JDSOR
Ridge Augmentation by 10.5005/jp-journals-10039-1022
CASE REPORT
Ridge Augmentation by Guided Bone
Regeneration Technique
1
Kausar Parwez Khan, 2Shankar T Gokhale, 3Mohd Amjad Tahseen, 4Sidharth Shankar, 5Garima Singh, 6Priya Saxena
ABSTRACT
Resorption of the edentulous or partially edentulous alveolar
ridge or bone loss due to periodontitis or trauma frequently
com­promises fixed prosthesis placement. Therefore, augmen­
tation of an insufficient bone volume is often indicated to attain
predictable long-term functioning and an esthetic treatment
outcome. Guided bone regeneration (GBR) techniques have
been used for vertical and horizontal ridge augmentations with
accep­table results. The principle of guided bone regeneration
can be applied for localized ridge augmentation in a staged
app­roach. The technique is based on the principle of guided
bone regeneration utilizing barrier membranes. In the present
article, the GBR surgical procedure is presented. In addition, the
different aspects of the surgical technique needed to achieve a
predictable success are also discussed.
Keywords: Guided bone regeneration, Guided tissue rege­ne­
ration, Ridge augmentation, Bone graft, Membrane.
How to cite this article: Khan KP, Gokhale ST, Tahseen
MA, Shankar S, Singh G, Saxena P. Ridge Augmentation by
Guided Bone Regeneration Technique. J Dent Sci Oral Rehab
2014;5(2):99-102.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Resorption of alveolar bone following loss of teeth is an
inevi­­table outcome. In cases with trauma or congenital
defects, this resorption is further increased. The term ‘loca­
lized alveolar ridge defect’ refers to volumetric deficit of
bone and soft tissue within the alveolar process. The most
commonly used classification for ridge defect is the Seibert’s
nomen­clature. Another classification was given by Allen that
classifies the defects from Type A to Type C (Table 1).1,2
Various techniques for ridge augmentation include
distra­c­tion osteogenesis, guided bone regeneration and
piezo­­surgery. The distraction osteogenesis and piezosurgical
tech­ni­ques are more invasive techniques compared to guided
1,3-6
Postgraduate Student, 2Professor
1-6
Department of Periodontology and Implantology, Institute of
Dental Sciences, Bareilly, Uttar Pradesh, India
Corresponding Author: Kausar Parwez Khan, Postgraduate
Student, Department of Periodontology and Implantology, Institute
of Dental Sciences, Bareilly, Uttar Pradesh, India, e-mail: kausar
5983@gmail.com
Journal of Dental Sciences and Oral Rehabilitation, April-June 2014;5(2):99-102
Guided Bone Regeneration Technique
bone regeneration (GBR) procedure. Guided bone regenera­
tion is based on principles of guided tissue regeneration3
(GTR). Guided tissue regeneration was first developed in the
early 1980s by Nyman et al.3 Melcher described the concept
of selective cell repopulation of defects to enhance healing.4
Exclusion of fast-growing epithelium and connec­tive tissue
from a periodontal wound for 6 to 8 weeks allows the slower
growing tissues, including osteoblasts, cementoblasts and
perio­dontal ligament cells occupy the space adjacent to the
tooth.3,5 Guided bone regeneration concept employed the
same principles of specific tissue exclusion but was not
asso­­ciated with teeth. Thus, the term applied to this tech­
nique was GBR. This case report presents GBR proce­dure
for management of alveolar ridge defects and its out­come
after 6 months.
Principles of Guided Bone Regeneration6
To achieve better clinical outcomes, the GBR barrier should
possess the following properties:
Cell Exclusion
In GBR, the barrier membrane is used to prevent gingival
fibroblasts and/or epithelial cells from gaining access to the
wound site and forming fibrous connective tissue.
Tenting
The membrane is carefully fitted and applied in such a man­
ner that a space is created beneath the membrane, completely
isolating the defect to be regenerated from the overlying
soft tissue.
Scaffolding
This tented space initially becomes occupied by a fibrin clot,
which serves as a scaffold for the ingrowth of progenitor
cells. In GBR, the cells will come from adjacent bone or
bone marrow.
Stabilization
The membrane must also protect the clot from being
disturbed by movement of the overlying flap during healing.
It is therefore often, but not always, fixed into position with
sutures or mini bone screws.
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Kausar Parwez Khan et al

Table 1: Seibert’s and Allen’s classification of ridge defects combined horizontal and vertical (Seibert’s Class III).The
Criteria for classification Seibert’s Allen’s 2-dimensional periapical radiograph of the patient showed
nomenclature nomenclature that there was association of osseous defect comprising of
Horizontal or buccal Class I Type B
tissue loss with normal
differential bone loss in the same region (Fig. 2).
ridge height Later, comprehensive treatment plan was done, after
Vertical tissue loss with Class II Type A 4 weeks of completion of phase I therapy, the case was
normal ridge height
scheduled for surgical procedure in anticipation of ridge
Combined horizontal and Class III Type C
vertical bone loss augmen­tation. Full thickness flap was raised by giving
crestal incision in the region of the missing tooth 21 and
Framework
continued by giving sulcular incision to the adjacent teeth
Where necessary, as in nonspace maintaining defects, such as for proper accessibility (Fig. 3). After complete debridement
dehiscence or fenestration, the membrane must be supported and isolation, defect was found to be of both horizontal and
to prevent collapse. vertical pattern falling under Siebert’s Class III classifica­
tion of volumetric deficit of bone and soft tissue within the
CASE REPORT
alveolar process (Fig. 3). An AlloplastBioGraft bone graft
An 18-year-old boy reported to the department of perio­ was placed into defect and care was taken not to overfill
dontics with the chief complaint of replacement of upper the defect and over the grafted area, resorbable guided
left front tooth. The patient gave the history of trauma 6 tissue regeneration membrane (Periocol GTR) was stabi­
months back following that the tooth got avulsed. The patient lized by giving periosteal suturing (Figs 4 and 5). Finally
was systemically healthy. On intraoral examination, upper flap was closed by simple interrupted sutures and perio­
left central incisor was found missing and ridge deficiency dontal dressing Coe-Pak was given over the surgical site
was also seen in the same region (Fig. 1). Ridge defect was (Figs 6 and 7). Postoperative instructions were given and

Fig. 1: Preoperative image showing ridge defect in 21 region Fig. 2: Preoperative IOPAR of 21 region

Fig. 3: Mucoperiosteal flap reflection showing ridge defect Fig. 4: Placement of bone graft (BioGraft HA)

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Ridge Augmentation by Guided Bone Regeneration Technique

Fig. 5: Placement of GTR membrane Fig. 6: Placement of suture

Fig. 7: Periodontal dressing placed Fig. 8: Postoperative view after 1 week

Fig. 9: Postoperative view after 6 months Fig. 10: Radiographic view after 6 months of surgery

also adviced Amoxicillin (500 mg), three times daily for 5 He was recalled after 1 and 6 months for further evaluation
days, and Ibuprofen (400 mg) thrice daily was prescribed for and maintenance showing appre­ciable improve­ment in ridge
3 days along with 10 ml of chlorhexidine (0.2%) mouthwash both vertically as well as labiolingually (Figs 8 and 9). Post­
twice daily for 14 days. operative radiograph (6 months) also showed appreciable
The patient was recalled after 1 week for suture removal. improve­ment in bone regeneration (Fig. 10). Then finally
Healing was satisfactory with no postsurgical compli­cations. fixed prosthesis was given to the patient (Fig. 11).
Journal of Dental Sciences and Oral Rehabilitation, April-June 2014;5(2):99-102 101
Kausar Parwez Khan et al
Fig. 11: Prosthesis placement after 6 months
DISCUSSION
The most commonly seen localized alveolar ridge defects are
the combined Class III defects (56% of cases) followed by
horizontal Class I defects (40% of the cases). Vertical defects
were reported to be found in 4% of the patients.7 Large
vertical and horizontal bone defects pose a prosthodontic
challenge as it is difficult to restore esthetics and function
along with the complete closure of the defect. Such clinical
conditions are not successfully treated by conventional fixed
or removable prosthesis alone.8 Guided bone regeneration
can be successfully used in either a simultaneous approach
or a staged approach.9 Four prerequisites need to be fulfilled
for predictable success with GTR:7
a. Achievement of primary soft tissue healing: When a soft
tissue dehiscence occurs, the exposure of the membrane
leads to its contamination with bacteria from the oral
cavity and frequently to an infection in the membrane
site.
b. Use of an appropriate barrier membrane: The structure
of the membrane should not allow the penetration of cells
through the membrane, which is an important factor for
its success as a physical barrier.
c. Stabilization and dose adaptation of the membrane to
the surrounding bone: Close adaptation is necessary to
achieve a sealing effect to prevent the ingrowth soft tissue
cells derived from the gingival connective tissue, because
these cells are able to compete with bone-forming cells in
the created space underneath the membrane. In addition,
stabilization of the membrane is useful for maintaining
close adaptation of the membrane to the bone during
wound closure.
d. Creation and maintenance of a secluded space: The use
of an appropriate supporting device is useful in surgical
sites without an intact buccal bone wall for natural space
making.
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Autogenous bone grafts stabilize the blood clot, are bio­
com­­patible and absolutely safe from the standpoint of disease
transmission, and have good space maintaining capacity.
Additional factors important for achieving complication-
free primary soft tissue healing are meticulous and careful
handling of the soft tissues, precise wound closure with matt­
ress and interrupted sutures, and appropriate post­operative
treatment and medication.7 Mineralized and demi­ne­ralized
freeze-dried bone allografts have been utilized as a mem­
brane-supporting device in ridge augmentation procedures
with encouraging clinical results.10 For achie­ving predictable
results, a sufficiently long healing period is important. Sites
of early membrane removal attain less gain in bone height.11
CONCLUSION
The guided bone regeneration procedure is a surgical proce­
dure of choice for localized hard tissue ridge augmentation.
A predictable result can be achieved if the prescribed surgi­
cal protocol is followed. However, the surgical procedure is
technically demanding and requires a precise and systematic
surgical technique. Furthermore, the method is not comple­
tely developed yet. Therefore, the GBR technique should be
used with extreme care for predictable results.
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