Autogenous Onlay Graft For The Maxillary Anterior

The patient illustrated in the following clinical report is a 21 year old female, with a class III smile line, who sustained a traumatic injury to both maxillary central incisors. A greater fracture occurred to the left central incisor leading ultimately to its loss. The residual alveolar ridge defect associated with the removal of tooth #9 extended to the apex of the root with total loss of the labial bone plate and partial loss of the palatal wall.

Site preparation began with a crestal incision followed by vertical releasing incisions distal to each of the adjacent teeth and a full thickness flap elevated labially and palatally. All granulation tissue was removed from the future implant receptor site. The anterior mandible was selected as the donor site for a unicortical autogenous bone graft. A full flap initiated several millimeters below the mucogingival junction was elevated to expose the anterior mandible. The width of the maxillary defect was measured mesially-distally. This dimension was marked with a surgical bur on the labial of the anterior mandible. Using a variety of surgical burs, a unicortical bone graft consisting of the labial cortical plate and underlying trabecular bone was harvested from the mandible (Fig 4-5).

Using a combination of rongeurs and diamond burs, the autogenous graft was shaped and placed into the wedge shaped maxillary defect with the cortex facing superiorly and the trabecular bone contacting the host site. A sufficient quantity of bone was allowed to extend labially beyond the adjacent bone to enable the graft to be held firmly in place using a stiff surgical clamp. Then standard drills were used to prepare the implant receptor site (Fig 6). Additional blocks of bone were also harvested from the chin and were used apical to the cortical portion of the main graft and held in place with small stabilizing bone screws (Fig 7). Mimfix screws were used to secure a Gortex nonresorbable membrane over the grafted area following implant placement (Fig 8).

The postsurgical periapical radiograph illustrates the position of the implant, the bone graft, and the adjacent membrane stabilizing screws (Fig 9). Primary closure was accomplished over both the donor site and the grafted maxilla. Both surgical sites healed uneventfully. Shortly following the surgical procedure, the patient was refitted with a temporary removable partial denture which was worn until completion of the five month healing period.

Stage 2 surgery was performed with a coronal incision made slightly to the palatal aspect of the ridge, approximately at the position of the adjacent cingulum. Small vertical releasing incisions were designed to maintain the interdental papilla. A full thickness labial flap was required to retrieve the nonresorbable membrane and the fixation screws. The autogenous bone grafts were evaluated for stability while simultaneously noting the bone fill between the cortical plates.

A 1 mm CeraOne abutment was tightened to the implant using 32 Ncm of torque. A provisional crown was then constructed for the implant abutment and the adjacent central incisor. The master impression for both the implant restoration and the traditional natural tooth crown were made at the same time. Two weeks following second stage surgery the final ceramo-metal gold crowns were delivered and the patient continued to heal uneventfully (Fig 10,11).

The patient has returned on a semi-annual basis for reevaluation with no changes in soft or hard tissue configurations during a 4-year follow-up.

Special thanks to Fort Washington Dental Lab Inc.

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