A 47-year-old woman presented a severe alveolar defect associated to the failure of the implants in the left side of the mandible (Fig. 1, 2 and 3). A 2-step approach was schedule. Twelve weeks after explantation, bone reconstruction was performed with Fresh Frozen Bone block (Fig. 4) in combination with autogenous particulate cortical bone harvested from tibia (Fig. 5) ad modum Khoury (Fig 6, 7 and 8). Transposition of the inferior alveolar nerve was performed simultaneously due to the emergence on the top of the residual crest (Fig. 2). Autogenous bone marrow aspirate was added. Three 3,5x12 mm Galimplant IPX implants were placed sixteen weeks later (Fig. 9, 10, 11 and 12). A connective tissue graft was placed coronally to improve the soft tissue quality and quantity (Fig. 13). Bone sample for histological examination was obtained (Fig. 14).. Sixteen weeks later the exposure of the implants was performed and three multiunit abutments of height three were screwed and properly tightened. Provisional prosthesis was screwed two weeks later (Fig 15 and 16).

Discussion

Autogenous bone is still the gold standard in bone regeneration, however a donor site is required. Khoury technique is considered a predictable procedure for bone augmentation in moderate to severe alveolar bone defects (1). Fresh frozen bone is a reliable alternative to autogenous bone in implant surgery (2). Combination of both bone sources would provide the advantages of each one separately. To minimize the morbidity associated to this procedure, fresh frozen bone was used as cortical plates and marrow aspirated provided the ideal environment to induce bone formation (3) in combination with autogenous particulate bone (4, 5). Results of the biopsy also confirmed this procedure as an alternative in bone reconstruction.

Conclusion

In conclusion, at the light of the results it is an alternative treatment for the management of vertical defects at the posterior mandible sector.

Bibliography:

1. Khoury F, Hanser T. Mandibular Bone Block Harvesting from the Retromolar Region: A 10-Year Prospective Clinical Study. Int J Oral Maxillofac Implants. 2015;30:688–97. 
2. Carinci F, Brunelli G, Zollino H, Franco M, Viscioni A, Rigo L, et al. Mandibles grafted with fresh-frozen bone: An evaluation of implant outcome. Implant Dent. 2009;18:86–95. 
3. Soltan M, Smiler D, Prasad HS, Rohrer MD. Bone block allograft impregnated with bone marrow aspirate. Implant Dent. 2007;16:329–39. 
4. Lacerda SA, Lanzoni JFA, Bombonato-Prado KF, Campos AA, Prata CA, Brentegani LG. Osteogenic potential of autogenous bone associated with bone marrow osteoblastic cells in bony defects: A histomorphometric study. Implant Dent. 2009;18:521–9. 
5. Smiler D, Soltan M, Lee JW. A histomorphogenic analysis of bone grafts augmented with adult stem cells. Implant Dent. 2007;16:42-53.

Paciente varón de 48 años con parálisis cerebral infantil, no colaborador. Referido para colocar los implantes en el maxilar superior e inferior. Empezamos por el arco inferior que es el que estaba peor. Un año después el paciente no es capaz de limpiar los dientes, y presenta una gran acumulación de placa en la rehabilitación híbrida inferior. En maxilar superior presenta una periodontitis agresiva que no responde al tratamiento conservador, después de años en fase de mantenimiento, decidimos quitar los dientes del arco superior, esperar la curación de los tejidos blandos, la confección de la férula baritada y la colocación de los implantes dentales.

Paciente con edentulismo de largo tiempo de evolución, con alteración del plano oclusal e hipodesarrollo en anchura del maxilar superior. Acuda para rehabilitación de la arcada superior. El estudio radiológico evidencia hiperneumatización de los senos maxilares, presencia de quiste nasopalatino y sobreerupción de la premaxila.

Plan de tratamiento:

1- Resección de 3mm en altura del proceso alveolar para compensar sobreerupción.

2- Retirada del quiste nasopalatino.

3- Colocación de implantes 11i y 21i.

4- Colocación de implantes en reborde infraorbitario correspondiente con las posiciones 13 y 21i.

5- Colocación de implantes cigomáticos en posiciones 15i y 25i.

6- Fijación de injertos tipo onlay procedentes de paredes laterales del maxilar y hueso de banco congelado con aspirado medular.