International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583
Minimally Invasive Surgery for Horizontal Ridge
Augmentation (Subperiosteal Tunneling): A Case
Report
Roberto Miers1, Helton Panisson1, Norival Francisco de Souza Junior1, Márcio Adriano Vavassori1, Thais
Ustulin Fuzer2, Túlio Del Conte Valcanaia3, Guenther Shuldt Filho1
1
São Leopoldo Mandic College/ Curitiba PR Unit
2
School of Dentistry of Bauru/ University of São Paulo/ São Paulo SP
3
University of Itajaí Valley /Itajaí SC
Abstract: This case report emphasizes the importance of planning for excellent resolution of complex cases. A female patient wearing
a total prosthesis for 20 years exhibited severe horizontal resorption in the premaxillary area, making rehabilitation with implants
impossible. The maxilla was regenerated using a lyophilized allogeneic bone from a tissue bank, and subperiosteal tunneling was
performed. The technique recovered the lost bone thickness after dental extractions, thus allowing the placement of eight implants, five
of them in the grafted area. The patient was rehabilitated with a complete fixed prosthesis, recovering function and aesthetics.
Keywords: Bone Graft, tunneling technique, dental implant, ridge augmentation, minnimaly invasive surgery, maxilary reconstruction,
periosteal cell
1. Introduction properties [9]. It reduces morbidity and surgical time, in
addition to unlimited availability [9, 12]. However, it has the
After dental extraction, the process of resorption of the following disadvantages: risk of disease transmission, high
alveolar process begins. After 90 days, resorption of the processing cost, and need for specialized storage sites [7,
buccal bone plate occurs in the alveoli filled only with 13].
coagulated blood, despite the existing bone formation,
causing a significant loss of volume [1, 2, 3]. This loss of Several procedures of bone grafting for regeneration have
volume causes a bone defect, preventing the placement of been reported, such as guided bone regeneration, block
implants in favorable positions, impairingthe function of the grafting, and osteogenic distraction [12]. One of the
teeth, and subsequently compromising the final cosmetic techniques of guided bone regeneration is subperiosteal
result [4, 5, 6]. Therefore, procedures may be necessary to tunneling, suggested by Kent et al. In this technique, two
correct the defects caused by resorption in the alveolar ridge vertical incisions are created in the ridge, and the area
[7]. between them is totally detached, forming a tunnel. The
graft material is positioned, and the area is sutured [14, 15].
Autogenous bone has long been considered the gold This allows the bone graft to be covered by an intact
standard amongbone grafting materials due to its osteogenic, periosteum [16]. Because it is minimally invasive, this
osteoinductive, and osteoconductive properties, in addition technique has a shorter surgical time and lower
to its immunocompatibility [7, 8, 9, 10]. However, it has the postoperative morbidity [16, 17, 18].
following limitations in relation to morbidity: increased
surgical area, unpredictability regarding resorption, longer Complete fixed prostheses anchored on implants have been
surgical time, and quantity restriction [8, 9, 10]. widely used for the rehabilitation of edentulous maxillae and
mandibles, and four to six mandibular implants and six to
Considering the limitations of the use of autogenous bone, ten maxillary implants are usually placed [19]. To achieve
there is a constant search for materials that can be used as predictability and stability, the planning of the anchoring of
bone substitutes. Bone graft substitutes must be the prosthesis on the implant should ensure that the implants
biocompatible, nonantigenic, susceptible to sterilization, are placed in strategic positions, thus allowing the
easy to handle, and have good osteoinductive and dissipation of applied forces, the balance of the action arms,
osteoconductive properties [7, 9]. Ideally, a material used for and strength of the prosthesis [12, 20, 21].
grafting should maintain space, be stable, be an
osteoconductor, be easy to handle, be predictable from the 2. Case Presentation
point of view of resorption, and be susceptible to remodeling
[11]. A 44-year-old female patient, nonsmoker and with
leucoderma, sought dental care following the major
Bone substitutes can be of homologous, heterologous, or complaint of aesthetic and functional dissatisfaction with the
alloplastic origin. A homolonous graft is a type of graft upper total prosthesis used for 20 years.
where the donor is an individual of the same species as the
recipient. It has osteoinductive and osteoconductive
Volume 9 Issue 4, April 2020
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20421020345 DOI: 10.21275/SR20421020345 1318
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583
Figure 1: Intraoral pictures of the patient
Anamnesis showed that the patient had good general health Vertical incisions were created using a #15C blade (Swann-
and no systemic problem. Intraoral examination revealed Morton, England) in the areas corresponding to the
resorption of the alveolar ridge (change in thickness). maxillary canines, followed by careful detachment of the
Computed tomography (CT) scan confirmed resorption and gingival and periosteal tissue to create a tunnel in the
showed that the ridge was 2 to 3 mm thick in the grafting area and preserve the integrity of the gingival tissue.
premaxillary region, which prevented the placement of
implants. To compensate for bone resorption of the buccal bone plate
and enable the placement of implants for the creation of a
protocol-type prosthesis, bone grafting was performed with
homogenous bone from the tissue bank of the Institute of
Orthopedics and Traumatology of the Hospital das Clínicas
of the Medical School of the University of São Paulo. The
freeze-dried particulate bone used was hydrated in 3-mL
rifamycin sodiumat 10 mg (EMS®, SA/São Paulo) to
minimize the risk of infection and promote hydration.
Figure 2: Previous computed tomographyimages
Increasing the thickness of the maxilla with a homogenous
bone graft using the tunneling technique and subsequently
placing an implant to create a complete fixed prosthesis
were considered the treatment strategies. The patient was
administered with 500 mg of amoxicillin (GSK®, England)
and 4 mg of dexamethasone (Aché® Laboratórios
Farmacêuticos, SA/São Paulo) 1 hour before the surgical
Figure 4: Allogeneic graft obtained from the tissue bank of
procedure. Anesthesia was induced by blocking the
the Institute of Orthopedics and Traumatology of the
infraorbital and greater palatine nerves with mepivacaine 2%
Hospital das Clínicas of the Medical School of the
with 1:100, 000 epinephrine (Nova DFL®, Rio de Janeiro,
University of São Paulo
RJ).
After being soaked for 5 minutes in the antibiotic solution,
the material was inserted and compacted in the recipient site
using a Molt elevator.
Figure 3: Vertical incisions and tunnel creation
Figure 5: Insertion of the graft and sutures
Volume 9 Issue 4, April 2020
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20421020345 DOI: 10.21275/SR20421020345 1319
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583
The area was sutured with a 5.0-mononylon thread After the healing period, a new CT scan was requested to
(Ethicon®, USA) using simple interrupted stitches. plan the placement of the implants for the creation of the
protocol-type prosthesis. The positioning of the implants
Two daily doses of 600-mg ibuprofen arginine (Zambon®, was defined through reverse planning, and through it, a
Italy) were prescribed to control postoperative pain, and surgical guide was prepared to assist the milling.
three daily doses of 500-mg amoxicillin (GSK®, England)
were prescribed for 7 days to prevent and control infections.
The patient also received several healthcare instructions on
postoperative care and hygiene maintenance. The stitches
were removed after 15 days.
Healing and bone formation were expected to be observed
after 5 months, and the patient was monitored monthly to
assess the adaptation of the upper total prosthesis and tissue
integrity.
Figure 7: Computed tomography images obtained after a 5-
month healing period
The patient was administered with 500 mg of amoxicillin
(GSK®, England) and 4 mg of dexamethasone (Aché
Laboratórios Farmacêuticos SA, São Paulo) 1 hour before
the surgical procedure.
Figure 6: Intraoral photograph of the ridge after the
regeneration procedure
Figure 8: Prosthetic treatment planning and surgical guide
Anesthesia was induced by infraorbital and palatine nerve
blockade with mepivacaine 2% with 1:100, 000 epinephrine
(New DFL®, Rio de Janeiro, RJ). A supracrestal incision
and two bilateral relaxing incisions were created in the
second molar areas using a #15C blade (Swann-Morton,
England). Gingival tissue detachment was performed to
preserve the integrity of the gingival tissue.
Eight implants were placed. Classic Ci implants measuring
3.75 x 11.5 mm (Systhex®, Curitiba, PR) were placed in the Figure 9: Implants in place
regions corresponding to teeth 17, 15, 13, 11, 21, 23, and 25,
and a classic Ci implant (Systhex®, Curitiba, PR)measuring Systhex®/Curitiba, PR, countersink drill.
3.75 x 10.0 mm was placed in the region corresponding to
tooth 27. The area was sutured with 5.0-mononylon thread (Ethicon®,
USA) using simple interrupted stitches.
Drilling was performed according to the protocol determined
by the manufacturer using a lance drill, a 2.0 drill, a 2/3 pilot To control postoperative pain, three daily doses of 600 mg
drill, a 2.8 drill, and a 4.1 of ibuprofen arginine (Zambon®, Italy) and one daily dose
of dexamethasone (Aché Laboratórios Farmacêuticos SA,
São Paulo) were administered for 2 days. Three daily doses
of 500 mg of amoxicillin (GSK®, England) were prescribed
for the prevention and control of infections during 7 days.
The patient also received several healthcare instructions on
Volume 9 Issue 4, April 2020
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20421020345 DOI: 10.21275/SR20421020345 1320
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583
postoperative care and hygiene maintenance. The stitches The patient also received several healthcare instructions on
were removed after 15 days. postoperative care and hygiene maintenance. The stitches
were removed after 15 days.
Osseointegration was expected to be observed after 5
months, and subsequently, the implants underwent
reopening surgery.
Anesthesia was induced by performing the infiltrative
technique with mepivacaine 2% with epinephrine 1:100, 000
(New DFL®, Rio de Janeiro, RJ). A supracrestal incision
and relaxing incisions in the second molar region were
created using a #15C blade (Swann-Morton, England).
Mini conical abutments(Systhex®, Curitiba, PR) with 32 Figure 10: Hybrid, complete-fixed prosthesis in place
N/cm of torque were placed, and protection cylinders
(Systhex®, Curitiba, PR) with 10N/cm of torque were After 20 days, the impression copings (Systhex®, Curitiba,
subsequently screwed on the components. The patient’s PR) were installed and attached with a pattern acrylic resin
complete prosthesis was smoothed and relined using a new (GC America INC®, USA). The transfer impression was
base material (Soft Provisório_ TDV Dental Ltda, Pomerode created using Zetaplus and Oranwash condensation silicone
SC). (Zhermack SpA®, Italy).
The area was sutured with 5.0-mononylon thread (Ethicon®, The test plate for delimitation of the reference lines and
USA) using simple interrupted stitches. determination of the intermaxillary relations was created
after 20 days. Seven days later, the teeth were tested, and
To control postoperative pain, three daily doses of 600 mg aesthetic adjustments were made.
of ibuprofen arginine (Zambon®, Italy) were administered.
Figure 11: Intra- and extraoral photographs of the final result
The new hybrid complete fixed prosthesis was installed 10 obtained with the treatment. The peri-implant tissues were
days after the test with a 10 N/cm torque in the hex head healthy with no signs and symptoms of inflammation, and
screws (Systhex®, Curitiba, PR). bone normality was confirmed with a new cone beam CT
scan.
3. Discussion
For a successful implant treatment, the position of implant
placement must be consistent with the prosthetic planning
performed for the prosthesis to be created [2]. The literature
regarding alveolar bone resorption that occurs after tooth
extraction is significantly extensive [9]. In view of the need
to install implants in ideal positions and the bone loss that
occurs after extractions, both preservation and bone
recovery procedures have been widely studied [22].
Among the materials available for bone grafting, autogenous
bone is considered the gold standard due to its osteogenic,
osteoinductive, and osteoconductive properties [23].
However, it has several disadvantages such as higher
Figure 12: Panoramic X-ray and computed tomography intraoperative morbidity, availability limited to the donor
sections of the installed implants area, increased surgical time, increased surgical risk, and
higher postoperative morbidity [10, 22].
After 18 months with the functioning prosthesis, the patient
was satisfied with the functional and aesthetic result
Volume 9 Issue 4, April 2020
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20421020345 DOI: 10.21275/SR20421020345 1321
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583
Among the bone substitutes, homologous graft, obtained 4. Conclusion
from the body of another individualof the same species as
that of the recipient, has osteoinductive and osteoconductive The resolution of complex cases is challenging for dental
properties because bone morphogenetic proteins are surgeons. It requires the surgeon and the prosthodontist to
preserved after processing [24, 25]. The advantages of this perform a comprehensive approach, aiming to circumvent
type of graft are the elimination of surgery in the donor area, the limitations and significantly meet the patient’s
unlimited availability, shorter surgical time, and lower intra- expectations.
and postoperative morbidity [25]. With the standardization
of protocols, the current risk of disease transmission is In addition to requiring precise planning, the surgeon’s
practically nonexistent, and these grafts are thus considered knowledge on the surgical techniques and high skill level are
safe with good applicability [14, 25, 26, 27]. essential in these cases. Moreover, it requires the
prosthodontist to produce technical works with correct
Although the long-term results of allogeneic grafting are dissipation of forces to provide satisfactory function and
similar to those of autogenous grafting, it has higher rates of aesthetics.
resorption [10]. To circumvent resorption, allografts can be
associated with xenografts, which have osteoconductive Finally, the stability of the final work is only possible if the
capacity and form a good framework because their patient cooperates by following the recommendations of the
architecture and composition are similar to those of the healthcare professionals involved in the resolution of the
human bone [8, 9, 10, 24]. case.
The technique of bone regeneration through periosteal 5. Conflicts of Interest
tunneling is performed by creating two vertical incisions to
access the bone bed [16]. The use of this type of incision The authors declare that there are no conflicts of interest in
preserves the keratinized gingival mucosa because the relation to the publication of this article.
incision is limited to the alveolar mucosa [28]. This allows
minimal aesthetic changes due to the presence of small scars
after the repair process [18]. Additionally, the incidence of References
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Licensed Under Creative Commons Attribution CC BY
Paper ID: SR20421020345 DOI: 10.21275/SR20421020345 1322
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
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