al
., 2014). According to the
literature, the high index of exposure and the
nutrition difficulty involved in the use of block
bone grafts, or particulate bone grafts, when
performed on the alveolar ridge in areas with
this type of defect, are factors that directly and
negatively affect the results of these types of
grafts (Bormann
et al
., 2011; Tavares
et al
.,
2013).
The technique of segmenting using
interpositional bone grafts, or sandwich
osteotomy, has become more popular in recent
years among surgeons treating this type of
condition due to the low level of exposure, a
lack of complications, the easy nutrition of the
graft and the high percentage of success
(Bormann
et al
.; Laviv
et al
.; Triaca
et al
., 2014).
Using this technique, it is possible to readjust
height defects of between 4 and 8 mm and to
reposition badly-positioned implants, thereby
optimizing their long-term function, esthetics
and stability (Nóia
et al
.).
This technique was developed using
autografts between the osteotomized segments.
The literature currently contains studies that
* Dentistry Department, University of Araras (UNIARARAS/SP), Araras, Brazil.
** Dentistry Department, College Ciodonto, Rondônia, Brazil.
**** Dentistry Department, APCD Piraciaba, Piraciaba, Brazil.
**** Division of Oral and Maxillofacial Surgery, Universidad de La Frontera, Temuco, Chile.
***** Center for Biomedical Research, Universidad Autónoma de Chile, Temuco, Chile.
476
used this material safely and successfully
(
Bormann
et al
.; Bell, 2013; Tavares
et al
.;
Laviv
et al
.). However, since the technique
leads to a high index of vascularization and
predictability, recent studies have sought to
use biomaterials as an alternative to bone
autografts, without negatively affecting the
clinical results (Tavares
et al
.; Xuan
et al
.,
2014).
Therefore, the aim of the present study
was to report a clinical case that treated a ver-
tical defect of the alveolar ridge using sand-
wich osteotomy and a block bone graft of
bovine origin between the osteotomized
segments.
CASE REPORT
A 32-year old female patient with
leucoderma sought rehabilitation with implants
after complaining of the loss of dental elements
for many years, which had negatively affected
her in terms of esthetics and chewing
capabilities.
A clinical examination revealed the
absence of dental elements 13 and 14,
keratinized gingiva and a thick gingival
phenotype, as well as a gingival height defect
in the region (Fig. 1). A tomographic
examination revealed a bone deficiency of 6
mm in height in the region of the missing teeth.
Fig. 3. After incision and mucoperiosteal
displacement, vertical and horizontal osteotomies
were designed to enable the mobilization of the bone
segment in the occlusal direction. This was done in
order to correct the height defect, as well as to create
space for the interposition of the bovine block bone
graft.
Fig. 2. Tomographic image showing the bone loss at
a height of approximately 6mm.
Fig. 1. Initial clinical photograph showing the absence
of elements 13 and 14, as well as the thick gingival
biotype and the height defect of the gums.
In addition, there was a distance of
approximately 20 mm between the resorbed
ridge and the floor of the maxillary sinus and
the floor of the nasal cavity (Fig. 2).
The proposed treatment plan involved
sandwich osteotomy, with the interposition of
a bovine block bone graft, to treat the height
defect and enable the future installation of den-
tal implants.
The surgery began by anesthetically
blocking the anterior and middle superior
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S. Sandwich osteotomy with interposition of a bovine
block bone graft for vertical ridge augmentation.
Int. J. Med. Surg. Sci., 2(2)
:475-479, 2015.
477
alveolar nerves, as well as the nasopalatine
nerve and the greater palatine nerve, with
articaine 4% solution at 1:100.000 (Dfl, Rio
de Janeiro-Brazil). This was followed by a li-
near incision 3mm above the mucogingival
junction. The next step involved
mucoperiosteal displacement and the design
of the vertical and horizontal osteotomies,
using sagittal saws. The final design of the
osteotomies, as well as the mobilization of the
bone segment, was performed with chisels,
taking care not to lacerate the palatal mucosa
(Fig. 3).
Subsequently, the bovine block bone graft
(Lumina-Bloco, Critéria, São Carlos-Brazil) was
prepared and placed in the space created by
the mobilization of the bone segment. It was
then completely fixed with a plate and 1.5 mm
screws (Engimplan, Rio Claro-Brazil). Special
care must be taken with bovine block bone
grafts, as they tend to crumble at the time of
interposition (Figs. 4 and 5).
A membrane of absorbable collagen was
placed over the grafted region (Lumina-Coat,
Critéria, São Carlos-Brazil). The procedure was
finished with catgut continuous suture and
absorbable wire 3-0 (Point-suture, Fortaleza-
Brazil). The patients provisionary prosthesis
was adapted so that it would not pressurize
the reconstructed area (Fig. 6).
Seven months after the graft, the patient
was reassessed prior to the installation of the
dental implants. After careful mucoperiosteal
displacement, the fixation system was remo-
ved and the incorporation of the bovine block
bone graft was confirmed, with a considerable
gain in height correcting the pre-existing defect
(Fig. 7). The next step involved the milling and
installation of two dental implants (Conexão,
São Paulo-Brazil), in accordance with the
surgical guide and the reverse planning carried
out (Fig. 8).
Fig. 4. Bovine block bone graft prepared for
interposition.
Fig. 6. Performance of catgut absorbable suture. Note
the adaptation (stretch) of the mucous due to the
correction of the height defect. Another significant
factor is the adaptation of the provisionary prosthesis
of the patient, without putting pressure on the graft
region.
Fig. 5. Bovine block bone graft in position and the
segment fixed with a plate and screws. Note that the
block tends to fragment during the act of interposition.
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S. Sandwich osteotomy with interposition of a bovine
block bone graft for vertical ridge augmentation.
Int. J. Med. Surg. Sci., 2(2)
:475-479, 2015.
478
DISCUSSION
Nowadays, patients who seek treatment
involving dental implants usually wish to restore
their masticatory function, comfort, esthetics
and phonetics, regardless of the existence of
atrophy, disease or injuries of the
stomatognathic system. In this context, sand-
wich osteotomy has been shown to be viable
and predictable in the treatment of vertical
defects of the alveolar ridge (Bormann
et al
.;
Laviv
et al
.).
According to the literature, this technique
is indicated for the correction of vertical defects
located in the anterior region of the jaw and
mandible, as well as the posterior region of the
mandible (Laviv
et al
.; Triaca
et al
.). Maxillary
sinus pneumatization usually occurs in the pos-
terior region of the jaw, which leads to the
contraindication of this technique, as it favors
the elevation of the maxillary sinus floor.
However, Nóia
et al
. reported a case in
which this technique was used in the posterior
region of the jaw (dental elements 14, 15 and
16). According to the authors, a loss of bone
height, starting from the crest of the alveolar
ridge, was recorded, without maxillary sinus
pneumatization. In the clinical case presented
in this study, the procedure was conducted in
the area between the anterior and posterior
regions of the jaw (elements 13 and 14), without
pneumatization of the maxillary sinus or nasal
cavity, both of which would have prevented the
procedure from going ahead.
Studies published in the literature on the
use of the sandwich osteotomy technique
routinely use bone autografts between the
osteotomized segments (Bormann
et al
.; Nóia
et al
.; Bell
et al
.; Tavares
et al
.). However, these
same studies state that this technique exhibits
a high level of predictability in the results as a
result of the continuous contact between the
graft and a four-wall defect, which strongly
favors its nutrition and a considerably lower
degree of reabsorption.
In the clinical case presented in this study,
bovine block bone grafts were used between
the osteotomized segments and provided a
clinically satisfactory result after seven months,
favoring a vertical gain of approximately 6 mm,
as well as the installation of two dental implants
in the region. No similar report has been found
in the literature.
Another important factor to be discussed
is related to the fact that the authors of previous
studies involving the interposition of autografts
Fig. 7. After removing the fixation system, it was
possible to visualize the excellent incorporation of
the bovine block bone graft, as well as the correction
of the bone height defect.
Fig. 8. Panoramic radiography providing a partial view
of the implants installed.
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S. Sandwich osteotomy with interposition of a bovine
block bone graft for vertical ridge augmentation.
Int. J. Med. Surg. Sci., 2(2)
:475-479, 2015.
479
between osteotomized segments recommended
the installation of implants four or five months
after reconstructive surgery, stating that this
time period was sufficient for bone incorporation
and neoformation of segments (Bormann
et al
.;
Nóia
et al
.; Bell
et al
.; Tavares
et al
.; Felice
et
al
., 2014). In this clinical case, which used bovine
grafts, we decided to allow a period of seven
months to pass before installing the implants.
This is due to the fact that this modality of graft
does not exhibit the same properties or capacity
as autografts. Thus, the process of bone
incorporation and neoformation with bovine
grafts is slower.
CONCLUSION
The results suggest that bovine block bone
grafts were used between the osteotomized
segments and provided a clinically satisfactory
result. Further studies are required to determine
whether this treatment leads to predictably results.
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S.
Osteotomía en Sandwich con Interposición de Injerto Óseo Bovino en Bloque para Aumento Vertical de Reborde.
Int. J. Med. Surg. Sci., 2(2)
:475-479, 2015.
RESUMEN: El objetivo del estudio fue reportar un caso clínico de un paciente con defecto vertical del
reborde alveolar, el cual impedía la instalación de implante dental sin tratar el defecto. Un paciente de 32 años de
edad se presentó con un defecto en altura de 6 mm aproximadamente en el sector de dientes 13 y 14. EL paciente
se trató utilizando un bloque de hueso bovino en una técnica de osteotomía con injerto interposicional. No se
observaron complicaciones en el periodo postoperatorio; después de siete meses, dos implantes dentales fueron
instalados en la región y clínicamente se observó la incorporación del material de injerto. Se puede concluir que
el uso de injerto óseo en bloque de origen bovino puede ser aplicado en esta técnica.
PALABRAS CLAVE: Aumento de reborde alveolar; Injerto óseo; Implante dental.
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Correspondence to:
Prof. Dr. Claudio Ferreira Nóia
University of Araras (UNIARARAS)
Dentistry Department
Av. Dr. Maximiliano Baruto, 500
Jardim Universitário, Araras
São Paulo - Zip-code: 13607-339
BRAZIL
Email: claudioferreira2004@yahoo.com.br
claudionoia@uniararas.br
Received: 16-04-2015
Accepted: 22-06-2015
NÓIA, C. F.; ORTEGA-LOPES, R.; DE SÁ, B. C. M.; NÓIA, C. F.; DE OLIVEIRA, F. A. C. & OLATE, S. Sandwich osteotomy with interposition of a bovine
block bone graft for vertical ridge augmentation.
Int. J. Med. Surg. Sci., 2(2)
:475-479, 2015.