Natural Implant Restoration in Stable Alveolar Bone (NIRISAB)—Concepts in Clinical Practice: Long-Term Follow-up on Three Cases of Ridge Reconstruction Using the Tunnel Approach With Remote Incision
One of the most challenging aspects of dental alveolar ridge augmentation surgery is achieving proper wound closure and uneventful healing. To date, most of the open flap approaches have been fraught with complications. Many of these complications can be eliminated if the soft tissue incision is placed away from the surgical site. This paper describes the clinical application of a remote incision in various ridge augmentation surgeries as developed by Dr Hilt Tatum. It is part of the concept of natural implant restoration in stable alveolar bone that Dr Tatum introduced in the early 1970s.
Buccal and occlusal views of the severely atrophic first molar edentulous sites.
CBCT images showing the left and right sites. Although it is possible to place root form implants into the residual bony ridges, the crown:implant ratio and trajectory of the implants would be highly unfavorable.
View of the remote incision access point at the medial of the first premolar, 1 tooth anterior to the graft.
CBCT cross-sectional view of the lower right grafted site. The lower density allograft bone is visible.
CBCT coronal view of the bilateral grafted sites.
CBCT occlusal view of the bilateral grafted sites.
CBCT model rendering of the grafted site. The allograft, at the time of placement has a relatively low mineral content and therefore is not visible in 3-dimensional rendering.
Immediate postgrafting occlusal views and 2-week postgrafting occlusal views of the left (top) and right (bottom) grafted sites. The gain in ridge width was quite dramatic at this stage.
Comparing the pregrafting views (left) and the 4-month postgrafting occlusal views of the sites. Obvious gains in ridge width is noticeable.
CBCT views of the grafted sites showing increased density of the grafted areas. The increase bone mineralization is now visible in the CBCT 3-dimensional rendering.
(a and b) Left implant (Ankylos A 9.5) placement and sulcus former. (c and d) Right implant (Ankylos A 9.5) placement and sulcus former. (e) Occlusal CBCT view showing the new buccal cortical plate formation at the left grafted site, whereas that of the right side was disturbed at the time of implant placement. (f) Sutured implant site using the VBIF technique.
CBCT cross-sectional views of the right and left implants in place. Proper implant trajectory is achieved in the newly reconstructed bone.
Periapical radiographic images (a and b) at the time of implant placement, (c and d) at 9 months after integration, (e and f) at 1 year, and (g and h) at 3 years.
Periapical radiographic images (j and k) at year 12 after implant placement. (i and l) Intraoral photographs were taken at year 12.
CBCT cross-sectional image showing the deficient height and width of the residual ridge of the lower left posterior mandible.
Immediate postgrafting CBCT cross section and sagittal view of the grafted site showing the volume of bone block secured by a single bone screw.
Photographs of the grafted site immediately after surgery. Coe-Pak periodontal dressing was used to seal the gingival cut of the most distal premolar where the soft tissue tunnel was accessed.
(a) Dehiscence due to perforation of the overlying soft tissue by the bone block. (b) Side view of the grafted site at 6 months. (c) Periapical radiograph at 6 months showing the gain in bone height.
CBCT image showing a new crestal height at 15 mm.
(a) Periapical radiograph of implants showing crestal bone level at the time of placement. (b) Ankylos implants with sulcus formers in place. Closure with the VBIF technique and 4/0 chromic gut sutures. (c) CBCT image of implants in place. (d) Periapical radiograph at 4 months showing excellent crestal bone maintenance.
Final restorations photographs and corresponding radiograph of the lower left first and second molar implant supported screw retained FP1 prosthesis.
Year 2 photograph and corresponding radiograph of the lower left first and second molar implant-supported screw-retained FP1 prosthesis.
Ten-year photograph. (a) Periapical radiograph. (b) Horizontal and vertical bone loss is evident from many years of neglect and disrepair. Moderate gingival recession corresponds to the oral hygiene neglect. (c) Occlusal photo showing the missing occlusal access seal. Food impaction in the crown is evident.
Panoramic radiographic image showing the bone height deficiency in the right posterior maxilla and an impacted retained upper right third molar.
Purple line outlining the incision for remote access. CBCT image showing the areas of deficiency, impacted upper right third molar. The white arrow indicated the position of the bone incision for the down fracture.
Outline of the proposed subcentral bone graft volume and the position of the proposed irradiated bone block graft.
This CBCT image shows vertical and horizontal dimensional gain immediately after surgery. The subantral space was also grafted with cancellous bone.
(a) Panoramic image at 4 months after surgery showing newly formed bone height. (b) Panoramic images showing 2 Ankylos A14 (3.5 × 14 mm) implants in place.
(a) Cement-retained crowns restored the area. (b) View of the buccal corridor of the right side. (c) Occlusal view of the cement-retained crown. A healthy band of attached gingiva is observed with this patient.
(a) Radiograph of the implant crestal bone level at 1 year and view of the upper right gingival esthetics with plenty of keratinized gingival tissue. (b) A healthy band of attached gingiva is observed around these restorations. (c) Radiographic bone level of the implants at 7 years.
(a) Radiograph illustrating stable bone levels at year 12. (b) Intraoral photograph showing stable gingival health at year 12.
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