Alveolar reconstruction in the aesthetic zone: the challenge of non-contained defects

Dental trauma occurring during childhood often leaves complex late sequelae, such as chronic periapical infections or root resorptions. In this 29-year-old patient, an old trauma to the upper central incisor (#11) led to massive vestibulo-palatal and vertical bone loss. This type of so-called "non-contained" defect, characterized by the disappearance of the buccal plate, represents one of the most demanding reconstructive challenges in implantology, compromising both implant positioning and aesthetic integration.

The objective of this case report is to demonstrate the effectiveness of a sequential guided bone regeneration (GBR) approach to restore alveolar architecture. The documented strategy is based on the use of a titanium mesh (TM), chosen for its superior mechanical stability, combined with a composite graft mixing autogenous bone harvested from the ramus and bovine xenograft (Bio-Oss).

The clinical hypothesis is based on the fact that the rigidity of the titanium mesh, combined with the osteogenic potential of autogenous bone, allows for the reconstruction of a stable three-dimensional bone volume. This approach aims to transform a complex defect into a favorable site for prosthesis-driven implant placement, while managing the soft tissue phenotype to ensure long-term aesthetic stability.

Methodology

This case report documents the rehabilitation of a 29-year-old female patient presenting with a chronic periapical infection on the upper right central incisor (#11), a sequela of a previous dental trauma. The initial CBCT evaluation revealed a severe three-dimensional bone defect, with loss of the buccal plate and a vertical component preventing immediate implantation.

The clinical protocol was structured into two distinct surgical phases:

• Phase I — Reconstruction (GBR): Following the extraction of tooth #11, the authors performed bone augmentation using a composite graft combining autogenous bone (harvested from the mandibular ramus) and a bovine bone substitute. The volume was maintained by a titanium mesh adapted to the site and fixed with micro-screws to the buccal and palatal cortical walls. The assembly was protected by an absorbable collagen membrane, with tension-free mucosal closure using a coronally advanced flap after periosteal releasing incisions.
• Phase II — Implantation: After a 6-month healing period, the titanium mesh was removed to allow the placement of a morse taper connection implant (3.5 x 11.5 mm). The implant was positioned approximately 2 mm subcrestally to promote prosthetic emergence.

The success of the procedure was clinically validated by observing the bone gain during surgical re-entry and by achieving adequate primary implant stability.

Results of alveolar reconstruction and implantation

Initial CBCT evaluation revealed a severe three-dimensional bone defect at tooth #11, with complete loss of the buccal plate and a marked vertical component. This non-contained defect morphology precluded any immediate implantation.

The guided bone regeneration (GBR) protocol achieved the following clinical results after a 6-month healing period:

During the surgical re-entry at 6 months, the removal of the titanium mesh revealed a dense neoformed mineralized tissue, restoring the necessary alveolar architecture. The implant was positioned subcrestally (approximately 2 mm) to promote peri-implant aesthetics. The closure by coronally advanced flap, combined with a double layer of sutures (Vicryl 3-0 and silk 2-0/4-0), ensured healing without mesh exposure or soft tissue dehiscence.

Clinical analysis and perspectives

This clinical case illustrates the management of complex, so-called "non-contained" bone defects resulting from an old dental trauma. The loss of the buccal plate associated with a vertical component required a rigid reconstruction strategy. The use of a titanium mesh here allowed for the maintenance of the space necessary for regeneration, providing mechanical stability that absorbable membranes alone cannot guarantee against the pressure of the surrounding soft tissues.

The choice of a composite graft combining autogenous bone, harvested from the mandibular ramus, and a bovine bone substitute proves to be strategic. This approach allows for the combination of the osteogenic potential of native bone with the volumetric stability of the xenograft. The results observed during the re-intervention confirm the effectiveness of this combination in restoring an alveolar architecture compatible with prosthetically guided implant placement.

However, the titanium mesh technique remains demanding. The success of the regeneration is closely linked to achieving a hermetic primary closure, which is essential to prevent mesh exposure, a major complication of this protocol. Although the results are convincing for this patient, the limitations of the study lie in its single case report format. Long-term data regarding the stability of the peri-implant bone level under this configuration would be necessary to validate the durability of the aesthetic result.

Summary of results

This clinical case demonstrates the efficacy of guided bone regeneration (GBR) using a titanium mesh to restore a complex three-dimensional alveolar defect following trauma. The use of a composite graft combining autogenous bone and bovine xenograft allowed for stable volumetric reconstruction, creating a favorable site for implant placement in an optimal prosthetic position.

In concrete terms, for the practitioner:

• Mechanical stability: Opt for the titanium mesh for non-contained defects to ensure rigid space maintenance, essential against the pressure of the surrounding soft tissues.
• Material synergy: Combine autogenous bone for its cellular contribution and growth factors with a bovine bone substitute to ensure the long-term stability of the reconstructed volume.
• Surgical seal: Systematically perform periosteal release incisions and double-layer suturing (horizontal mattress and interrupted sutures) to ensure tension-free primary closure, thus preventing grid exposure.

Technical Lexicon of the Study

Non-contained morphology: Characterises a bone defect whose architecture does not present sufficient natural walls to maintain a graft material, requiring an external mechanical intervention to stabilise the volume.

Titanium meshes (TM): Titanium meshes used as rigid barrier devices to ensure space maintenance and mechanical stability of the graft, particularly in cases of complex three-dimensional reconstructions.

Guided bone regeneration (GBR): Therapeutic concept based on the exclusion of epithelial and connective cells in favor of selective osteogenic cellular repopulation under a protective barrier.

Soft tissue phenotype: Clinical parameters of soft tissues (notably mucosal thickness) whose modification directly influences crestal bone stability and the aesthetic integration of the future restoration.

Composite graft: Association of bone grafting materials combining autogenous bone (harvested from the patient for its biological properties) and xenogenic bone substitute (for its volumetric stability against resorption).

Cortical perforations : Surgical maneuver performed on the recipient bone site before grafting to promote vascularization and the recruitment of osteoprogenitor cells within the implanted material.

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