Journal of Oral Biology and Craniofacial Research 12 (2022) 853–858

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Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Reconstruction of osseous defect with symphysis block graft for

implant placement
John Roshan a, Surej Kumar L.K.b, Sherin N. Rahim c, Adersh G.A.b,
Mathew Joseph Thuruthel b, *, Ahammed Haris H d
a
Department of Implantology, PMS College of Dental Science and Research, Trivandrum, Kerala, India
b
Department of Oral and Maxillofacial Surgery, PMS College of Dental Science and Research, Trivandrum, Kerala, India
c
Government Medical College, Kasargod, Kerala, India
d
Oral & Maxillofacial Surgeon, Trivandrum, Kerala, India

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Symphysis being an autogenous bone graft serves as one of the best graft for augmenting osseous
Autogenous graft defects of alveolar process with excellent results. It has been favoured mainly due to its local availability,
Symphysis graft accessibility and lesser resorption compared to other bones in the region.
Implant grafting
Case report: A 21/M reported to the department of Implantology with the complaint of missing tooth in the upper
front tooth region since 1 year. History revealed extraction of upper left central incisor an year ago following
trauma. Diagnosis was made as Siebert’s Class I with horizontal bone loss irt 21 region with a bone defect of
10.54 x 5.08 x 4.85 mm. So a complete prosthetic rehabilitation protocol was made with an implant placement
and grafting was planned with symphysis being most favourable.
Conclusion: The mandibular symphysis is a reliable intraoral graft site that can be used in the office setting with
low morbidity. Because of the intraoral approach and lack of cutaneous scarring, patient acceptance is high.

1. Introduction 2. Case report

Bony defects may occur as a result of trauma, prolonged edentulism, A 21/M reported to the department of Implantology with the
congenital anomalies, periodontal disease and infection which often complaint of missing tooth in the upper front tooth region since 1 year
require hard and soft tissue reconstruction.1 (Fig. 1). History revealed extraction of upper left central incisor an year
Rehabilitation of such patients often requires a good alveolar ridge. ago following trauma. Patient was self-motivated and had visited
Autogenous bone grafts have been used for many years for ridge various centre for treatment. Medical history and personal history gave
augmentation and are still considered the gold standard for jaw recon­ no contributory findings. On clinical examination, an edentulous area
struction as it has osteogenic, osteoinductive and osteoconductive was seen in upper left incisor region.
properties. Since Orthopantamogram will not give a 3D assessment, a CBCT was
Of all the sites available intraorally, one of the most prominent bone advised which would address the cubic deficiency and also availability
grafting site is symphysis. Other than the local availability and acces­ of CBCT was there at our centre (Fig. 2).
sibility, it has much lesser resorption than other bone grafts of the CBCT revealed significant buccal cortical bone loss and on further
region. volumetric analysis, the defect size was measured (Buccolingual width
However, the benefits of using this graft is not being utilized by of 3.13 mm at crest) (Fig. 3). The study model revealed an inter-arch
surgeons and implantologists. This area has been neglected over the past space of 12 mm. After evaluating the CBCT and study model, diag­
years despite its many success reports in literature. So here we report a nosis was made as Siebert’s Class I with horizontal bone loss irt 21 re­
case of implant placement with symphysis graft to further strengthen gion with a bone defect of 10.54 x 5.08 x 4.85 mm.
and promote its use among practitioners. So a complete prosthetic rehabilitation protocol was made with an

* Corresponding author.
E-mail addresses: drjohnroshan@gmail.com (J. Roshan), surejkumarlk@gmail.com (L.K. Surej Kumar), shrnrhm@gmail.com (S.N. Rahim), adarsh0004@gmail.
com (G.A. Adersh), mathewthuruthel7@gmail.com (M.J. Thuruthel), ahamed.harys@gmail.com (A. Haris H).

https://doi.org/10.1016/j.jobcr.2022.09.010
Received 7 February 2022; Accepted 22 September 2022
Available online 26 September 2022
2212-4268/© 2022 Craniofacial Research Foundation. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Roshan et al. Journal of Oral Biology and Craniofacial Research 12 (2022) 853–858

Fig. 1. Pre-operative photo.

Fig. 2. CBCT cut showing bone deficiency in 21 region.

Fig. 5. Graft harvesting from symphysis using piezoelectric device.

Fig. 3. Axial cut showing bone width of 3.13 mm.

Fig. 4. 3D Reconstructed view showing donor site and recipient site graft measurements.

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Fig. 8. 3-0 black silk suture used to close the recipient site.

3.2. Donor site preparation

Fig. 6. Graft placed at recipient site with 2 self-tapping titanium screws and A crevicular incision was given extending from lower first premolar
osseograft placed around the graft. to the other side. Mucoperiosteal flap was reflected. Osteotomy was
performed using a piezoelectric device creating a unicortical cut (Fig. 5).
The cuts were made atleast 5 mm inferior to root tips and 5 mm superior
to inferior border of mandible. The graft was harvested with an osteo­
tome and was recontoured to adapt it to the recipient site.

3.3. Graft placement

Graft was placed into the defect. It was stabilised with 2 self-tapping
titanium screws (2 × 10mm) and osseograft placed around the margin of
harvested graft (Fig. 6). It was then covered by an absorbable collagen
membrane which was held in place using bone tacks (Fig. 7).
After stabilizing the collagen membrane, the site was closed with 3–0
black silk sutures (Fig. 8). The donor site was filled with a hemostatic
collgen sponge and the periosteum and muscle attachment were care­
fully sutured in one layer and the mucosa closed as a second layer using
resorbable sutures.
Post-operatively patient was given antibiotics, analgesics and anti-
inflammatory medication. Patient was recalled on every alternate day
to check for wound dehiscence and hematoma. Clinically, the operated
sites showed good wound healing post-operatively after 10 days.
Patient was recalled once in 3 months to take radiographs to check
for bone formation. After 10 months, the recipient site showed good
wound healing and bone formation.
A new CBCT showed patchy to coarse bony trabecular pattern of D2-
D3 type of bone in relation to recipient site and increased buccolingual
Fig. 7. Absorbable collagen membrane held in place using bone tacks. width of 7.2 mm at crest (Fig. 9). So the implant size was selected as per
CBCT measurements and was finalized as 4.3 × 13mm of Dentium
Implant.
implant placement and grafting was planned with symphysis being most
favourable. For a more precise planning, the defect size and donor site
bone were measured and estimated on the CBCT (Fig. 4). 3.4. Implant placement procedure
Routine blood investigations were done to rule out any systemic
disease and were found to be within normal limits. Patient was subjected After 1 year following symphysis graft placement, implant was
to procedure on the 5th day from the first visit having the time required placed. In order to place the implant, a crestal incision was given along
for basic investigations. with 2 releasing incisions around 22 region. Full thickness mucoper­
iosteal flap was reflected to expose the titanium screws and bone tacks
3. Surgical procedure which were then removed (Fig. 10). Following this, Dentium Implant
(4.3 × 13mm) placed crestally over which coverscrew was placed and
3.1. Recepient site preparation the site closed using 3-0 black silk suture (Fig. 11).
After 3 months, secondary stability was verified and crown pros­
A crestal incision and 2 vertical releasing on either side of 22 region thesis was delivered (Fig. 12).
were given. Full thickness muoperiosteal flap reflected. Granulomatous However, the smile line of the patient was showing spacing between
tissue and other soft tissue were removed from the site giving the visi­ 11,21,22. So prosthetic rehabilitation of adjacent teeth were carried out.
bility of bare bone having defect. As the first step, impression was taken using irreversible hydrocolloid
material. Diagnostic casts were poured in using type III dental stone.

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Fig. 9. Bone graft fixation with screws seen. Patchy to coarse bony trabecular pattern of D2-D3 type of bone noted.

Diagnostic wax-up was done for visible reference as to what changes are
necessary for achieving the desired result for the patient. Putty index
was made following that. Crown cutting done for 22, temporisation done
using protemp and luted using freegenol. Indirect mock-up was done on
the patient using the previously formed putty index (protemp used).
Patient recalled for final cementation of zirconia crown irt 22 and
composite restoration irt 11 for closing midline diastema, thus achieving
the desired aesthetic results by the patient (Figs. 13 and 14).

4. Discussion

Defect management in the anterior maxilla especially in a young

patient can be a real challenge for surgeons and clinicians. Various
techniques like distraction osteogenesis, guided bone regeneration and
onlay grafting has been suggested in the literature. However, autoge­
nous bone graft remains the most sought after due to its incredible
properties and uptake. These days most surgeons and patients prefer
harvesting bone from an intraoral site due to close proximity, less donor
site morbidity and convenient access. The most common intraoral sites
for bone harvesting include ramus buccal shelf, symphysis, retromolar
area and maxillary tuberosity.
Symphysis comprises of 65% cortical bone and 35% cancellous bone
and has more cancellous bone than any other intraoral site. Literature
suggest that it has lesser resorption rate due to intramembranous bone
formation. Symphysis graft can be harvested from the midline as a block
graft of size 1.5 x 6 cm(approx.) or as paramedian harvest of 2 blocks of
size 1.5 x 3cm(approx.).2 The graft thickness is 3–11 mm, with most sites
providing 5–8 mm. The density of the graft is D-1 or D-2.3 These grafts
are mainly used for horizontal/vertical ridge augmentation or for filling
osteotomy gaps during orthognathic surgery and the cancellous part of
Fig. 10. Graft completely taken up by recipient site leaving the titanium this bone can be used for sinus augmentation procedures.2
screws behind. For harvesting the symphysis graft, osteotomy cuts were given
conventionally according to Rule of 5’s by Misch4 who said that superior
cut should be 5 mm below root apices and inferior cut should be 5 mm
above the lower border and vertical cut should be at least 5 mm away
from mental foramen.
But Pommer et al.5 in 2008 advised new safety margins for reducing
the risk of injury to mandibular incisive canal and the safety margins
were depth of graft should be 4 mm and distance to the tooth apices at
least 8 mm. Lower border of mandible should be kept intact with the 5
mm safety distance from the mental foramen.
Various techniques to harvest graft include: 702 Fissure bur, Oscil­
lating saw, Trephines, Disc, Piezoelectric instruments. Different patterns
of graft that can be obtained are J-graft, Ring graft, Rectangular block
graft, Cylindrical bone cores.3
The advantages of symphysis graft include easy accessibility, cortico-
cancellous bone morphology, more cancellous bone than any other
intraoral site and can easily be harvested by less experienced implan­
Fig. 11. Placement of Dentium implant 4.3 × 13mm at 21 region. tologists and practisioners.
Disadvantages include increased donor site morbidity in comparison
to ramus block graft and longer waiting period for rehabilitation since it

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Fig. 12. Cement retained prosthesis delivered irt 21.

will prevent migration of epithelial cells and fibroblasts which could

hinder the growth of bone.
As with the option of immediate vs delayed implant, immediate
implant is always associated with higher failure rate, so naturally we
decided to go for delayed implant post symphysis grafting.
So, we managed to treat a young patient having bone defect with the
help of symphysis autograft which yielded a 100% success rate with
subsequent placement of implant and a complete prosthetic rehabilita­
tion to the patient without any morbidity.

5. Conclusion

Extraction following trauma usually leads to bone loss and it may be

Fig. 13. Final cementation of zirconia crown using dual cure resin cement irt
rehabilitated with an implant but will compromise the esthetics. In such
22 and direct composite restoration on 11.
scenarios, a bone grafting can be done to augment the bone horizontally
or vertically before implant placement so that both function and es­
is a 2-stage procedure. thetics are obtained. The mandibular symphysis is a reliable intraoral
Some of the contraindications include mandible with long anterior graft site that can be used in the office setting with low morbidity.
teeth, inadequate mandibular height or width, gross vertical bone loss Because of the intraoral approach and lack of cutaneous scarring, patient
and width augmentation spanning more than 4 teeth. acceptance is high. Bone harvested from the mandibular symphysis is
As with any other grafts, intraoperative complications include mainly cortical in nature, allowing application of rigid fixation in situ
bleeding, mental nerve injury, block graft fracture, potential bicortical and thus providing good primary stability. These grafts can be easily
harvest. Other post-operative complications are pain, swelling, infec­ carved to intimately fill in defects and provide good alveolar contour.
tion, neuro-sensory deficits including altered sensation of lower lip,
chin, chin ptosis and dysesthesia of anterior mandibular dentition.1 Funding
Various techniques have been employed to fix the grafted bone
which include plate fixation, mesh, screws and pin to name a few. They This research did not receive any specific grant from funding
often carry complications which include wound dehiscence and screw agencies in the public, commercial or not–for–profit sectors.
exposure.
In the current case, we used self tapping titanium screws to prevent Declaration of competing interest
micro-rotation of the graft which would result in compromised healing,
resorption and graft non-union.1 None.
Osseograft was placed around the harvested graft to provide a good
contour and to eliminate any dead space between the graft and recipient
site.2 Absorbable collagen membrane was used to cover the graft as it

Fig. 14. Before and after final prosthetic rehabilitation.

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Acknowledgements 2 Stern A, Barzani G. Autogenous Bone Harvest for Implant Reconstruction. Dental Clinics
of North America; 2015.
3 Desai A, Mehta D, Tarun Kumar A, Thomas R. Current concepts and guidelines in chin
All authors have none to declare. graft harvesting: a literature review. Int J Occup Health Saf. 2013;3(1):16.
4 Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar
References defects with mandibular symphysis grafts for dental implants: a preliminary
procedural report. Int J Oral Maxillofac Implants. 1992;7:360–366.
5 Pommer B, Tepper G, Gahleitner A, Zechner W, Watzek G. New safety margins for chin
1 Pikos M. Mandibular block Autografts for alveolar ridge augmentation. Atlas Oral bone harvesting based on the course of the mandibular incisive canal in CT. Clin Oral
Maxillofac Surg Clin. 2005;13(2):91–107. Implants Res. 2008;19:1312–1316.

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