Indian Journal of Dental Research

: 2014  |  Volume : 25  |  Issue : 4  |  Page : 445--448

Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix

Arun Kumar Vidyadharan1, Anjana Ravindran2,  
1 Department of Endodontics and Implant Dentistry, S.U.T.A.M.S Medical College, Trivandrum, India
2 Department of Prosthodontics P.M.S Dental College, Trivandrum, Kerala, India

Correspondence Address:
Arun Kumar Vidyadharan
Department of Endodontics and Implant Dentistry, S.U.T.A.M.S Medical College, Trivandrum


Background: Patient wanted to restore her lost teeth with implants in the lower left first molar and second premolar region. Cone beam computerized tomography (CBCT) revealed inadequate bone width and height around future implant sites. The extraction socket of second premolar area revealed inadequate socket healing with sparse bone fill after 4 months of extraction. Aim: To evaluate the clinical feasibility of using a collagen physical resorbable barrier made of human pericardium (HP) to augment localized alveolar ridge defects for the subsequent placement of dental implants. Materials and Methods: Ridge augmentation was done in the compromised area using Puros® demineralized bone matrix (DBM) Putty with chips and an HP allograft membrane. Horizontal (width) and vertical hard tissue measurements with CBCT were recorded on the day of ridge augmentation surgery, 4 month and 7 months follow-up. Intra oral periapical taken 1 year after implant installation showed minimal crestal bone loss. Results: Bone volume achieved through guided bone regeneration was a gain of 4.8 mm horizontally (width) and 6.8 mm vertically in the deficient ridge within a period of 7 months following the procedure. Conclusion and Clinical Implications: The results suggested that HP Allograft membrane may be a suitable component for augmentation of localized alveolar ridge defects in conjunction with DBM with bone chips.

How to cite this article:
Vidyadharan AK, Ravindran A. Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix.Indian J Dent Res 2014;25:445-448

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Vidyadharan AK, Ravindran A. Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix. Indian J Dent Res [serial online] 2014 [cited 2021 Apr 14 ];25:445-448
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Full Text

Treatment of vertical bone defects is often necessary for the placement of implants in the ideal position for prosthetic restoration. Successful bone augmentation of large vertical maxillary and mandibular alveolar ridge defects is difficult to achieve. Various techniques have been described for the reconstruction of these large vertical defects prior to implant placement. These techniques have included autogenous onlay block grafts, [1],[2],[3],[4] autogenous particulate grafts, [5],[6],[7],[8],[9] guided bone regeneration (GBR) with membranes or titanium mesh [10],[11] distraction osteogenesis [12] and a combination of these. [13],[14],[15] GBR is a predictable therapeutic technique that can be used separately in a staged approach to first augment the ridge or in conjunction with implant placement when primary stability of the implant is a desirable. When a staged approach is used 9-12 month, healing period is recommended to allow fuller maturation of the new osseous tissue prior to implant placement. Critical sized alveolar ridge defects in the horizontal and vertical dimensions may occur following tooth loss, fractures or pathological processes. Such defects may compromise the ideal implant placement prescribed prosthetically leading to an unfavorable outcome.

In a clinical report, Taskonak and Ozkan [16] described guided bone augmentation for treatment of a facial maxillary alveolar bone defect to enhance the aesthetic result for an All-ceramic fixed partial denture (FPD). A combination of decalcified freeze-dried bone allograft and resorbable human pericardium (HP), in conjunction with cortical channel expansion, was used for the augmentation process to eliminate a secondary surgical procedure. Post-operative examinations showed marked improvement in the alveolar bone contour. The regeneration of the missing osseous structure was accomplished to support the future aesthetic soft tissue contours. This osseous regenerative technique significantly increased the functional and aesthetic outcome of the final FPD by restoring the alveolar ridge defect to its original dimension.

Puros; pericardium is a natural biological dressing designed for guided tissue regeneration and GBR procedures. It retains the natural collagen matrix and mechanical properties of native pericardium due to the proprietary Tutoplast; process. Puros demineralized bone matrix (DBM) is derived from demineralized human bone which has osteoinductive properties. The carrier in the Puros DBM putty ensures good handling properties as well as resistance to graft migration.

Shin and Sohn [17] described a technique regarding repairing completely perforated sinus membrane after the removal of a mucocele using human collagen pericardium membrane (Tutoplast; pericardium) and fibrin adhesive (Greenplast; ) to stabilize collagen membrane.


The purpose of this study was to evaluate the clinical feasibility of using a native collagen resorbable membrane made of HP and an allograft with bone chips to augment localized alveolar ridge defects for the subsequent placement of dental implants.


0Clinical case

A 53-year-old female presented to the clinic. Her chief request was to have an implant placed in 35, 36 [Figure 1]. Her dental history revealed that root canal treatment had been performed on tooth 35, and the bridge was placed connecting 37 with 35 to replace 36, 5 years ago. Four months back she had 35 extracted due to periapical lesion and bone loss around 35. Radiographic evaluation cone beam computerized tomography and orthopantamogram (CBCT and OPG) revealed vertical and horizontal bone loss at tooth 35 and 36 area [Figure 2] and [Figure 3]. With antibiotic prophylaxis, a GBR procedure was performed under local anaesthesia using 2% lidocaine with 1:100,000 epinephrine (Henry Schein, USA). A midcrestal incision between teeth 37 and 34 was performed. These incisions extended intrasulcularly around 37 and 34. A full thickness muco-periosteal flap was raised. Seibert type III classification ridge defect [18] was found that extended 3 mm horizontally and 10 mm vertically around 35. Using high speed airotor handpiece with a small diamond round bur (No. 8) decertification was performed on the buccal plate of the surgically exposed area. A GBR procedure was performed using Puros; DBM putty with bone chips and (Zimmer dental, Carlsbad, CA, USA) Puros; HP allograft membrane (Zimmer dental, Carlsbad, CA, USA) [Figure 4]. Tension-free primary wound closure was achieved with periosteum releasing incision. Resorbable suture material using (4.0 chromic gut, Henry Schein, USA) was used for the midcrestal closure by mattress suturing technique. Circumferential incisions were closed using 4-0 vicryl suture material.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Cone beam computerized tomography and intra oral periapical (IOPA) after 4 months healing period revealed appearance of satisfactory bone filling around the areas [Figure 5]. At 7 months OPG showed sufficient bone regeneration around the previous bone deficient areas, and Implant installation was planned [Figure 6]. This procedure was performed under local anesthesia using 2% lidocaine with 1:100,000 epinephrine (Henry Schein, USA). A midcrestal incision was made slightly followed by intrasulcular incision to the midbuccal of teeth 37 and 34. A full thickness muco-periosteal flap was reflected to visualize the bone regeneration. Measurements were taken to assess the bone fill [Figure 7]. Two platform switching implants, 4 and 5 mm diameter, 12 and 10 mm length, (Biomet 3i, Palm Beach Gardens, FL, USA) were placed at tooth 35 and 36 respectively following the manufacturer's protocol. Implant stability was established with the implant motor torque set to >30 N/cm. The incision was closed using simple interrupted resorbable 4.0 vicryl sutures. The patient was prescribed 0.2% chlorhexidine as an oral rinse; to be used twice a day for 2 weeks. One week follow up X-ray showed no post-operative complications. Eight month post implant loading IOPA was recorded [Figure 8]. No significant findings were found.{Figure 5}{Figure 6}{Figure 7}{Figure 8}


Bone remodeling after extraction results in vertical and horizontal bone loss. [19],[20] Depending on the anatomic position, different surgical techniques can be performed to improve the bone dimensions of the implant site. Many authors have reported on the use of autogenous bone grafts to restore bony defects and allow for the correct positioning of implants. [1],[2],[3],[4],[5],[6],[7],[8],[13],[14],[16] However, when treating a severely atrophic alveolar ridge, it is common to encounter large volume defects that must be fully reconstructed to create an aesthetic and functional result. With these large volume defects, it has often been necessary to obtain bone from extraoral sources.

Boyne has reported the outcomes of ridge augmentation techniques using a membrane with a particulate graft. Guided bone regenerative membranes are used to separate tissues during healing, retard apical migration of epithelium to the site, maintain the necessary space for bone growth (tenting) and protect the graft material in the defect. [11] Bovine and HP membranes were evaluated in a study by Thomaidis et al. [21] Fifty adult male New Zealand white rabbits were used in this study. Five groups of 10 animals each were used: Human fascia lata membrane, HP, human fascia temporalis, bovine pericardium (BP), and expanded polytetrafluoroethylene (e-PTFE). According to the results, the fascia lata, HP, BP, and e-PTFE advance bone regeneration and can be successfully used as GBR membranes for osseous defects beyond the critical size. The defect in the HP group was filled with a mature, mainly newly formed bone, lamellar in its greatest part, with distinct bone trabeculae and marrow sites.

In this case study Puros; HP collagen membrane and DBM putty with bone chips were used. DBM is easy to manipulate and has excellent handling characteristics which allows easy malleability as well as resist to graft migration. Puros; HP allograft membrane gives the ease of placement and conformity to graft the site. According to Rothamel et al. HP membranes are seen to promote osteoblast and periodontal ligament cell proliferation in vitro studies. [22] Graft containment and good primary closure of the incision to avoid exposure of the graft was essential for bone regeneration at the bone defect. Four month follow-up radiographs showed satisfactory bone filling at the defect areas. The healing phase was uneventful and on reopening at 7 months for implant placement bone volume measurements showed that 3-4 mm horizontal and 5-6 mm vertical bone augmentation was achieved. Tactile perception at the time of the osteotomy for implant placement revealed a type 2 bone (Misch classification) at the regenerated site. Two platform switching tapered implants (Biomet 3i, Palm Beach Gardens, FL, USA),

4 and 5 mm diameter, 12 and 10 mm lengths, were placed in tooth 35 and 36 respectively using the manufacturers protocol. IOPA taken 8 months after implant loading showed minimal crestal bone loss.


This case report demonstrated that DBM with bone chips in conjunction with HP Membrane is a viable treatment for localized ridge augmentation. This technique allowed a successful reconstruction of a large volume defect and permanent implant placement in the ideal position. Long-term follow-up is needed to evaluate the stability of the graft after implant loading. Moreover, more cases using the present protocol using DBM and HP membrane in GBR augmentation procedures are necessary to determine the predictability of this new procedure.


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