Open Journal of Stomatology, 2013, 3, 433-439 OJST
http://dx.doi.org/10.4236/ojst.2013.38072 Published Online November 2013 (http://www.scirp.org/journal/ojst/)
Is the immediate use of guided bone regeneration on
exposed dental implant threads beneficial?
Anwar Ramadhan1*, Abdulaziz Ali1, Hessah Aljiran1, Kholoud Hasan1, John Madda2
1Department of Oral and Maxillofacial Surgery, Al-Amiri Hospital , Kuwait City, Kuwait
2Department of Pathology, Al-Amiri Hospital Center, Kuwait City, Kuwait
Email: *dr.anwarramadhan@hotmail.com
Received 23 September 2013; revised 24 October 2013; accepted 31 October 2013
Copyright © 2013 Anwar Ramadhan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Thin buccal bone has a risk of thread exposure, and
placement of a graft is the mainline of treatment for
thread exposure. However, this process takes time as
the patient is expected to wait for healing to occur
before the implant can be placed. To overcome the
waiting period, this study views a different method.
This study examines the use of guided bone regenera-
tion on the day of implant placement on buccal bone
where thread exposure occurs. This process has the
advantage of avoiding the patient to go through mul-
tiple operations till receiving the final prosthetic
treatment, also saving time and money for both the
patient and the practitioner.
Keywords: GBR; Implant; Threads; Exposed
1. INTRODUCTION
The effect of becoming partially or totally edentulous can
have a severe impact on the social, psychological and
functional status, which may cause the patient to feel
older, depressed, lose confidence, and have emotional
relationship problems. Over the years in dentistry, a vari-
ety of options arose to help these patients overcome these
complications. Dentures, bridges and more recently den-
tal implants are being used with each having their own
sets of advantages and disadvantages. Dental implants
are becoming a common choice of treatment in edentu-
lous areas with a success rate of 94% - 97% giving the
patient a satisfying aesthetic and functional effect [1-5].
As there are numerous advantages to dental implants,
there are also disadvantages. Complications can occur
when the quality or quantity of jawbone is affected, so
bone augmentations have become the standard treatment
to create a favorable implant site.
Time needed for maturation of bone after augmenta-
tion can take a considerable amount of time before im-
plants can be placed, and thus the question arises if all
osseous defects should be treated in this way. The addi-
tional time and visits needed are able to affect the cost of
the treatment, the time until the final prosthesis is placed,
and the amount of surgical intervention needed. And as
such reducing this time would be preferable for both the
clinician and the patient.
Implant thread exposure is one of the complications
that can occur after implant placement due to jawbone
anatomy, which can lead to an effect on implant stability,
soft tissues, and esthetic.
Treatment of these implants after formation of dehis-
cence and/or fenestrations with guided bone regeneration
(GBR) has proved to be an effective treatment with
overall survival rate of the implant of 84.7% - 100% with
63% - 100% coverage of the defect [6-16].
The basic concept of GBR is to allow space for bone
formation by excluding non-osteogenic tissue invasion
using a barrier membrane. In this way, the slower prolif-
erating cells from the bone can have adequate time to
form into the space.
In this case study, buccal thread exposure that is pre-
dicted to happen will be managed with implant place-
ment and GBR at the same visit; bypassing the process
of bone augmentation followed by implant placement
after bone maturation. Therefore, saving time for both
the clinician and the patient will be accomplished.
2. CASE 1
A 46 years old female patient, non-smoker, fit and
healthy was referred to AL-Amiri Dental Center(Oral
and Maxillofacial department) for a bone graft consulta-
tion to the 14 region.
*Corresponding a uthor.
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A. Ramadhan et al. / Open Journal of Stomatology 3 (2013) 433-439
434
2.1. Initial Exam
During the initial clinical and radiological exam (Fig-
ure 1), the alveolar ridge showed good vertical height
compared to the alveolar crest of the adjacent teeth with
approximately 3 mm reduction in buccal thickness in the
14 region.
The treatment options were discussed with the patient
including bone grafts, but the patient decided on having
an implant. If thread exposure does occur then guided
bone regeneration can be carried out with Implantium
(Dentium, South Korea), sizing 12 mm length × 3.6 mm
diameter.
2.2. Preoperative
Rinse with chlorhexidine 2% twice for two days and 2 g
Amoxicillen one hour preoperatively.
2.3. Operation Procedure
Alveolar crest incisions were made from the upper right
lateral extending to the second premolar. This was fol-
lowed by a releasing incision distal to the upper right
second premolar (Figure 2). A mucoperiosteal flap was
Figure 1. (Case 1) Preoperative panoramic radiography show-
ing the vertical height of the missing upper right first premolar.
Figure 2. (Case 1) Implant thread buccally exposed at the first
premolar region of approximately 8 mm.
then raised and followed by implant preparation done
according to the Implantium drilling sequence. The im-
plant was manually introduced into bone with 8 mm
thread exposed buccaly. Yet, primary stability was at-
tained (Figure 2).
The exposed thread was covered with allograft bone
(TranZgraft: cortical cancellous 0.5 cc; 250 - 1000 mi-
crons) followed by a resorbable membrane 10 mm × 20
mm (Collagen) (Figures 3 and 4).
Figure 3. (Case 1) Implant threads covered with allograft bone.
Figure 4. (Case 1) Collagen membrane placed over the allo-
graft bone.
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A. Ramadhan et al. / Open Journal of Stomatology 3 (2013) 433-439 435
2.4. Postoperative
Amoxicillen 500 mg 3 times a day for 7 days was pre-
scribed and the patient was monitored weekly to asses
the primary healing for a month. During this period, no
abnormal signs or symptoms were reported or observed.
2.5. Second Stage of Surgery
After a healing period of three months, the patient re-
turned for placing the healing abutment with no symp-
toms. Bone graft matured over the cover screw showing
extensive bone coverage at the buccal side (Figure 5),
and any excess bone was removed and sent to histopa-
thology to investigate the maturation of the bone graft
(Figures 6 and 7).
3. CASE 2
3.1. Initial Exam
A 44 year old female patient attended the surgery
Figure 5. (Case 1) Complete bone healing after 3 months.
Figure 6. (Case 1) Radiographic follow-up after 3 months.
Figure 7. (Case 1) Histological picture of bone removed over
cover screw after 3 months during the second stage. H12-2448
mature bone with osteoblasts H&E X200. Bone was fixed in
formalin and decalcified for 30 minutes in acidic solution
(TBD-1 Rapid Decalcifier from Thermo Scientific), washed in
running tap water before being processed for routine paraffin
impregnation and embedding. 4 micron thick section were cut,
fixed on glass slides and stained with Haematoxylin and Eo-
sin (H&E). The sections were examined under transmitted po-
larized and non-polarized light. Polarized light enhances visu-
alization of bone lamellae. There is a progressive conversion of
acellular material (upper left in photo) into mature lamellar
bone with osteocytes (bottom right of the trabeculum). Notice
the haphazard lamellae in the upper right of less mature bone
compared to the lower organized lamellae of a more mature
part of bone.
requesting implants in the 15, 45, 46, 47 regions. Upon
clinical and radiographical examination (Figure 8), the
patient had insufficient bone thickness at the buccal side.
The vertical height in the 15 region was good. The
treatment options were discussed with the patient in-
cluding bone grafts, nonetheless the patient decided on
having an implant and if thread exposure does occur then
guided bone regeneration can be carried out with As-
tratech dental implant 10 mm in length and 3.0 mm in
diameter was planned to be placed.
3.2. Preoperative
Rinse with chlorhex idine 2% twice for two days, and 2 g
amoxicillin one hour preop e ratively.
3.3. Operation Procedure
An initial alveolar crest incision was made mesial to the
upper right first premolar to the right first molar, fol-
lowed by a releasing incision mesial to the upper right
first molar. Mucoperiosteal flap was raised and showed
buccal bone defect (Figure 9). Next, an implant pr epara-
tion was made according to the Astratech dental drilling
sequence. The implant was then inserted manually
showing 7 mm of thread exposed buccally with primary
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A. Ramadhan et al. / Open Journal of Stomatology 3 (2013) 433-439
436
Figure 8. (Case 2) Preoperative panoramic radiography show-
ing the vertical height of the missing upper right second pre-
molar.
Figure 9. (Case 2) Baccal bone defect after raising the flap.
stability (Figure 10).
Hence, the thread was covered with allograft bone
(TranZgraft: cortical cancellous 0.5cc; 250 - 1000 mi-
crons) followed by a resorbable membrane 15 mm × 20
mm (collage n) (Figures 11 and 12).
3.4. Postoperative
Amoxicillen 500 mg was prescribed 3 times a day for 7
days. The patient was followed up on a weekly basis to
assess the primary healing for a period of one month.
During that period no signs of complications or symp-
toms were reported.
3.5. Second Stage Surgery
Three months later, the patient returned for the placement
Figure 10. (Case 2) Implant thread exposed buccaly at the
second premolar region of approximately 7 mm.
Figure 11. (Case 2) Implant thread covered with allograft bone.
of the healing abutment, and when asked for any symp-
toms; none were reported. The bone graft extended over
the cover screw showing bone coverage at the buccal
side (Figures 13 and 14). Excess bone was removed
from the buccal side and above the cover screw, and then
sent to histopathology to investigate the bone graft
maturation (Figure 15).
4. DISCUSSION
Two cases were predicted with the risk of threads expo-
sure during clinical examination. Clin ically, bo th showed
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A. Ramadhan et al. / Open Journal of Stomatology 3 (2013) 433-439 437
Figure 12. (Case 2) Collagen membrane placed over the al-
lograft bone.
Figure 13. (Case 2) Complete bone healing after 3 months.
thin buccal thickness and patients were informed about
the bone graft at the buccal defect followed with implant
insertion after bone healing as first option treatment to
avoid the risk of thread exposure, and they knew that the
treatment would take 6 months until they receive the fi-
nal prosthetic. Both patients refused the long treatment
period. The second option was the GBR. Patients were
informed about the risk of success rate. Yet, both patients
accepted the second option.
Figure 14. (Case 2) Radiographic follow-up after 3 months.
Figure 15. (Case 2) Histological picture of bone removed over
cover screw after 3 months during second stageH12-3237 ma-
ture bone H&E X200. Bone was fixed in formalin and decalci-
fied for 30 minutes in acidic solution (TBD-1 Rapid Decalcifier
from Thermo Scientific), washed in running tap water before
being processed for routine paraffin impregnation and embed-
ding. 4 micron thick section were cut, fixed on glass slides and
stained with Haematoxylin and Eosin (H&E). The sections
were examined under transmitted polarized and non-polarized
light. Polarized light enhances visualization of bone lamellae.
Case 2 shows bone maturation. Haversian canals are scattered
throughout the lamellar bone. Note osteocytes around Haver-
sian canals.
During surgical procedure, the vertical threads expo-
sure showed more than 7 mm on the buccal plate which
were reflected in this article (Figures 2 and 10). Expo-
sures were during the insertion of dental implants in the
maxilla at the premolar region. The management was
immediate GBR with allograft bone followed by colla-
ge n membr ane.
After three months during the second stage (Figures 5
and 13), Bone integrated over the cover screw in both
cases. Therefore, bone was removed and sent for histo-
logical evaluation. The histological pictures confirmed
the success of bone maturation during 3 months (Figures
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A. Ramadhan et al. / Open Journal of Stomatology 3 (2013) 433-439
438
7 and 15).
Delayed or immediate thread exposure after implant
can be managed in multiple ways. These include mem-
brane coverage, and different types of bone grafts (auto-
grafts, allografts, alloplasts, or xenog rafts) [12,17-20].
In 1999, Lorenzoni et al. published a study of 82 pa-
tients. They received 85 implants in combination with
only expanded polytetrafluroethylene (e-PTFE) for cov-
ering the height of bone loss from 2 - 10 mm. After 24
months, the mean bone loss was 1.5 mm resulting in
success. Survival rates in maxilla and mandible in 2
years of all functional implants were 100% [17].
In 2005, P.A. Fugazzotto reported 98.3% success rate
of 423 implants that were placed in the maxilla and man-
dible using resorbable tricalcium phosphate or deminer-
alized freeze-dried bone allograft (DFDBA) as GBR
technique followed with expanded polytetrafluoroethyl-
ene (e-PTFE) in the study [18].
Juodzbalys et al. managed to treat vertical bone loss of
3.8 - 10 mm defect successfully by simultaneous guided
bone regeneration technique with a success rate of 95%
[12].
The survival rate o f all fun ctional implants after one to
five years was 100%. In the first year, the marginal bone
level deficiency was 1.3 mm, and after five years follow
up vertical bone loss 2 mm was demonstrated [12].
Briefly, our studies aim is to reduce the number of
surgical procedures and to save time and cost by avoid-
ing the augmentation in the buccal alveolar ridge as a
first surgical procedure before inserting the implant after
bone augmentation healing.
The success and survival rate of grafting buccal
threads exposure in d ental implant during the insertion of
the implant by guided bone regeneration technique are
well-documented [17-19] .
According to a recent literature (2012), the success
rate of this type of procedur e can reach up to 100% in the
maxilla and mand ible. On other hand, the surviv al rate of
GBR procedure range from 93.7% to 100% in the follow
up period of 1 to 11 years [19].
In our report the cases were followed one year, the re-
sult showed no resorption of the bone during first year
(Figures 16 and 17). On the other hand, the advantages
in this study showed short treatment period. Patients re-
ceived their final prosthetic in three months without any
complications by reducing the multiple surgical proce-
dures.
However, the report cannot confirm the success and
survival rates as the number of patients were insufficient,
but literatures confirmed it with good results by using
guided bone regeneration in threads exposure [17-19].
5. CONCLUSIONS
This study puts forward that using immediate guided bo n e
Figure 16. (Case 1) Bitewing x-ray taken after one year.
Figure 17. (Case 1) Final prosthetic Result of 14 region after
one year functioning.
regeneration over thread exposure at the time of implant
insertion has several advantages such as reducing treat-
ment period and saving money.
The success of implant integration with bone is based
on primary stability. If you achieve this primary stability
and you conceal the implant well, the survival rate will
rise.
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