CASE REPORT

Implant Bone Rings. One-Stage

Three-Dimensional Bone Transplant
Technique: A Case Report
Mark R. Stevens, DDS1*
Hany A. Emam, MS2
Mahmoud E. L. Alaily, MS3
Mohamed Sharawy, PhD4

A variety of techniques and materials has been used to provide the structural base of bone
and soft tissue support for dental implants. Alveolar bone augmentation techniques include
different surgical approaches such as guided bone regeneration, onlay grafting,
interpositional grafting, distraction osteogenesis, ridge splitting, and socket preservation. In
the case presented, a technique was used to augment the alveolar bone three-dimensionally
with autologous ‘‘bone rings’’ and immediate implant placement in a 1-stage procedure
following teeth extraction. Bone rings (circular osteotomies) were outlined at the symphysis
area using trephine burs, and a central osteotomy for implant placement was done before its
removal. The rings were then removed and sculptured to fit the extraction socket; this was
followed by screwing the implant through the ring, gaining its primary stability from the
prepared basal bone.

Key Words: trephine bone grafting, immediate implants, bone rings

INTRODUCTION surgery is the main issue but also the

precision in execution of the surgical tech-

T
he definitive implant restoration
needs to be surrounded by hard niques should be considered to obtain an
and soft tissue environment that overall favorable outcome.2
is in harmony with the surround- This article describes a surgical technique
ing dentition.1 The amount of of restoring maxillary incisors using immedi-
bone and soft tissue present prior to implant ate implants and autogenous bone graft in
the form of ‘‘bone rings’’ harvested from the
1 symphysis.
School of Dentistry, Medical College of Georgia,
Augusta, Ga. A 45-year-old woman presented with
2
Oral and Maxillofacial Surgery, Faculty of Oral and
Dental Medicine, Cairo University, Egypt; Medical
persistent mobile maxillary central and
College of Georgia, Augusta, Ga. lateral incisors after definite periodontal
3
Private practice, Cairo, Egypt.
4
Oral Biology/Anatomy, Medical College of Georgia,
treatment (pocket depth ranged from 6 to
Augusta, Ga. 8 mm). The panoramic radiograph showed
* Corresponding author, e-mail: mastevens@mail.mcg.
edu
moderate to severe bone loss around the
DOI: 10.1563/AAID-JOI-D-09-00029 teeth. The patient underwent extensive full

Journal of Oral Implantology 69

Immediate Implants and Bone Grafting
mouth periodontal therapy including scal-
ing, root planing, and oral hygiene in-
structions to control her periodontal prob-
lem. The inflammatory condition stabilized;
however, mobility of the maxillary incisors
did not improve and temporary splinting
was not acceptable or predictable. Diagnos-
tic casts were mounted to visualize the
treatment plan for immediate implant place-
ment with simultaneous bone augmenta-
tion.
Surgical procedures
The patient was instructed to rinse with
0.12% chlorhexidine gluconate mouthwash
just prior to surgery for 1 minute. Surgery
was performed under deep conscious
sedation (Propofol) and local anesthesia
(articaine 4%, epinephrine 1:100 000) for
pain control. Preoperative antibiotic clin-
damycin, 600 mg, was administered intra-
venously.
Bone rings harvesting
The symphysis was accessed through a
genioplasty incision. The mental nerves were
exposed and protected. Using an 8-mm
trephine bur and under copious saline
irrigation, multiple circular osteotomies were
outlined, spaced, and drilled through the
exposed symphysis. The bone discs outline
were placed 3–4 mm away from the root
apices of the mandibular anterior teeth.
During this step, the trephine was slightly
torqued to partially loosen the bone discs to
facilitate its subsequent removal without
fracture. An implant drill was subsequently
used to prepare central osteotomies corre-
sponding to the final implant diameter to be
placed in the center of each disc converting
it to a ‘‘bone ring.’’ The osteotomies
corresponded to eventual placement of 3.0-
mm diameter implants. The ‘‘bone rings’’
were then carefully removed from the chin.
Four rings were harvested using the de-
scribed procedure (Figures 1 and 2).
70 Vol. XXXVI/No. One/2010
Implant surgery
Gingival sulcular incisions were made
around the teeth to be extracted with 2
oblique vestibular releasing incisions. The
incisor teeth were extracted atraumatically.
Soft tissue remnants in the extraction
socket were carefully removed to ensure
complete removal of all contaminated
tissues. Sequential osteotomies through
the extraction sites were accomplished for
immediate implant placement as recom-
mended by the implant manufacturer. The
osteotomies were performed at least 3 mm
apical to the extraction socket as recom-
mended in the literature to obtain primary
stability. The bone rings were then used to
guide the pilot drill over the socket and
assist in their optimum prosthetic planned
positions.
The harvested bone rings were then
snuggly fitted in the extraction socket. Minor
contour adjustments were necessary to
ensure their adaptation and stability. Im-
plants were then tapped through the ‘‘bone
rings,’’ achieving and even increasing the
primary stability of ‘‘bone ring’’ and implant
to the basal alveolar bone. Countersinking of
the implants 1 mm was performed within
the bone rings to compensate for the
anticipated crestal bone resorption and
provide the best emergence profile by the
surrounding soft tissue drape.
Using a bone curette, scraping of
cancellous bone from the harvested site
was used to fill any observed gaps found
between the bone rings and the implant
preparation site. Concurrently, augmenta-
tion of facial defect was also accomplished
to further reconstruct the alveolar bone.
Sharp edges were identified and gently
rounded by low speed fissure bur under
copious saline irrigation. Periosteal scoring
was then accomplished at the base of the
flap to advance and expand the soft tissues
and provide primary closure without ten-
sion (Figures 3 and 4).
 Stevens et al

FIGURES 1–4. FIGURE 1. Bone rings outlined in the symphysis with the central osteotomies corresponding
to the diameter for implants to be placed. FIGURE 2. Bone rings after removal from the symphysis.
FIGURE 3. Three dimensional augmentation using ‘‘bone rings’’ with simultaneous implant placement.
FIGURE 4. Diagrammatic representation of the ‘‘bone ring’’ technique.

A pressure bandage was applied to the When placing an implant in an immedi-

chin after layered closure and resuspension
of the mentalis muscle to provide continued
soft tissue support and to minimize postop-
erative edema.
Treatment outcome
All implants were osseointegrated. On in-
spection during the second phase surgery
(6 months), improvement in the overall
alveolar bone height and consequent soft
tissue level was achieved at the augmented
site. This was further supported by the
postoperative panoramic radiograph (Fig-
ures 5 and 6). No signs of infection or
dehiscence were noted around the implant’s
bone interface.
The patient showed complete satisfac-
tion with the final prosthesis with respect
to esthetics and function (Figures 7 through
9).
ate extraction site, the surgeon needs to
consider the socket dimension and possible
gaps that occur around the coronal aspect of
the implant.3,4 One area that is overlooked or
difficult to simultaneously reconstruct is the
crestal bone height, especially after its loss
due to periodontitis.5,6 Another concern with
immediate implant placement with anterior
teeth sockets is the thin facial cortex of the
alveolar housing. This residual bone can
rapidly resorb or dehisce, compromising
the implant.7,8
There are several advantages proposed
by this technique, including a 3-D augmen-
tation of the native alveolar ridge, elimina-
tion of the socket gap implants interface,
and the ability to provide additional stability
of the implant at the crestal region of the
implant. The additional stability is achieved
through screwing the implants to the bone

Journal of Oral Implantology 71

Immediate Implants and Bone Grafting

FIGURES 5 AND 6. FIGURE 5. Preoperative panoramic radiograph (left) showing marked bone resorption
around maxillary incisors. Periapical radiograph (right) showing preoperative crestal bone level.
FIGURE 6. Postoperative (6 months) panoramic radiograph (left) showing the increased crestal bone
height gained by the ‘‘bone rings’’ around the implant (yellow arrows). Note the sites of the bone rings
harvested from the symphysis (white arrows). Periapical radiograph (right), showing bone surrounding
the cervical part of the implants (arrows). Note the integration of the bone rings with the crestal bone
and the cervical part of the implants.

rings, which are carpentered to fit snuggly
into the socket walls. This technique is also
advantageous in cases where there is insuf-
ficient primary implant stability secondary to
insufficient bone volume at the apical aspect
of the extraction site, and subsequent apical
drilling is not possible.
The simultaneous onlay crestal augmen-
tation by the ‘‘bone rings’’ at the residual
socket also enhances the soft tissue contour
and helps resist soft tissue contraction in this
highly esthetic zone. The ‘‘harvested’’ bone
rings ‘‘can be carved to any desired dimen-
sions, thus ideally reconstructing any alveo-
lar defect to optimize the biomechanical and
esthetic outcome. The implant also symbiot-
ically provides stabilization of the bone graft
to promote graft union and minimize graft
resorption.
Considering the treatment and healing
time, rather than performing 2 surgeries for
socket augmentation, waiting for graft heal-
ing, and reopening for implant placement, a
1-stage procedure for augmentation with
simultaneous implant placement can be
done in an acceptable operative time.9,10
This also will prevent further bone resorption
and soft tissue shrinkage with subsequent
loss of attached gingiva due to a second
surgery if a staged procedure is used.
Clinical reports have suggested that a
history of periodontal or endodontic infec-
tions is a predictive marker for implant
infection and failure. This clinical experience

72 Vol. XXXVI/No. One/2010


FIGURES 7–9. FIGURE 7. Probe denoting facial bone level aspect after periodontal depth measurement.
FIGURE 8. Abutment placement. FIGURE 9. Final restoration.
has led most clinicians to avoid the imme-
diate implant placement at infected sites and
to consider infection as a contraindication
for immediate placement. However, the
present case report was performed in
accordance with a study made by Casap et
al11 who concluded that successful immedi-
ate implantation in infected alveoli can be
obtained, depending on complete removal
of all contaminated tissues and controlled
regeneration of the alveolar defect.
With the aid of advanced radiographic
techniques (computed tomography) for pre-
operative bony assessment and by using
graded trephine burs with different sizes, it is
possible to exactly harvest a precise pre-
calculated height and diameter bone graft
needed to augment the extraction socket
with simultaneous implant placement in the
optimum 3-D position.12 Also, in restoring
multiple missing adjacent teeth, an exact
width of the needed bone rings can be
Stevens et al
predetermined in the treatment plan and
can be harvested in an exact dimension from
the chin providing a precise custom-made
augmentation at the desired area.
It should be mentioned that proper
preoperative treatment planning is manda-
tory in order to obtain favorable results.
During the grafting procedure, vertical and
horizontal measurements of the socket
defects were obtained to provide a 3-D
review for both bone ring graft dimensions
and to assist in implant emergence profile.
Care should be taken during bone rings
harvesting from the symphysis because
they may fracture during removal. It is
prudent to map out planned areas should it
be necessary to harvest additional bone
rings. Autogenous bone, which is still
considered the gold standard, is accompa-
nied by the usual donor site morbidities,
such as pain, edema, infection, and occa-
sionally paresthesia.
Journal of Oral Implantology 73
Immediate Implants and Bone Grafting
The patient was closely monitored clini-
cally and radiographically once a week for 1
month to ensure proper healing. Possible
early complications include dehiscence, graft
exposure, and infection. Late complications
include graft resorption, implant mobility,
and failure. In the present case, minor bone
changes were compensated by adding to
the crown length (limited cervical collar)
without compromising the biomechanics.
The patient was strongly encouraged to
maintain oral hygiene measures with chlor-
hexidine mouthwash and was maintained for
5 days on antibiotics (clindamycin 300 mg/
8 hours) to minimize the risk of infection.
Brufen, 400 mg/8 hours, was used for pain
control. Temporary prosthesis was kept out
of occlusion, and the underside of the bridge
was also relieved to avoid any pressure on
the surgical site during the healing period.
In conclusion, the proposed technique
offers multiple advantages of a 1-stage
procedure for immediate implant placement
and 3-D bone augmentation. Proper treat-
ment planning and careful surgical execution
are essential to ensure predictability.
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