FRAnCiSley ÁvilA SouzA1, AnA PAulA FARnezi BASSi1, AleSSAndRA MARCondeS ARAnegA1,
dAnielA Ponzoni1, gABRielA BuFulin leonARdi2, FeRnAndA BRASil dAuRA JoRge BooS3,
eloÁ RodRigueS luvizuTo4, HeloíSA HelenA níMiA5, idelMo RAngel gARCiA JúnioR1
1DDs, Ms, PhD. Professors of the surgery and Integrated Clinic Department at the Araçatuba of Dental school – Univ est Paulista Júlio de Mesquita Filho - UNesP, Brazil 2Undergraduate student of the Araçatuba of Dental school – Univ est Paulista Júlio de Mesquita Filho - UNesP 3DDs, Ms. student of the Post-Graduation Course in Dentistry, Area of Concentration in oral and Maxil ofacial surgery and Traumatology of the Araçatuba of Dental school – Univ est Paulista Júlio de Mesquita Filho - UNesP 4DDs, Ms, PhD. substitute Professor of the surgery and Integrated Clinic Department at the Araçatuba of Dental school – Univ est Paulista Júlio de Mesquita Filho - UNesP 5Nurse, Ms. Professor of Pontifical Catholic University. Puc-Minas, Poços de Caldas, Brasil. student of the Post-Graduation Course in Nurse of the Guarulhos University – UNG., Brazil Reconstruction of maxillary ridge atrophy
caused by dentoalveolar trauma, using autogenous
block bone graft harvested from chin: a case report
To CITe ThIs ARTICle souza FÁ, Bassi APF, Aranega AM, Ponzoni D, leonardi GB, Boos FBDJ, luvizuto eR, Nímia hh, Garcia IR Júnior. Reconstruction of maxil ary ridge atrophy caused by dentoalveolar trauma, using autogenous block bone graft harvested from chin: a case report. J osseointegr Dentoalveolar traumas are very common, and mainly affect children and adolescents. The main causes are car accidents, sporting activities and aggressions. There are some predisposing factors for this condition, such as accentuated overjet, childhood obesity (1), Background Dentoalveolar trauma, especially when involving
upper lip incapable of covering the anterior teeth, and front teeth, negatively affect the patient's life; in particular, protrusion of the maxillary central incisor (2). The most tooth avulsion is a complex injury that affects multiple tissues, common dento-alveolar traumas include fractures, and no treatment option offers stable long-term outcomes. luxations and tooth avulsion; the latter occurs when The aim of this study was to report a case of reconstruction of the tooth is completely forced out of its alveolar socket. atrophic anterior alveolar ridge after tooth loss, performed with The most conservative treatment for avulsion is tooth autograft harvested from the chin, and subsequent prosthetic reimplantation; however, frequently this is not possible, rehabilitation with the use of an osseointegrated implant. leading to sequelae that include psychological effects Case report A 23-years-old Caucasian girl, presented an
on the patient, compromising oral function, esthetics atrophic alveolar bone in the area of tooth 11, as a result of tooth and self-esteem (3), and biological damage to the hard resorption 10 years after a tooth reimplantation procedure. and soft tissues of the affected region (4). Nevertheless, Reconstruction was performed with autogenous bone harvested even when reimplantation is performed, the main and from the chin. After 6-months healing period to al ow autograft most likely complication is tooth resorption, which may incorporation, a dental implant was inserted. After further 6- trigger extensive bone resorption and severe atrophy months, a screw-retained implant supported metal-ceramic of the maxilla (5). This condition makes implants prosthesis was fabricated.
insertion and prosthetic rehabilitations impossible or Results The prosthetic rehabilitation was successful, and after
difficult. In these cases, bone regeneration procedures a fol ow-up period of 5 years, the achieved result was stable.
are mandatory to allow the implant placement in a Conclusion It can be concluded that the autogenous bone graft
correct tridimensional situation (6).
harvested from the chin, is a safe and effective option for alveolar The goal of bone reconstructions by means of grafts ridge defects reconstruction, al owing a subsequent placement is to re-establish adequate bone dimension, allowing of a dental implant supporting a prosthetic restoration.
correct rehabilitation with osseointegrated implants (7). Autogenic bone grafts are considered the gold standard among grafting materials in dentistry (8). This is due to their relative resistance to infection, KeywoRDs Autogenous bone graft; Dentoalveolar traumatism; incorporation by the host, without the occurrence of osseointegrated implants; Prosthetic rehabilitation; Tooth avulsion.
a foreign body reaction (9), in addition to osteogenic, osteoinductive and osteoconductive capacity (8). The June 2014; 6(2) ariesdue

Souza F.A. et al. autogenous bone graft may be of trabecular, cortical or FIG. 1A Adhesive mixed (osseous coagulum and particulate bone) bone partial denture.
from an intra or extra-oral donor area (10). The main extra-oral donor sites are the iliac crest and calvarium, and the intra-oral sites are the chin, retromolar areas and maxillary tuberosity (11). The use of extra-oral areas involves extensive surgeries, greater morbidity and costs, requiring hospitalization of the patient (12), whereas grafts from intra-oral sources are obtained more easily due to the proximity between the donor and receptor sites, when possible under local anesthesia, and with less discomfort to the patient, in addition to a low resorption potential (8). On the other hand, the thickness defect.
main disadvantage of using intra-oral donor areas is the limited quantity of bone tissue available (13).
One of the factors to be considered in the choice of donor area is the quantity of bone graft required. Among the intra-oral bone sites, the chin region is one of the most used, particularly in case of receptor areas that need a small quantity of bone volume and small augmentation of the alveolar ridge. The chin presents both cortical and medul ary bone types, which ensure good incorporation, rapid revascularization and extremely little loss of grafted bone volume (8, 14). Moreover, it offers a thick block, larger bone volume, and moderate post-operative pain and edema, when compared with other intraoral donor areas (15). The limits of harvesting grafts from the mental symphysis are connected to the presence of the roots of teeth, mental foramen, inferior cortical and lingual cortical borders (16). One of the main limitations of this technique is the proximity to the mental nerve, that could be damaged and cause an alteration of sensitivity (8). At present, there is great concern about the adequate placement of implants, allowing a more functional FIG. 2 Initial panoramic radiograph.
prosthetic rehabilitation from the biomechanical point of view, and enhanced esthetics, with benefits to the patient's self-esteem, and a high level of satisfaction. was born. She reported that, at that time, the protocol Therefore, the aim of this study was to report a case for late reimplantation was performed, with surface of reconstruction of atrophic anterior alveolar ridge, treatment of the tooth, endodontic treatment and performed with autograft harvested from the chin, and definitive restoration at the site of the coronal opening. rehabilitated with an implant-supported prosthesis.
Nine years after, tooth 11 was lost as related by the patient, because it had become mobile, with presence of a purulent exudate. The surgical procedure for CASe RePoRT
extraction was performed by the same clinician and an adhesive fixed partial denture was fabricated on tooth Case history
11, with adhesive abutments on teeth 12 and 21 (Fig. A 23-year-old Caucasian girl, showed attendance 1a).
at the clinic of Oral and Maxillofacial Surgery of the The patient reported to have used the denture up to Araçatuba of Dental School – UNESP, in order to the moment of referral, but she complained about the replace a partial fixed adhesive denture on teeth 12, difficulty of cleaning it, and exacerbation of the nasal 11, and 21 with an osseointegrated implant. There was filter sinking due to the alveolar bone resorption in absence of tooth 11, lost as a consequence of tooth correspondence of tooth 11. resorption: the patient had suffered a tooth avulsion During the clinical intra-oral examination, bone at the age of 10 years. On the day of the avulsion the resorption of the vestibular wall was observed, in tooth was reimplanted by a dental surgeon specialized correspondence of the missing tooth (Fig. 1b). A in Pediatric Dentistry, in the city where the patient panoramic radiograph was requested (Fig. 2), in which ariesdue June 2014; 6(2)

Reconstruction of traumatized atrophic ridge with bone block graft. A case report of 3 positions (17), in the mandible. In addition, subperiosteal infiltrative terminal anesthesia was also performed in the vestibule of the anterior regions of the maxilla and mandible with the intention of curbing possible hemorrhages. Surgical access began in the receptor area with a Newman mucoperiosteal incision using a scalpel blade (15s, Feather, Feather Safety, Japan) mounted in a scalpel handle (Hu-Friedy, Berlin, Germany), for detachment and exposure of the receptor site (Fig 3a). Extensive bone resorption was observed in the FIG. 3B Vestibular vestibular-palatine direction, proved by the thinness of wall thickness.
the receptor site (Fig. 3b). Decortication of the vestibular bone plate was performed by means of a Maxicut spherical bur (Edenta, Zahn-Labor, Labordental, São Paulo, Brazil) and perforations with Bur 702 (Maillefer Instruments, Ballaigues, Switzerland), mounted in a straight multiplicator handpiece (Kavo do Brasil, Joinvile, Brazil) with electric motor (Kavo do Brasil, Joinvile, Brazil), under constant irrigation with 0.9% physiological solution (Darrow, Rio de Janeiro, Brazil). An incision was made in the mucosa at the depth of the anterior vestibular fornix, then a perpendicular muco- it was possible to observe bone tissue without signs of periosteal incision to detach and expose the chin donor bone rarefaction, with preserved bone height between area was performed (Fig. 4a). The size of the graft the alveolar crest and floor of the nasal fossa.
necessary for the reconstruction was delimited in the Complementary exams were requested in order to donor area (Fig 4b), followed by monocortical osteotomy evaluate the patient's general state of health, which (Fig. 4c), performed with Bur 702. The monocortical included hemogram, complete coagulogram, fasting block bone graft was removed with the aid of Wagner glycemia, urea, creatinine and electrolyte dosages chisels and hammer (Quinelato, São Carlos, Brazil), as (Sodium, Potassium and Calcium); thus, the patient shown in Figure 4d. The recipient site was shaped for was graded into surgical risk ASA I, in accordance with passive graft accommodation insertion (Fig. 5a) and the American Society of Anesthesiologists (1963). fixation by means of 2 bicortical screws measuring Reconstruction of the alveolar ridge corresponding 1.3x11.0 mm (SIN, Sistema de Implante Nacional, São to tooth 11 was planned, by means of an autogenous Paulo, Brazil) (Fig. 5b). The desired thickness achieved bone graft harvested from the chin, with an implant after performing the graft can be noted (Fig. 5c). Then, supported prosthetic rehabilitation to be performed at the sharp angles were rounded off in order to avoid possible exposure and/or fenestrations and the area After the pre-operative review, on the day of surgery, was sutured with simple "U"-shaped stiches, using the patient received preventive antibiotic therapy of 5.0 nylon thread (Mononylon, Ethicon, Johnson, São 2g of Amoxicillin (Amoxicilina, Eurofarma, São Paulo, José dos Campos, Brazil). Moreover, the acute edges Brazil) and 5 mg of Diazepam (Valium, Products Roche of the donor area were rounded off; the muscle plane Chemistry and Pharmaceutics, Rio de Janeiro, Brazil) was sutured with Polyglactin thread 910 (Vicryl 5.0, to control anxiety, in addition to verbal tranquilization Ethicon, Johnson, São José dos Campos, Brazil) and the throughout the surgical procedure.
mucosal plane with 5.0 nylon thread (Fig. 5d). After suturing, a compressive micropore dressing was placed (Johnson & Johnson, São José dos Campos, The surgical procedure began with intra-oral antisepsis Brazil) on the chin and upper lip, and kept in place with 0.12% chlorhexidine digluconate (Periogard, for 24 hours. A maintenance therapy prescription was P&G, São Paulo, Brazil), and extra-orally with topical prescribed, with 500 mg Amoxicillin (Amoxicilina, application of 10% PVPI (Riodeine, Rioquímica, São Eurofarma, São Paulo, Brazil) every 8h for 7 days, José do Rio Preto), and apposition of sterile fields. 100mg Nimesulide (Nimessulida, Medley, Campinas, Anesthesia was performed with bilateral regional block Brazil) every 12h for 3 days, in addition to pain of the anterior middle superior alveolar nerve, and of control with 500 mg Sodium Dipyrone (Dipirona the nasopalatine nerve in the maxilla. Sódica, Eurofarma, São Paulo, Brazil) every 6h in case Similarly, bilateral pterygo-mandibular anesthesia of pain. Furthermore, the patient was instructed to was performed by means of the Smith technique perform a careful oral hygiene with moderate topical June 2014; 6(2) ariesdue

Souza F.A. et al. FIG. 4A Access to Delimitation of bone graft.
of bone graft by means of chisels.
FIG. 5B Fixation of bone graft in of bone graft in receptor area.
receptor area.
FIG. 5D suturing donor areas.
mouth washes with 0.12% Chlorhexidine Digluconate described. After exposure of the reconstructed area, (Periogard, P&G, São Paulo, Brazil) starting on the day the 2 bicortical stabilization screws of the graft were after surgery. On the same day, the adhesive prosthesis removed and remodeling of the bone graft in the was bonded with resin cement. reconstructed area was observed (Fig. 6). The bone After 14 days, the sutures were removed and the graft was fixed to the residual bone with absence of wound was inspected to detect any infections and mobility, indicating that incorporation had occurred. dehiscences. The patient was visited at least once per Therefore, in this area, a cylindrical dental implant month until implant surgery.
with a hexagon connection (SIN, Sistema de Implante Nacional, São Paulo, Brazil) measuring 4.0x13.0 mm was placed (Fig. 7). Thus, the patient's adhesive After 6 months the patient was submitted to the same denture was bonded with resin cement, in order to pre-operative and surgical procedures, as previously avoid any interference in the peri-implant mucosa. ariesdue June 2014; 6(2) Reconstruction of traumatized atrophic ridge with bone block graft. A case report • Absence of bone resorption of the graft.
Remodeling of bone graft after 6 There was successful implant osseointegration into the area reconstructed with the autogenous block bone graft harvested from chin, as the clinical and radiographical results satisfied the criteria for evaluation of implant survival suggested by Chiapasco et al. (18): • Absence of persistent pain or dysesthesia; • Absence of peri-implant infection with suppuration; • Absence of vertical or horizontal implant mobility after masticatory force; • Absence of continuous peri-implant radiolucency.
After a follow-up period of 5 years, stability of the result achieved was assessed by means of clinical (Fig. 9) and radiographical (Fig. 10) evaluation.
FIG. 8 Provisional The most conservative treatment for tooth avulsion is tooth reimplantation (5), with success rate ranging from 4% to 50% (19). When failure occurs, it is almost always associated with tooth and bone resorption (4); these bone defects are not only due to dento-alveolar traumas, but also could be a consequence of diseases, surgeries, tooth extractions or physiological resorption that may affect bone quantity, height and volume (7).
The most common surgical procedure for reconstruction Suture removal was performed 7 days after implant retained definitive crown after five years After further 6 months, a new panoramic radiograph was taken to evaluate the implant osseointegration, and the absence of bone resorption. Re-opening of the implant site was performed, and transfer molding with square transfer coping (SIN, Sistema de Implante Nacional, São Paulo, Brasil) was placed. A provisional screw-retained resin denture (Fig. 8) was screwed with a torque of 10 N/cm. Then, a definitive metal ceramic screw-retained denture was delivered.
There was incorporation of the block bone graft harvested from chin in the receptor site (maxilla), as the clinical and radiographical results showed: • Absence of persistent pain, dysesthesia or infection with suppuration in the donor site or reconstructed • Absence of bone graft mobility during implant FIG. 10 Five years fol ow-up panoramic radiograph.
June 2014; 6(2) ariesdue Souza F.A. et al. of such areas is bone grafting, for which materials volume and preventing subsequent bone loss (12, 30). of autogenous, allogeneic, xenogenic and synthetic For this reason, in the case here reported, the implant origin are used. In this case report, autologous bone was placed six months after the bone graft, which was chosen due to its osteogenicity. In the literature, corresponded to the final stage of autogenous bone autogenous bone grafting has been established as the grafts incorporation (8). In relation to the success of best material for reconstructions, because it has live bone grafting procedures, many studies report that immunocompatible bone cells that are essential in the surgical techniques performed, donor site, recovery early stages of osteogenesis (20) and allows a better time, and time of implant placement are also crucial. incorporation into the receptor site (8). Among the donor areas for autografts, intraoral sites are preferred to extraoral ones due to their convenient access, proximity between the donor and receptor sites, lower degree of morbidity after graft harvesting It can be concluded that the autogenous bone graft and minimum discomfort to the patient (21). However, harvested from the chin is a safe and effective option in some cases it is not possible to use intraoral donor for alveolar ridge defects reconstruction, allowing areas, particularly when a large quantity of bone is a further placement of dental implant supporting a required. In case of single tooth area replacement, prosthetic restoration.
partial anterior reconstructions, or sinus membrane elevation in a single maxillary sinus (14, 22), the intraoral donor site provides a sufficient quantity of bone to reconstruct the alveolar defect.
Some authors (23, 24) reported that bone harvested 1. Petti s, Cairella G, Tarsitani G. Childhood obesity: a risk factor for traumatic from the mandible offers benefits inherent to its injuries to anterior teeth. endod. Dent. Traumatol 1997;13:185-188.
embryological origin, such as small loss of grafted bone 2. Petti s, Tarsitani G. Traumatic injuries to anterior teeth in Italian school volume and good incorporation into the host. Moreover, children: prevalence and risk factors. endod. Dent. Traumatol 1996;12:294- others authors (25, 26) showed that a low level of grafted 3. Giannetti l, Murri A, Vecci F, Gatto R. Dental avulsion: therapeutic protocols bone resorption occurs due to the microarchitecture and oral health-related quality of life. eur J Paediatr Dent 2007;8:69-75.
of the mandibular cortical and trabecular bone plates. 4. Andersson l, Andreasen Jo, Day P, heithersay G, Trope M, Diangelis AJ, In the present case report, there was a considerable Kenny DJ, sigurdsson A, Bourguignon C, Flores MT, hicks Ml, lenzi AR, bone graft remodeling due the receptor site condition, Malmgren B, Moule AJ, Tsukiboshi M. International Association of Dental where a high level of bone resorption occurred as a Traumatology guidelines for the management of traumatic dental injuries: result of dento-alveolar trauma. A previous study (27) 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.
5. Araújo MAM, Valera MC. Tratamento Clínico dos Traumatismos Dentários. reported that bone resorption level after alveolar são Paulo: Artes Médicas: eAP-APCD, 1 ed 1999;277p.
ridge (maxillary sites) augmentation with mandibular 6. Klokkevold PR, han TJ, Camargo PM. Aesthetic management of extractions block bone graft represents 20% of initial volume for implant site development: delayed versus staged implant placement. for lateral augmentation and up to 41.5% in case of Pract Periodontics Aesthet Dent 1999;11:603-610.
7. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation procedures The chin region as a donor site in bone grafting inimplant dentistry. Int J oral Maxillofac Implants 2009;24:237-259.
procedures offers a low degree of morbidity (28), 8. Carvalho PsP, Pelizer eP. Fundamentos em Implantodontia. Uma visão contemporânea. 1a ed. são Paulo: Quitenssence. 1 ed 2011;502p.
relatively good bone quantity and quality due to 9. Cricchio G, lundgren s. Donor site morbidity in two different approaches to the presence of cortical and medullary bone (21), in anterior iliac crest bone harvesting. Clin Implant Dent Relat Res 2003;5:161- addition to a small loss of bone volume when grafted. In this case report, the chin was used as donor site due 10. Nkenke e, stelzle F. Clinical outcomes of sinus floor augmentation to the cortical-medullary anatomic characteristics of for implant placement using autogenous bone or bone substitutes: a the graft, thus providing a reconstruction with greater systematic review. Clin oral Implants Res 2009;20:124-133.
bone volume in the reconstructed area, where there 11. Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone Joint surg Am 2011;93:2227-2236.
was extensive bone resorption.
12. Marx Re, Morales MJ. Morbidity from bone harvesting in major jaw For a good integration of the grafted bone tissue into reconstruction: a randomized trial comparing the lateral anterior and the receptor bed and its good vascularization (29), the posterior approaches to the ilium. J oral Maxillofac surg 1988;46:196-203.
surgical site should be immobilized, avoiding obstacles 13. Paleckis lGP, Picosse lR, Vasconcelos lw, Carvalho PsP. enxerto ósseo: por during its healing phase. The placement of a temporary que e quando utilizá-lo. Implant News 2005;2:369-372.
prosthetic (adhesive fixed denture), both during graft 14. Kahn A, shlomi B, levy y, Better h, Chaushu G. The use of autogenous incorporation and implant osseointegration, allowed block graft for augmentation of the atrophic alveolar ridge. Refuat hapeh Vehashinayim 2003;20: 54-64.
healing of the treated site without interferences or 15. Misch, Ce, Dietsh F. Bone-grafting materials in implant dentistry. Implant Implant placement soon after incorporation of the 16. yates DM, Brockhoff hC, Finn R, Phillips C. Comparison of intraoral graft has a stimulating effect on bone, maintaining its harvest sites for corticocancellous bone grafts.Int J oral Maxillofac surg ariesdue June 2014; 6(2) Reconstruction of traumatized atrophic ridge with bone block graft. A case report 24. Zins Je, whitaker lA. Membranous vs. endochondral bone autografts: 17. smith Ae (1918) Apud: steadman FsTJ. Anestesia local en odontología. implications for craniofacial reconstruction. surg Forum 1979;30:521-523.
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25. Misch CM, Misch Ce, Resnik RR, Ismail yh. Reconstruction of maxillary 18. Chiapasco M, Romeo e, Coggiola A, Brusati R. long-term outcome of alveolar defects with mandibular symphysis grafts for dental implants: a dental implants placed in revascularized fibula free flaps used for the preliminary procedural report. Int J oral Maxillofac Implants 1992;7:360- reconstruction of maxillo-mandibular defects due to extreme atrophy. Clin oral Implants Res 2011;22:83-91.
26. ozaki w, Buchman G. Investigation of the influence of biomechanical force 19. Gonda F, Nagase M, Chen RB, yabata h, Nakajima T. Replantation an analysis on the ultrastructure of human sagittal craniosynostosis. Plast Reconstr of 29 teeth. oral surg oral Med oral Pathol 1990;70:650-655.
20. Guskuma Mh, hochuli-Vieira e, Pereira FP, Garcia-Júnior IR, okamoto 27. Cordaro l, Amadé Ds, Cordaro M. Clinical results of alveolar ridge R, okamoto T, Magro-Filho o. evaluation of the presence of VeGF, augmentation with mandibular block bone grafts in partially edentulous BMP2 and CBFA1 proteins in autogenous bone graft: histometric and patients prior to implant placement. Clin oral Implants Res 2002;13:103-11.
immunohistochemical analysis. J Craniomaxillofac surg 2013;doi: 10.1016/j.
28. schliephake h, Kroly C, wustenfeld h. experimental study by fluorescence jcms.2013.05.022. [epub ahead of print].
microscopy and microangiograph of remodeling and regeneration of bone 21. Misch CM. Comparison of intraoral donor sites for onlay grafting prior to inside alloplastic contour augmentation. Int J oral Maxillofac Implants implant placement. Int J oral Maxillofac Implants 1997;12:767-776.
22. Mathias MV, Bassanta AD, saturnino AR, simone Jl. enxertos Autógenos 29. Branemark PI, Adell R, Albrektsson T, lekholm U, lundkvist s, Rockler B. com sítios Doadores na Cavidade oral. RGo 2003;51:249-256.
osseointegrated titanium fixtures in the treatment of edentulousness. 23. Rabie AB, Dan Z, samman N. Ultrastructural identification of cells envolved in the healing if intramembranous and endochondral bones. Int J oral 30. lidstrom RD, symington JM. osseointegrated dental implants in Maxil ofac surg 1996;25:383-388.
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June 2014; 6(2) ariesdue


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