Augmentation of Narrow Anterior Alveolar Ridge Using Autogenous Block Onlay Graft in a Pediatric Patient: A Case Report

INTRODUCTION

Traumatic tooth loss is frequently encountered in pediatric patients. It often leads to alveolar resorption. There can be two possible reasons for this. First, it could be due to the avulsion of bone substance during an accident. Second, as resorption of the alveolar crests that happen subsequently following intraosseous stimulation of PDL.¹ If these alveolar defects are left untreated, it can cause further bone loss and atrophy of the ridges leading to collapse of the arch therefore, restoration of these defects is of utmost importance to limit further destruction of alveolar bone, thereby providing more comprehensive treatment in the near future.² Removable partial denture remains the treatment of choice to replace the missing anterior teeth but the fact that it adds onto the residual alveolar resorption,³ has shifted the focus of treatment modality to other alternatives. One such widely used treatment option includes dental implant but implant placement is usually restricted to patients with completed craniofacial growth.⁴ It must be delayed until the age of 15 years for girls and 18 years for boys⁵ except in severe cases of ectodermal dysplasia.⁴ However, one of the main prerequisites for dental implant placement being adequate bone in the traumatized area⁵ also necessitates the augmentation of alveolar bone using reconstructive procedures aiding in structural and functional restoration.

Various methods using varied bone grafting materials have been employed in literature for reconstructing deficient ridges, namely autogenous grafts, bone substitutes, and membrane techniques. However, by far autogenous grafts have remained the “gold standard” in repairing atrophied alveolar and bone defects.⁶ This is because there is less risk of graft rejection and their excellent osteoinductive properties.

Moreover, experimental studies have shown that when placed as block onlay grafts, intramembranous bone grafts are more advantageous as they show better volume steadiness and also cause less postoperative resorption when compared with endochondral bone obtained from the iliac crest.^6,7 This article presents a case report showing block onlay grafts extracted from mandibular symphysis used for augmenting the alveolar ridge to reconstruct the alveolar anatomy and improve esthetics as well as facilitate adequate bone density with superior bone quality for implant prosthesis in the future.

CASE DESCRIPTION

A 12-year-old boy reported to the Department of Pediatric and Preventive Dentistry, AB Shetty Memorial Institute of Dental Sciences with the chief complaint of missing teeth and depression in the front teeth area during a fall from a bicycle 2 years ago and wanted an esthetic restoration for the same. Clinical examination revealed missing 11 and 12 associated with horizontal alveolar atrophy causing a wide depression on the side of the missing teeth (Fig. 1), confirmed radiographically (Ortho Pantomogram) (Fig. 2). On bone mapping, the width of the bone was only 4 mm which indicates severe bone resorption following trauma. Considering the huge amount of resorption undergone due to trauma; we decided to augment the ridge horizontally to restore alveolar anatomy after discussing with patient and his parents so as to provide a comprehensive treatment in the near future.

DISCUSSION

Loss of incisors and canines often tends to cause considerable loss of alveolar bone, chiefly in sagittal dimensions. Therefore, it is imperative to augment both hard and soft tissues to attain a functional restoration. Initial clinical investigation revealed that bone grafts yield a viable alternative for the reestablishment of alveolar defects before dental implant placement.⁸ In-depth clinical and radiological examination is required to rule out the extent of bone loss first, and then strategize a suitable bone augmentation procedure. Several bone grafting techniques are accessible for reconstructing the deficiencies of alveolar ridges, namely autografts, allografts, and xenografts. Autogenous bone grafts are advocated in bone augmentation procedures because of their osteogenic and osteoinductive potential.⁹ Autologous grafting techniques such as compressed particulate cancellous bone and marrow, corticocancellous blocks, and cortical grafts have been used successfully to restore alveolar defects.⁹ Mandibular grafts are intramembranous in source exhibit increased revascularization and healing than endochondral bone grafts.⁹ Since they are cortical bone in nature, they show little resorption and excellent incorporation on the recipient site.⁶ Intraoral grafts require less surgical and analgesia time since the donor as well as the recipient site are from the same operating field, thereby offering reduced morbidity in graft extraction when compared with extraoral donor sites. Block graft is associated with minimal resorption and requires the usage of an overlying membrane only when the sizes of the graft are inadequate. The outcome of mandibular block grafts recognized in the literature is advantageous and appreciable regardless of certain restrictions like the patient’s postoperative temporary neurosensory and functional disturbances.⁹ Block graft is extracted from different anatomical regions such as mandibular symphysis, body, and ramus, therefore, resulting in altered graft morphology and volume.⁹ Hence, thorough anatomical and clinical evaluation is required for the selection of site, to get the superlative volume and form of bone that have a close similarity with the defect morphology. Advantages of mandibular symphysis over other grafts include easy access, availability of greater quantities of bone above other intraoral sites, low morbidity, minimal discomfort, and no cutaneous scar. They can hence be proficiently utilized for alveolar ridge augmentation to correct the atrophic alveolar defects.

CONCLUSION

Traumatic injuries are unavoidable in pediatric patients and any deviation from the normal appearance due to these injuries can have an adverse effect on their personality. Atrophy of alveolar ridges in a growing patient may lead to structural malformation therefore it is imperative to correct these structural defects to maintain the arch integrity and cause uniform growth. In such cases, bone grafting procedures may be considered as an alternative for augmenting the atrophic alveolar ridges.^10,11 This procedure can act as an important predictor of success for future surgical phases leading to successful and esthetic results. Bone grafting procedures not only help augment the atrophic alveolar ridge and aid in esthetic and functional restoration of alveolar anatomy, but it also helps establish adequate bone density providing the site with superior bone quality. In the case presented above, bone grafting procedure was shown to successfully augment the narrow anterior alveolar ridge at the trauma site, repairing the bony depression and preparing it for receiving implant prosthesis in future.

CLINICAL SIGNIFICANCE

In a pediatric patient, it is imperative to treat trauma-induced alveolar deformity before growth ceases, as any delay can further worsen the skeletal and dental malformation. Hence, a comprehensive treatment approach should be considered to achieve esthetic as well as functional restoration.

REFERENCES

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