Khoury Bone Augmentation Tunneling-Technique

46 | IDENTITY
Ponte A., Happe A., Khoury F.:

The tunnel technique: Procedure for bone grafting before implant placement: a case study
in Dentsply Friadent Identity 3: 46-49, 2006
the tunnel technique

Procedure for bone grafting before implant placement:
a case study
| Dr. Alessandro Ponte | Dr. Arndt Happe | Prof. Dr. Fouad Khoury
INTRODUCTION
Bone grafting before implant placement has become a routine A tension-free wound closure is a key factor in the success
procedure over the last 20 years. A 5-year survival rate of up to of bone grafts. Periosteal incisions are a common technique
98.3% for implants placed in grafted bone has been reported. for flap extension. However, too many relief incisions in the
Autologous bone grafts are considered the gold standard. periosteum may also result in an excessively thin or stretched
wound flap. This type of soft-tissue management may result in
However, the success rate of the grafting procedure may be perforation or flap necrosis above the bone graft.
influenced by various risk factors. A particular challenge is
posed by an extensive graft of the alveolar ridge, with relatively In 1987 Härle reported on a tunneling access in connection
high complication rates of up to 20% being reported, most with a technique for preprosthetic jaw ridge grafting in the
commonly dehiscence. More serious complications such as mandibular side-tooth region with bone replacement materials.
dehiscence or mobilization of the graft were observed in one In the clinical experience of the authors the use of a tunneling
third of smokers compared to a complication rate of only 7.7% technique for preparation without a crestal incision can present
for non-smokers. Complications such as flap necroses, dehis- an alternative with autologous bone grafts to conventional
cence and resorption are frequently soft-tissue complications. surgical procedures with a trapezoid flap design.
IDENTITY | 47
MATERIAL AND METHOD

Medical history
The 59-year-old patient, a smoker, presented with partial denti- distally at the grafting site. The distal incision corresponds with
tion in her lower jaw. Her general health was good with health the mesial relief incision of the access flap at the donor site.
status P1 in the ASA classification system (www.asahq.org). Tunnel preparation of the soft tissue was carried out at the
The second premolar and the first and second molar on the left graft site from the mesial incision to the distal incision without
side of the lower jaw were missing. The remaining alveolar pro- relief incisions in the periosteum to establish access to the
jection showed a serious horizontal and vertical defect (Fig. 1). remaining alveolar ridge (Fig. 4). The dissection of the soft tis-
The treatment plan initially proposed grafting the three-dimen- sue from the local bone was extended approximately 10 mm
sional defect with autologous bone from the ramus region of lingually and 25 mm buccally from the alveolar ridge. A block of
the lower jaw on the same side to enable placement of two bone for grafting was removed from the rising ramus of mandi-
implants of appropriate diameter to support a fixed restoration. ble with a diamond disk (Frios MicroSaw, Dentsply Friadent,
A panoramic x-ray was taken before the surgical procedure to Mannheim). The graft was divided sagittally (Fig. 5). The buccal
show the anatomy of the donor region and the grafted region cortical section of the graft was trimmed and fitted to the
(Fig. 2). defect. It was fixed with two osteosynthesis screws, which
maintained a distance from the existing bone (Fig. 6). The
SURGICAL PROTOCOL remaining graft was made into particles and used to fill the
The patient was treated under intravenous sedation. Infiltration space between the graft and the underlying bone (Fig. 7). The
anesthesia with 4% Articain and 1:100 000 epinephrine was incisions were closed with resorbable sutures (Resorba 4-0, 5-0).
administered (Ultracain forte™, Aventis Pharma). Antibiotics After surgery a panoramic x-ray was taken (Fig. 8).
with augmentan (1 g) was administered during surgery to pre-
vent infection. Antibiotics were administered orally for a period The soft tissue had healed 10 days after surgery. The sutures
of 14 days after the surgical procedure. were removed 14 days after surgery. A vestibuloplasty was con-
ducted 16 weeks after the bone graft and two Xive implants,
Nimesulid 300 mg (Aulin™, 300 mg, Roche) was prescribed for diameters 3.8 and 4.5 mm, (Dentsply Friadent, Mannheim) were
two to three days to relieve postoperative pain. The patient successfully placed at the planned positions (Fig. 9 and 10).
was instructed to use an antiseptic mouthwash containing An additional minimal crestal graft was placed cervically in
chlorhexidine (2 %) three times a day for two weeks. region 35 with bone harvested while preparing the implant site.
Two vertical mucoperiosteal incisions were made mesially and A bone shield membrane was placed and fixed with Frios
1 2 3 4
48 | IDENTITY
DISCUSSION
membrane tacks. The wound was closed in accordance with The advantage of the technique described here is the minimally
the vestibuloplasty after Kasanjian (Fig. 11) to establish stable invasive biological application with two key factors:
soft-tissue conditions in the region of the implant site (Fig. 13).
The positions of the implants were checked with a panoramic 1_Blood circulation in soft tissue unimpaired
x-ray image (Fig. 12). The implant was uncovered 12 weeks later 2_Biomechanical properties of soft tissue unimpaired
(Fig. 14). At this stage the crestal pre-implant bone was disco-
vered to have regenerated well clinically (Fig. 15). After the Flap necrosis and wound dehiscence are the two major pro-
soft tissue had healed (Fig. 16) the newly regenerated alveolar blems in bone grafting surgery. They both contribute to uncovery
process (Fig. 17 and 18) is visible and two metal-ceramic of the graft with subsequent infection of the surgical site and
crowns were cemented to titanium abutments (Fig. 18 and 19). failure of the surgical procedure. The soft-tissue complications
A clinical and x-ray examination was conducted one year after are frequently the result of damaged blood circulation resulting
the restoration. The soft-tissue conditions were stable and from inadequate planning, insufficient flap extension or excessive
showed no signs of inflammation. The x-ray showed no signs of surgical trauma.
peri-implant bone resorption, with the crestal bone still at the
same level as the implant shoulder (Fig. 20). Soft tissue is frequently stretched or even overstretched to cover
the additional volume of the graft. In many cases an incision
is made in the periosteum to enlarge the flap extension.
5 6 7 8
9 10 11 12
IDENTITY | 49
Dr. Alessandro Ponte Dr. Arndt Happe Prof. Dr. Fouad Khoury
However, this can cause overstretching and excessively thin Dr. Alessandro Ponte
tissue. This reduces the mechanical quality and the blood Specialist in oral surgery
C.so Susa 50 10098 Rivoli (TO) Italy
circulation. The great advantage of the flap design with the
Via Frattina 119 00187 Rome, Italy
tunnel technique is the ability to avoid the crestal incision.
[email protected]
This technique retains the blood circulation and does not
damage the tissue. This is particularly important for patients Dr. Arndt Happe
with vascular problems, such as smokers, diabetics and Specialist in oral surgery
patients with scar tissue. ■ Schützenstr. 2 · 48143 Münster/ D
[email protected]
www.study-club-implantologie.de
Literature can be requested from the authors.
Prof. Dr. Fouad Khoury
Privatklinik Schloss Schellenstein GmbH
Center for implant dentistry and dental surgery
Am Schellenstein 1 · 59939 Olsberg/ D
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46 | IDENTITY

Ponte A., Happe A., Khoury F.:

the tunnel technique

MATERIAL AND METHOD

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