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Technical Note

Augmentation of residual alveolar bone height with tissue

engineering for dental implant placement

Balaji SM

Director and Consultant, Balaji

Dental and Craniofacial Hospital,
ABSTRACT
Teynampet, Chennai,
Tamil Nadu, India
Received : 24-04-14
Review completed : 07-06-14
Accepted : 24-06-14
The challenge of correcting deficient vertical alveolar height for dental implant placement has
been there since dental implants came in to regular clinical placement. The ability of various
methods to increase the residual alveolar height has met with varying results. The primary
reason is that the techniques were not quite successful in maintaining the required residual
alveolar height. Use of Bone Morphogentic Protein, especially rhBMP-2 has been met with high
degree of success in deficient vertical alveolar height in a mandibular ridge. The demonstration
of this using a case has been presented here.
Key words: Ameloblastoma, bone morphogenetic proteins, dental implant, tissue engineering,
vertical bone augmentation

Large mandibular defect as a consequence of tumor removal
leads to functional and esthetic compromise. Such defect
could lead to difficulties with speech and eating, loss of
support, loss of vertical dimension, an aged face and a
reduced range of expression, whereas prosthesis would
lack insufficient retention. Given this situation, the routine
activities of patient are compromised. Dental implants
offer a permanent and reliable solution for this problem.
Widespread use of dental implant system and better advances
in preprosthetic surgery has led to better results when such
implant systems are used. However, the vertical height
of the residual mandibular bone will be a problem in the
situation. Surgical methods for vertical height gaining in this
situation would be autogenous bone block grafting as the only
possibility as it has the maximum osteogenic potential and
remains the most reliable method.[1] However, such method
has a 0-25% chance of the grafted bone being resorbed most
of it after connecting implant abutments.[2]
Bone morphogenetic proteins(BMPs) are a group of
osteoinductive signaling protein molecules that mediate
Address for correspondence:
Dr.Balaji SM
Email:smbalaji@gmail.com
Access this article online
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PMID:
***
DOI:
10.4103/0970-9290.138360
410
bone volume, skeletal organogenesis and bone regeneration.
These molecules, particularly the BMP2 act at the cellular
level causing proliferation, differentiation and extracellular
osteomatrix formation. They also attract and stimulate the
adult mesenchymal stem cells to form bone. This eliminates
the need for unreliable alloplastic substitutes, risky
xenografts as well as issues related to autografts. BMP2 can
be synthesized by recombinant technology. This manuscript
intends to produce a novel way to increase the vertical
height of a postsurgical defect of mandible in a novel way
using only rhBMP-2 along with conventional way.
CASE REPORT
A 29yearold male sought treatment for a wellcircumscribed
ameloblastoma of mandible. The growth was present for
about 2years. At the presentation, the growth measured
7.524.8cm in maximum dimension. Cortical bone was
eroded in four different places [Figure 1a and b].
After investigations, surgical planning was performed.
Considering the benign biological potential of the tumor,
an enbloc removal of the tumor with preservation of
lower cortex of mandible and sufficient wide margin
along the proximal side was planned. In areas of breach,
complete removal of adjacent soft tissues was also performed
[Figure 2a and b]. The posttreatment functional rehabilitation
was also considered. As the defect was huge, immediate
functional replacement was not a possibility. In an attempt
to restore normalcy during excisional surgery, the defect
was reconstructed with rib graft. The graft was secured with
titanium screws [Figure 3a and b] overlaid with rhBMP-2
[Figure 4] as per then evidence.[3] As the vertical height of bone
Indian Journal of Dental Research, 25(3), 2014
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rhBMP2 and ridge augmentation Balaji
a b
Figure1: (a) Preoperative intraoral view, (b) CT scan showing
ameloblastoma in right mandible
a b
Figure3: (a) Rib graft harvested (b) Graft secured with titanium screws
Figure5: Reconstructed mandibular alveolar ridge after complete
healing
Figure7: Rehabilitation completed with prosthesis
would decrease with implant loading[2] placement of rhBMP-2
was considered along with implant placement. Later, after
adequate healing [Figure 5], six dental implants(Nobel Biocare,
Sweden, 13mm length,diameter) of appropriate length
were chosen and fixed [Figure 6a and b] after subperiosteal
placement of rhBMP2 in Absorbable Collagen Sponge carrier.
The entire periosteum had been previously dissected along
with tumor. The implants were allowed to heal and after
3months period, the super structures were placed as per
standard procedure [Figure 7]. The patient is being followed
for about 30months without any complications.
DISCUSSION
It has been shown through animal studies that vertical bone
augmentation(VBA) was enhanced by the application of
Indian Journal of Dental Research, 25(3), 2014
a b
Figure2: (a) En-bloc removal of the tumor, (b) Ressected portion of
the mandible
Figure4: Reconstruction completed with rhBMP-2
a b
Figure6 (a and b): Dental Implants placed in position
rhBMP2 with corticocancellous human bone block[1] as
observed in current report. Replacement of such postsurgical
defect of mandible for complete functional rehabilitation
requires complex treatment such as microvascular surgery[4]
or stem cell therapy,[5] which are at their preliminary
stages. Moreover, these procedures are time consuming
and the economic viability is being tested. There were no
longterm data on such therapy or published literature at
the time of the case rehabilitation. Use of rhBMP-2 with
bone graft for lost orofacial structures has been in regular
practice.[6] Successful use of rhBMP-2 aided VBA appeared
in maxillofacial literature recently.[7]
In the present case, the role of rhBMP-2 is probably to
compensate for the loss of vertical bone height that usually
accompanies the bone grafting in VBA. The osteogenic
potential of rhBMP-2 was utilized for this purpose. The
autologous bone graft provided the much needed osteogenic
signals, rhBMP-2 caused chemotaxis, both leading to
recruitment and aggregation of monocytes at the surgical
site and later its differentiation into osteoblastic cells.
Osteoblasts later differentiated into definitive osteoblastic
cells, which progressively laid the matrix. The matrix later
calcified. All these sequential, essential healing process
was occurring in the presence of the dental implants. This
ensured successful remodeling of the bone causing the
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rhBMP2 and ridge augmentation Balaji

much needed osseointegration. The 3months postoperative REFERENCES

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Wide resection and stripping of periosteum [8] ensured
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reconstructed mandible. The technique, mentioned herein
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How to cite this article: Balaji SM. Augmentation of residual alveolar bone
height with tissue engineering for dental implant placement. Indian J Dent
Res 2014;25:410-2.
Source of Support: Nil, Conflict of Interest: None declared.

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412 Indian Journal of Dental Research, 25(3), 2014