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Management of Curved Bone Defects in the Anterior Maxilla Using Bone

Bending via a Kerfed Khoury Split Bone Block Technique

Article in The International journal of periodontics & restorative dentistry · March 2023
DOI: 10.11607/prd.6469

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 203

Management of Curved Bone Defects in the

Anterior Maxilla Using Bone Bending via a Kerfed
Khoury Split Bone Block Technique

Howard Gluckman, BDS, MChD, PhD1 Reduced alveolar bone volume is a

frequent limitation in implant place-
ment.1 Vertical and horizontal graft-
ing procedures are often required
to enable implant placement in
bone with insufficient volume. Dif-
ferent techniques to correct alveolar
The loss of teeth causes inevitable resorption of the alveolar bone. In the anterior ridge deficiencies, including autog-
arches, the curved anatomy further adds to the challenge of rehabilitation. These enous bone grafting, guided bone
areas often require the shaping of membranes and multiple bone blocks through regeneration, ridge expansion, and
complex surgery to compensate for the curvature. The split bone block technique
distraction osteogenesis, have been
(SBBT) has been successfully used in complicated cases. However, the inability to
create curves from the blocks means that larger quantities of bone or membranes published in the dental literature.2
are needed to compensate for this. Bone bending based on an ancient wood- Autogenous bone remains the
bending technique known as kerfing is proposed to shape rigid SBB plates to gold standard graft material, given
recreate the natural anatomy of anterior arches. Three patients presenting with bone its regenerative, osteoinductive,
destruction of the anterior maxilla underwent bone augmentation before implant osteoconductive, and osteogenic
placement using the SBBT combined with kerfing. The plates were successfully
properties.3–6 In grafting tech-
bent to the shape of each maxilla without any deleterious effects. All bone grafts
healed uneventfully, and the bone curvature was successfully reconstructed. No niques, onlay bone grafts, particu-
complications were reported. Implant placement took place after 4 months and larly Khoury’s split bone block tech-
definitive restorations after 7 to 9 months. Clinical and radiographic assessments nique (SBBT), have shown positive
were performed at 1 year. Full customization of autogenous bone plates was possible results in complex alveolar bone
through kerfing. This approach resulted in an ideal bone curve and shape in the augmentations.7–10 With Khoury’s
facial and palatal aspects of the anterior maxilla. In addition, it enabled ideal implant
SBBT, a block is split into two or
placement with reduced bone harvesting volumes and decreased the need for
soft tissue augmentation to recreate the curved shape. This technique promoted three bone plates (1 to 2 mm thick)
close-fitting autologous osseous plates that followed the anatomical curvature of and secured with bone screws. This
the anterior maxilla, leading to optimal healing and excellent regeneration of the creates a bony envelope to sup-
ridge width. This principle can be valuable when dealing with complex anatomical port the autogenous bone chips.
defects. Int J Periodontics Restorative Dent 2023;43:203–210. doi: 10.11607/prd.6469 The cortical plates provide stability
to the highly cellular autogenous
particulate bone, whose turnover
Private Practice, Cape Town, South Africa; Implant and Aesthetic Academy, Cape Town,
1 and conversion to new bone is
South Africa; University of Pennsylvania School of Dental Medicine, Department of rapid and complete, leading to low
Periodontics, Philadelphia, Pennsylvania, USA; University of Western Cape School of volume loss of the graft, excellent
Dentistry, Department of Oral Medicine and Periodontology, Cape Town, South Africa.
bone quality, and reduced time to
Correspondence to: Dr Howard Gluckman, Enamel Clinic, 3rd Floor De Waterkant Centre, implant placement.5,11–13
9 Somerset Rd De Waterkant, Cape Town 8001, South Africa. Email: [email protected] Bone grafting procedures pres-
ent additional problems in the an-
Submitted July 14, 2022; accepted September 17, 2022.
©2023 by Quintessence Publishing Co Inc. terior arches.14 The arch curvature

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204

creates a unique challenge, often ing autogenous bone plates in the 22 presented with ferrules roots.
resulting in a flat graft profile. Multi- anterior maxilla of three patients After discussing different treat-
ple soft tissue grafts or further bone using Khoury et al’s SBBT7 and the ment approaches with the patient
augmentation may be required to kerfing technique.15 This novel ap- concerning costs, risks, and chal-
provide adequate bulk to achieve proach enables full customization lenges, the final plan included
ideal esthetics. The SBBT allows a of autogenous bone plates to fit the extraction of tooth 21 and sub-
more creative approach to this chal- curvature of the anterior maxilla or sequent (2 months later) autog-
lenge, given that multiple straight mandible, leading to improved heal- enous bone grafting of the areas
blocks can be screwed together ing, a reduced volume of harvested corresponding to teeth 11 and
to create a curve.5 However, it re- bone, a lower risk of postoperative 21. After 4 months of bone heal-
quires extra bone volume to be har- complications, ideal bone curves, ing, implants were placed. Implant
vested, which increases second-site and superior cosmetic outcomes. exposure was performed after 3
morbidity. In addition, the multiple months of integration and includ-
plates needed to create the curve ed the decoronation and prepara-
often have a sharp joint with an in- Material and Methods tion of tooth 22 for a pontic shield,
creased risk of flap perforation. The according to the technique pre-
larger number of bone screws re- Overview of Clinical Cases viously described by Gluckman
quired to stabilize multiple plates in- et al.17 The final restoration was
creases the risk of plate fracture and Three patients from a private den- a zirconium cantilever prosthesis
damage to the recipient site. Small- tal practice presenting pathologic including tooth areas 11, 21, and
er areas are unsuitable for multiple resorption of the anterior maxilla 22. The complete surgical process
plates, as the area is too small to underwent bone augmentation sur- and follow-ups for this patient are
handle the number of bone screws gery in 2020 and/or 2021 as part of shown in Figs 1 to 5.
needed to stabilize the plates. their rehabilitation treatment before Patient 2 was a 35-year-old
A woodworking technique implant placement. Patients signed healthy, nonsmoking man present-
known as kerfing has been success- an informed consent to authorize ing with extensive gum recessions
fully used to provide predictable the use of their clinical data for sci- on teeth 11 and 12. The patient had
bending of hardwood. It involves entific publication. All patients un- previously undergone periodontal
cutting consecutive parallel slots at derwent a full-mouth CBCT scan. surgery in the area. Upon radio-
equal distances and depths to al- In addition, mandibular CBCT scans graphic examination, severe local-
low wood parts to flex and curve.15 were used to evaluate the inferior ized periodontitis (stage III, grade
Physiologically, the biomechanical alveolar nerve and canal location C)18 was detected in the maxillary
characteristics of osseous tissue (in- to ensure safety during bone graft right incisors. The proposed treat-
cluding elasticity, flexural modulus, harvesting. Patients followed a strict ment plan accepted by the patient
and remodeling capacity) ensure its oral hygiene protocol during the included extraction of the right
capacity to bend without breaking.16 follow-up period. incisors, bone augmentation pro-
Thus, using the kerfing technique Patient 1 was a healthy, non- cedure, and placement of two im-
and the biomechanical properties smoking 52-year-old man who pre- plants. The surgical process and
of human bone tissue as a founda- sented with a failing partial fixed follow-ups for this patient are shown
tion, the innovative concept of bone denture extending from tooth 15 in Figs 6 to 9.
bending can be applied to bone to 22 (FDI tooth-numbering sys- Patient 3 was a 50-year-old
augmentation to create esthetic tem). Teeth 11, 12, and 14 were woman who presented with bone
curves. missing. A panoramic radiograph deficiency on the anterior max-
This case series describes the revealed dental caries and an api- illa due to the loss of both central
step-by-step procedures for bend- cal lesion at tooth 21; teeth 21 and incisors resulting from trauma at a

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 205

Fig 1 Patient 1. Initial

clinical view (a) with and
(b) without the prosthe-
sis.

a b

a b c

d e
Fig 2 Patient 1. Initial surgical procedure. (a) Surgical preparation of the recipient bed. (b) The facial bone plate was prepared with slot
cuts. (c) The first bone plate was fixed on top of the alveolar ridge using bone screws. Every effort was made to ensure the plates did not
touch the adjacent roots. (d) The first screw secured the bone plate at the correct position before bone bending. Placing the second screw
bent the plate into the curve. (e) Bone plates were fixed and stable in place. The facial plate was bent, creating a curvature that followed
the natural anatomy of the maxilla.

a b c
Fig 3 Patient 1. (a) Postoperative clinical view at the 4-month follow-up. (b) The reentry procedure at 4 months showed excellent vertical
and horizontal bone augmentation. (c) Two implants were placed at reentry.

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206

Fig 4 Patient 1. (a) Occlusal

view at the 9-month follow-
up and (b) with the final
restoration in place.

a b

Fig 5 Patient 1. Final CBCT scans of the implants at

(a) site 11 and (b) site 21. (c) Final radiographic view.

a b c

a b
Fig 6 Patient 2. The initial clinical view Fig 7 Patient 2. The facial and palatal bone plates were fixed into position, shown
showed extensive gingival recessions. (a) before and (b) after packing the autogenous bone chips.

young age. She had a fixed partial Surgical Procedures dine solution was used for extra-
prosthesis from teeth 12 to 22 that and intraoral disinfection. For each
failed due to an abutment fracture The required bone volume for each participant, blood samples were
of tooth 22, rendering the prosthesis patient was determined through drawn by venipuncture, collected
unsalvageable. After careful radio- preoperative CBCT analysis of the in platelet-rich fibrin (PRF) tubes,
graphic evaluation, the treatment recipient site. The ramus was the and prepared according to Dohan
plan included bone augmentation chosen site in all three cases due et al’s protocol.21 At the donor site,
in the areas of teeth 11 and 21, fol- to the availability of the required buccal and lingual infiltration of local
lowed by the placement of two im- cortical bone volume and reduced anesthetic (articaine 4%; Ubestesin,
plants, decoronation, and root sub- morbidity compared to the symphy- 3M ESPE) were given near the last
mergence of tooth 22 according to sis.20 The patients underwent pre- molar using a controlled delivery
Gluckman et al’s approach.19 A can- operative dental prophylaxis with system. An inferior alveolar nerve
tilever fixed partial prosthesis was 2 g amoxicillin, taken orally 1 hour block was not used to avoid mask-
placed over the area of tooth 22. before surgery. A 0.12% chlorhexi- ing potential signs of iatrogenic

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 207

nerve injury during surgery.5 A buc-

cal releasing incision was made ver-
tically at the distal aspect of the last
molar and extended to the ascend-
ing ramus as a subcrestal incision.
After reflection of a full-thickness
flap, the ramus bone was harvest-
ed utilizing a piezo bone-cutting a b

instrument (OT12 osteotomy tip, Fig 8 Patient 2. (a) Postoperative clinical view at the 4-month follow-up. (b) Implants were
placed at the reentry surgery at 4 months.
Mectron). Bone shavings were
harvested using the SafeScraper
(Geistlich Pharma) or the Auto-Max
Fig 9 Patient 2.
bone harvester (MegaGen). Using Final clinical view after
interrupted 6/0 Prolene (Ethicon, placing the definitive
crowns.
Johnson & Johnson) sutures, the
donor site was closed immediately
after harvest completion to reduce
the risk of infection and swelling.
The harvested bone block was
prepared using a Khoury Micro-
Saw (Dentsply Sirona). It was split
into two halves down the long axis
to produce two thin blocks, which modate the bending and cut-down buccal and palatal plates are used,
were further thinned with the Safe- where necessary. In areas where the buccal plate is placed first and
Scraper to a thickness of about the plates required bending, mi- the palatal plate second.
1.5 mm. The bone chips from the nor kerfing cuts were made on the Once the bone plates were
thinning process were collected, side where the plate was meant to firmly screwed in place, the autog-
stored in advanced PRF liquid (A- bend. The cuts were as symmetri- enous bone chips were packed
PRF), and covered with sterile gauze. cal in their spread as possible and between the plates to improve the
Next, the recipient site was pre- reached about half of the bone graft’s shape and quality. The area
pared to receive the bone graft. plate thickness. was covered with A-PRF mem-
The flap design was determined ac- If a bone plate was needed branes, followed by passive flap clo-
cording to the amount of horizontal on the incisal portion of the alveo- sure using interrupted 6/0 Prolene
and vertical augmentation required. lar ridge, it was the first plate to be sutures. Because patients 1 and 3
Under local anesthesia, double- screwed down to the ridge using required vertical bone augmenta-
releasing incisions were placed on 1-mm bone screws. The incisal plate tion, a connective tissue graft (har-
the facial aspect of the recipient site, was shaped and curved to conform vested from the palate under local
which is essential for passive flap to the ridge shape. Next, the labial anesthesia) was sutured into place
closure in vertical bone augmenta- bone plate was screwed down and to reduce the risk of bone expo-
tion. Once the full-thickness flap firmly secured on one side. The sec- sure due to flap dehiscence. Interim
was raised, a periosteal release was ond screw was inserted on the op- prostheses were adjusted to avoid
carried out while the local anesthet- posite side and screwed into place, disturbing the healing process and
ic was most effective. causing the plate to bend, thus con- prevent patient discomfort. Post-
The bone plates were oversized forming to the correct anatomical operative care included augmentin
compared to the defect to accom- curvature of the arch. When both (1,000 mg; twice daily for 5 days), a

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208

combination of analgesics and non- graft incorporation and excellent are several challenges related to
steroidal anti-inflammatory drugs esthetics. In addition, the successful guided bone regeneration, such
(three times a day), and chlorhexi- implant placement in the included as graft instability, space mainte-
dine mouthwash (1 week). Patients participants suggests that the bone nance, membrane exposure, in-
were followed up at 1 week and at grafts were revitalized at the implant- fection, and a long healing time
1, 6, and 12 months after the bone placement surgery, providing the (9 to 12 months) before implant
grafting surgery. A CBCT scan was ideal conditions for osseointegration. placement.2,25–27
performed at the 12-month follow- Compared to the long bones When compared to other aug-
up. Implants were placed 4 months in the body, the mandible presents mentation procedures, the SBBT
after the bone grafting surgery and a higher immature collagen con- used in the present study presents
were exposed 3 months later. De- tent and remodeling rate, possibly many advantages given the stability
finitive restorations were placed no leading to higher flexibility.22 This of the plates, rapid graft revascular-
more than 2 months after implant provides a potential biologic expla- ization and regeneration, low resorp-
exposure. nation for the bending that can be tion rate, high volumetric stability of
achieved in autogenous bone grafts the grafted area, low complication
harvested from the mandible. rate, shorter healing time (implant
Discussion According to the present au- placement after 3 to 4 months), and
thor’s experience, allografts and xe- shorter overall treatment duration.4
To the best of the present author’s nografts are not suited for bending The potential complications of au-
knowledge, this is the first study to through the kerfing technique. In togenous bone grafting should be
present the concept of bone bend- addition, due to their lower flexural considered during decision-making,
ing in the dental literature. Full modulus and higher brittleness than including increased second-site mor-
customization of autogenous bone autogenous grafts,23 these bone bidity and risk for complications.10
plates is possible through the kerf- substitutes fracture when subjected When harvesting bone from the
ing principles. This approach result- to bending forces. ramus, potential problems include
ed in an ideal bone curve and shape It is essential to highlight the nerve damage, exposure of the do-
in the facial and palatal aspects of technical difficulty of slot cutting. In nor site during healing due to inci-
the anterior maxilla, as the bone less-experienced hands, the slots sion opening, trismus, and mandibu-
plates achieved optimal fitting to can lead to bone plate fracture. lar fracture.28 Using 3D images from
the recipient bed. Furthermore, the Thus, chairside slot-cutting prac- CBCT scans during surgical planning
acellular plates held the highly cel- tice is recommended for increased can help reduce the risk of compli-
lular autogenous bone chips, creat- precision and predictability. In addi- cations.29 The novel approach pre-
ing a bony housing that resulted in tion, a tension-free, passive flap fully sented herein provides an effective
excellent bone quality with superior covering the grafted area is a pre- solution to improve the outcomes
graft contours, reduced block har- requisite for all bone augmentation of horizontal and vertical ridge aug-
vesting, and a shorter healing time. procedures.24 A connective tissue mentation procedures without in-
When dealing with extensive graft can be a suitable addition to creasing the risk for complications.
atrophy of the alveolar bone, bone decrease the odds of graft exposure In the present study, A-PRF was
augmentation is typically performed in vertical augmentations. used in conjunction with bone aug-
before implant placement to provide Guided bone regeneration us- mentation due to its positive impact
adequate bone volume to accommo- ing a membrane and autologous on vascularization, healing of soft
date the implants.2 The bending tech- bone graft or bone graft substi- and hard tissues, graft survival, bone
nique described in the present study tutes provides another treatment formation and maturation, and post-
caused optimal healing in all three option for horizontal and vertical operative pain.30 The low-speed
cases, likely contributing to improved ridge deficiencies.2 However, there concept used in A-PRF increases the

The International Journal of Periodontics & Restorative Dentistry

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 209

10. Chiapasco M, Casentini P. Horizontal

release of growth factors compared Acknowledgments
bone-augmentation procedures in im-
to previous PRF protocols.31 plant dentistry: Prosthetically guided re-
Findings from the presented The author would like to acknowledge Carla generation. Periodontol 2000 2018;77:
213–240.
novel approach raise a few biologic Pontes for her help with the manuscript, as
11. Tunkel J, Würdinger R, de Stavola L.
well as Dr Mark Bowes for the prosthetic
questions for upcoming studies, Vertical 3D bone reconstruction with si-
work. Additionally, the author acknowledges multaneous implantation: A case series
including the biochemical and cel-
dental technicians Trevor Bath and Grant report. Int J Periodontics Restorative
lular graft changes resulting from Peak from FK Dental and Shane Hanson from Dent 2018;38:413–421.
bending, the force range required 12. Miron RJ, Zhang Q, Sculean A, et al. Os-
Diceram. The author declares no conflicts of
teoinductive potential of 4 commonly
to bend oral bone without causing interest. employed bone grafts. Clin Oral Inves-
fracture, and the bending potential tig 2016;20:2259–2265.
13. Burchardt H. The biology of bone
of grafts harvested in other intra-
graft repair. Clin Orthop Relat Res
and extraoral locations. Neverthe- References 1983;174:28–42.
less, the present cases confirm that 14. Buser D, Martin W, Belser UC. Optimiz-
1. Hämmerle CHF, Tarnow D. The etiol- ing esthetics for implant restorations in
mandibular bone plates from the ogy of hard- and soft-tissue deficiencies the anterior maxilla: Anatomic and sur-
ramus prepared according to at dental implants: A narrative review. J gical considerations. Int J Oral Maxillo-
Periodontol 2018;89(suppl 1):s291–s303. fac Implants 2004;19(suppl):43–61.
Khoury’s approach can be suffi-
2. Esposito M, Grusovin MG, Felice P, 15. Taron JM. Integrative design compu-
ciently bent to create an ideal curva- Karatzopoulos G, Worthington HV, tation: Integrating material behaviour
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Conclusions 3. Cordaro L, Amadé DS, Cordaro M. Clin- of the Association for Computer-Aided
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To the best of the present author’s tion with mandibular block bone grafts 13–16 Oct 2011, Banff, Alberta, Cana-
in partially edentulous patients prior to da]. Banff: ACADIA, 2011:72–81, 413.
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proach promoted close fitting of cal study. Int J Oral Maxillofac Implants pontic-shield: Partial extraction therapy
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210

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