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26 | CERECDOCTORS.COM | QUARTER 2 | 2014
| | | B O LT C H I
35 36
37 38
DISCUSSION
The main goal of the buccal contour
augmentation technique utilized in this
case is to establish a facial bone wall of
sufficient height and thickness to serve as
support for long-term stable peri-implant
soft tissue contours. In addition, the buccal
contour augmentation also ensures a long-
term stable functional result as it has been
shown in studies that with a thick facial
bone wall there is less peri-implant hori-
zontal and vertical bone resorption. The
layered bone grafting technique ensures
that a bone wall of at least 3 mm thick-
ness can be established. The first layer of
the bone graft is comprised of a bone graft
material with a relatively higher substitu-
tion rate. This first layer is placed in direct
contact with the exposed implant surfaces
within the alveolar housing to accelerate
new bone formation. In this case, a corti-
cocancellous allograft (MinerOss, BioHori-
zons) was used for this purpose. However,
autogenous bone harvested locally can be
used for this purpose as well. The second
bonegraft layer is comprisedof abonegraft
material with low substitution rate, which
is placed directly on top of the first layer to
over-contourthealveolarridgeandthereby
ensure the long-term maintenance of the
created volume. In this case, an anorganic
deproteinized bovine bone mineral (Bio-
Oss, Geistlich) was used for this purpose.
The third layer of this buccal contour
augmentation is comprised of a double
layer of a slow resorbing membrane. This
membrane not only contains the two bone
graft layers but also provides a cell-occlu-
sive barrier function according to the prin-
ciples of guided bone regeneration. In this
Fig. 35: Preoperative smile view
Fig. 36: Postoperative smile view
Fig. 37: Preoperative facial picture
Fig. 38: Postoperative facial picture
Fig. 39: Eight months postoperative
CBCT views implant #7
Fig. 40: Eight months postoperative
CBCT views implant #10
case, a pericardium membrane (CopiOs,
Zimmer) was used since it provides a rela-
tively long-lasting barrier function and has
demonstrated excellent biocompatibility.
However, different collagen membranes
can be utilized for this purpose as well.
In addition, the PRF technique (www.a-
prf.com) was used to obtain autologous
platelet rich fibrin plugs and membranes,
which contain high concentrations of
various growth factors, leukocytes, mono-
cytes and macrophages. The addition of
this, PRF concentrate to the bone graft has
been shown to significantly accelerate and
enhance thewound-healing process.
In this case, a laboratory wax-up was
used to aid both in the treatment planning
of the guided implant surgery and also in
39 40
thedigital designof theprovisional restora-
tions after obtaining implant-level impres-
sions. It should be noted that a digital
virtual design/wax-up could be used as
well, rendering the entire restorative treat-
ment aspect completely digital. However,
a laboratory wax-up has the advantage
that it can serve as the guide for the entire
restorative process from the initial treat-
ment plan, to the design of the provisional
restorations, to the design of the final abut-
ment and restoration; thereby ensuring
consistent restorative contours throughout
all treatment phases.
For questions and more information,
Dr. Boltchi can be reached at
fboltchi@tx.rr.com.