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Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 445-448
Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix

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

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Date of Submission18-Feb-2013
Date of Decision31-Mar-2014
Date of Acceptance25-Jun-2014
Date of Web Publication10-Oct-2014


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.

Keywords: Demineralized bone matrix, human pericardium, localized alveolar ridge defect, osteoinductive property, primary closure

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;25:445-8

How to cite this URL:
Vidyadharan AK, Ravindran A. Localized ridge defect augmentation using human pericardium membrane and demineralized bone matrix. Indian J Dent Res [serial online] 2014 [cited 2023 Mar 30];25:445-8. Available from:
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.

   Materials and methods Top

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: Intra oral occlusal view of defect

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Figure 2: Pre-operative orthopantomogram showing defect

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Figure 3: Vertical measurement of defect

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Figure 4: Augmentation procedure with Puros® demineralised bone matrix putty with bone chips

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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: Bone fill after 4 months-cross section

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Figure 6: Orthopantomogram 7 months postoperative

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Figure 7: Measuring the volume of bone regenerated

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Figure 8: X-ray of implant with prosthesis after 8 months of loading

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   Discussion Top

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.

   Conclusion Top

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.

   References Top

1.Misch CM. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 1997;12:767-76.  Back to cited text no. 1
2.Rasmusson L, Meredith N, Kahnberg KE, Sennerby L. Effects of barrier membranes on bone resorption and implant stability in onlay bone grafts. An experimental study. Clin Oral Implants Res 1999;10:267-77.  Back to cited text no. 2
3.Proussaefs P, Lozada J, Rohrer MD. A clinical and histologic evaluation of a block onlay graft in conjunction with autogenous particulate and inorganic bovine mineral (Bio-Oss): A case report. Int J Periodontics Restorative Dent 2002;22:567-73.  Back to cited text no. 3
4.Keller EE, Tolman DE, Eckert S. Surgical-prosthodontic reconstruction of advanced maxillary bone compromise with autogenous onlay block bone grafts and osseointegrated endosseous implants: A 12-year study of 32 consecutive patients. Int J Oral Maxillofac Implants 1999;14:197-209.  Back to cited text no. 4
5.Buser D, Dula K, Belser UC, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. II. Surgical procedure in the mandible. Int J Periodontics Restorative Dent 1995;15:10-29.  Back to cited text no. 5
6.Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autografts and barrier membranes: A clinical study with 40 partially edentulous patients. J Oral Maxillofac Surg 1996;54:420-32.  Back to cited text no. 6
7.Buser D, Dula K, Hess D, Hirt HP, Belser UC. Localized ridge augmentation with autografts and barrier membranes. Periodontol 2000 1999;19:151-63.  Back to cited text no. 7
8.Misch CM, Misch CE. The repair of localized severe ridge defects for implant placement using mandibular bone grafts. Implant Dent 1995;4:261-7.  Back to cited text no. 8
9.Simon BI, Von Hagen S, Deasy MJ, Faldu M, Resnansky D. Changes in alveolar bone height and width following ridge augmentation using bone graft and membranes. J Periodontol 2000;71:1774-91.  Back to cited text no. 9
10.Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA. Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J Oral Maxillofac Surg 2008;66:235-45.  Back to cited text no. 10
11.Boyne PJ. Maxillofacial surgery. In: Habal MB, Reddi AH, editors. Bone Graftsand Bone Graft Substitutes. Philadelphia: W.B. Saunders; 1992. p. 291.  Back to cited text no. 11
12.Jensen OT, Cockrell R, Kuhike L, Reed C. Anterior maxillary alveolar distraction osteogenesis: A prospective 5-year clinical study. Int J Oral Maxillofac Implants 2002;17:52-68.  Back to cited text no. 12
13.Thor A. Reconstruction of the anterior maxilla with platelet gel, autogenous bone, and titanium mesh: A case report. Clin Implant Dent Relat Res 2002;4:150-5.  Back to cited text no. 13
14.Simion M, Jovanovic SA, Tinti C, Benfenati SP. Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1-5 year follow-up. Clin Oral Implants Res 2001;12:35-45.  Back to cited text no. 14
15.Fugazzotto PA. Report of 302 consecutive ridge augmentation procedures: Technical considerations and clinical results. Int J Oral Maxillofac Implants 1998;13:358-68.  Back to cited text no. 15
16.Taskonak B, Ozkan Y. An alveolar bone augmentation technique to improve esthetics in anterior ceramic FPDs: A clinical report. J Prosthodont 2006;15:32-6.  Back to cited text no. 16
17.Shin HI, Sohn DS. A method of sealing perforated sinus membrane and histologic finding of bone substitutes: A case report. Implant Dent 2005;14:328-33.  Back to cited text no. 17
18.Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part II. Prosthetic/periodontal interrelationships. Compend Contin Educ Dent 1983;4:549-62.  Back to cited text no. 18
19.Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.  Back to cited text no. 19
20.Cardaropoli G, Araújo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. J Clin Periodontol 2003;30:809-18.  Back to cited text no. 20
21.Thomaidis V, Kazakos K, Lyras DN, Dimitrakopoulos I, Lazaridis N, Karakasis D, et al. Comparative study of 5 different membranes for guided bone regeneration of rabbit mandibular defects beyond critical size. Med Sci Monit 2008;14:BR67-73.  Back to cited text no. 21
22.Rothamel D, Schwarz F, Sculean A, Herten M, Scherbaum W, Becker J. Biocompatibility of various collagen membranes in cultures of human PDL fibroblasts and human osteoblast-like cells. Clin Oral Implants Res 2004;15:443-9.  Back to cited text no. 22

Correspondence Address:
Arun Kumar Vidyadharan
Department of Endodontics and Implant Dentistry, S.U.T.A.M.S Medical College, Trivandrum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.142524

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

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