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Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 977-981

Three-dimensional bone grafting in dental implantology using autogenous bone ring transplant: Clinical outcomes of a one-stage technique

1 Departments of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ege University, Izmir, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Izmir Democracy University, Izmir, Turkey
3 Department of Prosthodontics, Faculty of Dentistry, Ege University, Izmir, Turkey

Date of Acceptance18-Feb-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. E Adali
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Izmir Democracy University, PO Box 35140, Karabaglar, Izmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_652_18

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Background: An insufficient bone volume at the maxillary anterior region often restricts dental implant treatment and commonly leads to poor aesthetic outcomes. The defective site requires bone grafting as an initial surgical intervention before dental implant placement. In dental implantology, reconstructing osseous defects using autologous block bone grafts, biomaterials, or a combination of both is a routine surgical procedure. This study aims to evaluate the efficacy of autogenous, symphyseal, bone ring block grafts after the augmentation of defective sockets and clinical application of grafts in the maxillary anterior region with immediate insertion of a dental implant in a single surgical procedure. Materials and Methods: The study included eight patients (five females and three males) with 12 defective sockets. The technique included removing the bone from the chin region for transplant, fitting the three-dimensional bone rings in the prepared sockets of the maxillary anterior region, and screwing the dental implants through the rings. Patients underwent postoperative clinical examinations every day during the first week and then every month for 6 months. Results: In two cases, the wound dehisced but healed by secondary intervention during the follow-up period. In one case, the ring graft sequestrated because of infection in postoperative month 2, the osseous defect was reconstructed with biomaterials. The remaining cases healed with no infection, and no other case failed during the first year. Conclusion: This technique showed promising and advantageous results, and thus, could be an alternative treatment to other autogenous graft techniques, particularly for defective sockets.

Keywords: Autogenous bone block, bone ring technique, ring block graft

How to cite this article:
Yuce M O, Adali E, Turk G, Isik G, Gunbay T. Three-dimensional bone grafting in dental implantology using autogenous bone ring transplant: Clinical outcomes of a one-stage technique. Niger J Clin Pract 2019;22:977-81

How to cite this URL:
Yuce M O, Adali E, Turk G, Isik G, Gunbay T. Three-dimensional bone grafting in dental implantology using autogenous bone ring transplant: Clinical outcomes of a one-stage technique. Niger J Clin Pract [serial online] 2019 [cited 2020 May 27];22:977-81. Available from:

   Introduction Top

In the maxillary anterior region, performing bone augmentation before dental implant placement to achieve an adequate bone volume has become routine with predictable and good aesthetic outcomes.[1],[2] Tooth loss owing to trauma, periodontal disease, or pathological malformation is followed by a natural bone resorption process, leading to reduced height and width of the alveolar crest. Nevertheless, because of the long-term absence of a tooth, the volumes of hard and soft tissues become deficient. Horizontal defects can be reconstructed with predictable clinical results; however, reconstructing vertical defects can be very challenging.[2]

Various different techniques have been described for reconstructing hard tissue defects such as onlay bone grafting, guided bone regeneration, and distraction methods.[3],[4],[5] An ideal augmentation technique must be selected considering the morphology of the defect at the planned implant site. A two-stage procedure is commonly indicated for an insufficient bone volume in the alveolar ridge where dental implant treatment is planned.[6],[7]

Reconstructing localized alveolar defects in the aesthetic region requires horizontal and/or vertical augmentation of autologous bone grafts, which is considered the gold standard of bone grafting procedures.[1],[5],[8] Because of its osteoinductive, osteoconductive, and osteogenic properties, autogenous bone block grafting is ideal for three-dimensionally reconstructing alveolar defects.[9]

The selection of donor sites depends on the required volume of bone replacement. Extraoral sites, such as calvarial bone, iliac crest, ribs, cranium, and proximal tibia, are used when a significant volume of bone is required for reconstruction. The mandibular symphysis, ramus, and maxillary tuber region are suitable as local/intraoral donor sites for corticocancellous bone grafts.[5],[10],[11]

The bone ring technique permits three-dimensional reconstruction of alveolar bone defects in the aesthetic zone with ring-shaped autogenous bone grafts harvested from the symphysis and simultaneous dental implant placement in a one-stage procedure. We hypothesized that bone ring technique using autogenous, symphyseal, bone ring block grafts in the esthetic zone will result a predictable and successful outcome with no incidence of postoperative infection after 1 year clinical evaluation.

   Materials and Methods Top

The study cohort included eight patients (five females and three males) who required dental implant rehabilitation in the maxillary anterior region. All selected patients had a bony defect at the site of the planned implants and all were clinically and radiologically indicated for horizontal and vertical bone augmentation. Patients with a history of hemorrhagic diathesis, use of bisphosphonates, infectious diseases such as human immunodeficiency virus infection, and irradiation to the head and neck region were excluded. The study was in accordance with the Helsinki Declaration, and the study protocol was approved by the institutional ethics committee before patient selection (26/10/2015, registration number: 15-9/8).

Before surgery, all selected patients signed consent forms that included details regarding the surgery and possible complications, and all patients underwent periodontal and dental examinations to achieve clinically acceptable oral hygiene. Radiographic examinations were performed using cone beam computed tomography with the Kodak Dental Imaging Software (Kodak 9000 3D CBCT system, Kodak Carestream Health, Trophy, France). The dimensions of the recipient site and the association of the remaining apical bone with the nasal floor and/or maxillary sinus were evaluated to determine the required autogenous bone volume for the transplant.

All procedures were conducted by one experienced surgeon under local anesthesia (Ultracaine DS Forte, Sanofi-Aventis; articaine hydrochloride 4%; epinephrine, 1:100000). A midcrestal incision with a vertical releasing incision was made at the recipient site and the full thickness of the buccal mucoperiosteal flap was raised to expose the defective alveolar ridge [Figure 1]. The defective socket was measured using a trephine bur (Meisinger USA LLC, Centennial, CO, USA) [Figure 2]. In all patients, the chin region was selected as the donor site. An incision was made between the mandibular canine teeth and 5 mm below the attached gingiva and intraoral sulcular, and the flap was then reflected. A 1-mm internal diameter trephine bur was selected to remove the bone cylinder, this diameter was more than that of the defect in the recipient site. While performing osteotomy at the donor site, attention was paid to the tips of the mandibular incisors. After creating the bone ring discs, implant osteotomy was performed in the centre of the ring graft under copious irrigation, while being careful not to perforate the lingual side [Figure 3]. A ring lifter was then used to harvest the ring block graft, which was kept in a sterile saline solution until the recipient site was prepared. The defective area was first prepared using the trephine bur to fit the bone ring transplant to the recipient area. Using the bone ring graft as a drill guide, the remaining apical bone of the defective socket was prepared using instruments included with the Ankylos implant system (Dentsply Sirona, York, PA, USA). After positioning the graft, the planned implant was inserted through the bone ring and then fixed and immobilized [Figure 4]. All implants were checked for initial stability. Finally, a cover screw was secured, and the sharp edges of the bone graft were smoothed by rounding the ring graft margin with a rounded burr. Then, the augmented area was covered with a barrier membrane for extra protection against the bone resorption process, and the area was primarily closed. Antibiotics (amoxicillin 1000 mg, every 12 h), analgesics, and anti-inflammatory drugs (naproxen sodium 550 mg, every 8 h) were prescribed for 7 days postoperatively. Patients underwent clinical examinations every day for the first week and then every month for 6 months postoperatively to check for the presence or absence of infection, dehiscence, and soft tissue shrinkage.
Figure 1: The defective alveolar ridge

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Figure 2: Measurement of the defective socket using a trephine burr

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Figure 3: Implant osteotomy was performed in the centre of the ring graft under copious irrigation

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Figure 4: Final position of the implants and autogenous ring grafts

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   Results Top

The study cohort included eight patients (five females and three males) with 12 defective sockets [Table 1]. All defective sockets were in the maxillary anterior region, and the chin region was selected as the donor site for all cases. A total of 12 bone ring grafts were harvested: Seven with a diameter of 7 mm and five with a diameter of 6 mm. All harvested bone ring grafts were rigidly fixed in place with the planned implant. All inserted implants were initially stable immediately after surgery.
Table 1: Demographic characteristics of the study patients

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In the 2nd postoperative month, one bone ring graft failed because of infection. This patient had lost his teeth because of periodontal disease. However, because there was sufficient volume of residual bone, the implant had osseointegrated into the apical zone and the defective area was filled during a second surgical intervention. In the 6th postoperative month, a panoramic examination was conducted, and surgery for placement of the healing cap was performed under local anesthesia for all patients. After 1 week, the healing cap was removed, and after a sequence of prosthetic treatments, a definitive restoration was successfully placed. All implants were followed up for 1 year after prosthetic restorations to evaluate the implant durability after loading [Figure 5].
Figure 5: All implants were followed up for 1 year after prosthetic restorations to evaluate the implant durability after loading

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   Discussion Top

Although an inadequate bone volume in defective sockets limits successful dental implant placement, improvements in clinical techniques and biomaterials have increased the indications for dental implant reconstruction.[2],[4],[12] A number of techniques such as distraction osteogenesis, guided bone regeneration, and onlay grafting have been described for augmenting bony defects. Autogenous bone transplantation is the gold standard for reconstruction.[13],[14],[15],[16]

Autogenous bone grafts, which have osteoinductive, osteogenic, and osteoconductive properties, undergo less resorption and have high concentrations of bone morphogenetic proteins and growth factors.[9],[17] Because of the disadvantages of harvesting extraoral bone grafts, such as greater resorption, morbidity at the donor site, need for general anesthesia, extended surgical duration and prolonged hospitalizzation, intraoral donor sites have become more popular than extraoral donor sites.[10] In addition, intraoral harvesting of the donor bone is less stressful for the patient; thus, intraoral donor sites are commonly preferred by surgeons for bone transplantation. The selection of an intraoral donor region is generally dependent on the required volume of replacement bone and on the anatomical situation of the patient. In this study, we preferred the chin region as the donor site because of easier access and a lower morbidity incidence.[18] Moreover, a graft from the chin contains more cancellous bone than other intraoral donor sites provides a greater amount of osteoprogenitor cells.[19],[20] Three to five bone rings for intraoral augmentation can be obtained from the chin region. However, attention must be paid to adjacent vital structures, including dental roots, nerves, and vessels.[21] In this study, no postoperative complication occurred in any patient because of harvesting a symphysis graft.

The bone ring technique, first reported by Giesenhagen and Yüksel in 2010,[22] provides three-dimensional augmentation with simultaneous implant placement in a one-stage procedure.[4],[5],[23] Moreover, the treatment period required for this technique is shorter than with that for other onlay grafting techniques because it does not require a second surgical intervention after graft consolidation.[4],[14] While preparing the implant bed, the surgeon uses two trephine cutters of different diameters to provide a snug fit of the bone ring transplant within the recipient site. The placed implant provides stabilization and fixation of the transplanted bone ring graft so that there is no need for additional fixation with osteosynthesis screws.[4],[5],[23]

Proximity and stabilization of the onlay graft/recipient site are vital for adequate healing of the graft.[24] Streckbein et al. reported that partial harvesting of cylindrical grafts from the retromolar region of the mandible and preparing the recipient site according to the graft geometry maximized the contact surface of the graft and recipient site.[10] To ensure success of the one-stage technique, graft healing is very important because graft failure implies implant failure.[4],[5] Hence, an onlay graft must be rigid and immobile to prevent bone volume loss. Particularly in the aesthetic region, bone ring grafts enhance the soft tissue contour by increasing the bone volume. The technique used in this study aimed to achieve a satisfactory outcome in the defective sockets in the maxillary anterior region. Omara et al. reported optimal wound healing at both the donor and recipient sites in all patients, with no incidence of postoperative infection.[4] Similarly, in this study, the donor and recipient sites achieved normal postoperative healing, thus the hypothesis of this study was accepted. However; one patient developed an infection in the postoperative 2nd month because of wound dehiscence. In this case, although the bone ring graft was mobile, the dental implant had osseointegrated into the apical zone. Because the bone ring graft completely failed, a second surgical intervention was performed to fill the defective area with an allograft. A clinical examination conducted after 1 week found no signs of erythema, suppuration, or infection.

Omara et al. examined the bone ring transplant cases radiographically immediately and at 6 months postoperatively. They measured crestal bone changes and reported minimal crestal bone resorption in the linear measurement during the follow-up period.[4] Distinctively, in this study, bone ring technique could be only clinically evaluated, radiological evaluations could not be included because of the limitations of the study.

In conclusion, this one-stage technique provides a more practical approach for autogenous bone grafting. However, future studies are required to further evaluate the advantages and disadvantages of this technique, as well as better assess the long-term clinical outcomes.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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