CASE SERIES

Reconstruction of Extensive Bucco-Palatal Defects Using Twin Block Grafts:

A Clinical Report of the Sandwich Technique in Two Cases
Sudhindra S. Kulkarni,* Srinath L. Thakur,* and Sujatha S. Kamath

Introduction: Three-dimensional alveolar ridge defects in the anterior maxilla necessitate bone augmentation before
implant placement. Bone volume, contour, and the overlying soft tissue form have to be optimized for an ideal outcome. A
large three-dimensional defect needs osteogenic bone to predictably reconstruct the defect. Autogenous bone in the form of
block and particulate is the graft of choice in such situations.
Case Series: Two cases are presented here with severe three-dimensional alveolar ridge deficiency in the maxillary
right lateral incisor and maxillary canine areas, respectively. Both cases had a three-dimensional bone and contour de-
ficiency. Restorative-driven positioning of the implant necessitated augmentation of the buccal and palatal aspects of
the defects. The defects were grafted with autogenous corticocancellous bone blocks harvested from the mandibular
symphysis. In both sites, one block was placed on the buccal side and the other on the palatal side, sandwiching the
host bone and the remainder of the gap filled with particulate autogenous bone. Implants were placed in both cases
5 months after the grafting, and the final restorations were placed 5 months subsequently. The implants and the grafts
successfully integrated at the sites with stable bone and soft tissue levels. At the 3-year follow-up, both implants showed
stable bone and soft tissue levels.
Conclusion: Autogenous corticocancellous block grafts used in a sandwich technique reconstructed the lost bone
volume, but also facilitated implant placement and optimal restorative outcomes. Clin Adv Periodontics 2016;6:182-189.
Key Words: Alveolar ridge augmentation; bone regeneration; bone transplantation; dental implants; osseointegration.

Background resorption, cysts, and tumors compromise the amount of

The availability of bone in adequate quantity is one of the
prerequisites for a successful outcome in dental implant
therapy. Trauma, periodontal disease, periapical pathol-
ogy, anatomic structures, postextraction remodeling and
* Department of Periodontology and Implantology, Sri Dharmasthala
Manjunatheshwara College of Dental Sciences and Hospital, Dharwad,
Karnataka, India.
Department of Prosthodontics and Implantology, Sri Dharmasthala
Manjunatheshwara College of Dental Sciences and Hospital.
Submitted December 11, 2015; accepted for publication March 30, 2016
doi: 10.1902/cap.2016.150085
bone available for implant placement.1-5 Although bone volume
is adequate at times, it may not be sufficient for appropriate
maxillo-mandibular relation; thus, a favorable functional and
esthetic outcome may be compromised.2-4
The defect dimension, anatomy, location, vascularity of the
recipient bed, availability of soft tissue for coverage of the
graft, religious concerns, and availability of grafting material de-
termine the technique, material, and the time of augmentation.3,4
Large defects need to be reconstructed for volume and
for the shape and form of the ridge; hence, autogenous
bone grafts are preferred because they offer mechanical
and biologic properties that are similar to the bone that
has been lost and offer the best possible outcomes.2,3,6-8

182 Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016


Three-dimensional ridge augmentations using autogenous
bone have been done with various techniques. The most com-
mon ones include the conventional block graft technique
wherein corticocancellous blocks are harvested from the
mandibular symphysis and are fixed to the recipient site with
fixation screws. The other techniques include the J-graft tech-
nique,9 the guided bone regeneration (GBR) technique using
titanium-reinforced mesh or membrane,10 and the sandwich
augmentation technique described by Khoury and Khoury.2
In the J-graft technique, bone is harvested in a J shape
from the mandibular ramusexternal oblique ridge area,
and the graft is secured such that vertical and horizontal
augmentation is possible.9
In the GBR technique using a titanium-reinforced mem-
brane or a mesh, the autogenous bone is harvested, crushed
in a bone mill, placed at the recipient site, and covered with
a titanium-reinforced membrane or mesh that will hold the
shape and form.10
The sandwich technique described by Khoury and Khoury2
involves grafting in two layers. The first layer is formed by
a thin cortical plate that is secured at a distance from the re-
cipient bed. This forms the new cortical plate and gives form
and volume and also leaves a free space between the atrophic/
deficient alveolar crest and the graft. The cortical bone acts as
an autogenous biologic membrane for stabilization of small
pieces of the particulate and cancellous bone that are well
packed in the free space to form the second layer; this give
the shape of an iliac crest graft with thick internal cortical
and cancellous bone and a thin external cortical layer with
high regenerative potential. The particulate graft area will
be replaced with vascularized bone in which the implants will
be placed and the cortical bone will provide shape to the
ridge. A vascularized interpositional connective tissue (VIP-
CT) pedicle from the palate is then advanced and covered
over the graft to get adequate primary closure.2
The following is a report of two cases with large three-
dimensional bone and contour deficiencies and their manage-
ment using a conventional twin-block sandwich technique.
Clinical Presentation, Case Management,
and Clinical Outcomes
Case 1 (Figs. 1 through 4)
A 23-year-old female patient was referred to the Department
of Implantology, Sri Dharmasthala Manjunatheshwara
(SDM) College of Dental Sciences and Hospital, Dharwad,
Karnataka, India, in December 2011 for replacement of
her missing maxillary right lateral incisor (tooth #7). The
patients history revealed that she had an over-retained
primary maxillary right lateral incisor (tooth D) and an
impacted maxillary right canine (tooth #6). She was undergo-
ing orthodontic treatment for the correction of malpositioned
teeth. During orthodontic treatment, an attempt was made
to bring the impacted tooth #6 to its proper position, but
the tooth did not move and was extracted. The remainder
of the orthodontic treatment was continued. At the time of
reporting to the Department of Implantology, orthodontic
treatment was nearing completion, and the patient was
Kulkarni, Thakur, Kamath
C A S E S E R I E S
referred for replacement of her missing tooth. Clinical ex-
amination revealed missing teeth #6 and #7, and tooth #5
had been moved orthodontically into the area of tooth #6.
The space present was adequate to replace the missing
tooth #7. A bucco-palatal deficiency in the area of tooth
#7 was observed (Fig. 1a). A radiograph showed a radiolu-
cent zone in the area of tooth #7 (Fig. 4a). The treatment
plan was explained to the patient, and informed written
consent was obtained. The treatment plan was to graft
the site from the buccal and palatal sides with autogenous
corticocancellous bone block and particulate graft in
a sandwich technique to reconstruct the lost bone volume
and contour and then place an implant.
Full-thickness mucoperiosteal flaps were reflected, and
the site was visualized. The site had a through-and-through
fenestration defect involving the bucco-palatal plate and
very thin bone at the crest (Fig. 1b). The defect was 11

7 mm (apico-coronal
mesio-distal dimensions).
Two corticocancellous blocks were harvested from the
mandibular symphysis using a piezosurgical saw. Care
was taken to keep a safe distance from the apices of the
roots of the teeth and maintain the integrity of the lower
border of the mandible. Cancellous bone was scooped
out from the area after harvesting the blocks. One block
was placed on the buccal side and the other on the palatal
side of the defect. A fixation screwx held both blocks across
the fenestration at the recipient bed, and the other secured
the graft to the host bone (Figs. 1c and 4b). The gap be-
tween the two blocks was filled with autogenous particu-
late bone graft mixed with platelet-rich fibrin (PRF). The
site was covered with a collagen membrane, and the flaps
were secured with 3-0 resorbable sutures{ (Fig. 1d). Five
months later, the site was reentered (Fig. 2a). A 10% to
15% reduction in the volume of the augmented bone
was observed, along with the loss of the thin rim of bone at
the crest (Fig. 2b). However, the volume was adequate enough
to facilitate implant placement. The implant osteotomy was
done with a 2-mm starter drill; later, slow-speed expanders
were used# (Fig. 2c), and a 3.75-mm-diameter, 13-mm-long
implant** was placed at 20-Ncm torque (Figs. 2d and 4c).
The implant was uncovered at 4 months, and temporary
restorations were placed. The final restorations were placed
6 weeks later (Figs. 3a, 3b, and 4d). Tooth #5 was restored
with a crown to shape it as a canine. The soft tissues had sta-
bilized and had crept coronally in the interproximal areas
around the restorations, and the bone levels were stable at
the end of 3 years of follow-up (Figs. 3c, 3d, and 4e).
Case 2 (Figs. 5 through 8)
A 21-year-old male patient was referred to the Department
of Implantology, SDM College of Dental Sciences and Hos-
pital from the Department of Orthodontics in March 2011
Piezotome 2, Acteon Satelec, Mrignac, France.
x
SK Surgicals, Pune, India.
ProGide, Equinox Medical Technologies, Amersfoort, The Netherlands.
{
VICRYL, Ethicon, Johnson & Johnson, Somerville, NJ.
#
Ridge splitting-bone spreading kit, Salvin, Charlotte, NC.
** SEVEN, MIS Implants Technologies, Shlomi, Israel.
Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 183
C A S E S E R I E S

(Figs. 5b through 5d). Corticocancel-

lous block grafts were harvested from
the mandibular symphysis using the
technique described above and were se-
cured at the recipient site (Figs. 6a and
8a). Two fixation screws were used to
secure the block graft to the buccal as-
pect of the defect and one screw to
secure the palatal block (Fig. 6b). Colla-
gen membrane was used to cover the
grafts. The flaps were approximated
and closed with 3-0 resorbable sutures.
Four months later, the site was reen-
tered, and a 10% to 15% reduction in
the graft volume was observed (Figs.
6c and 6d). The ridge width was ade-
quate enough to place an implant us-
ing the technique described above
(Figs. 7a, 7b, and 8b).
Four months later, the second-stage
procedure was performed, and a tem-
porary restoration was placed. Six weeks
FIGURE 1 Case 1. 1a Preoperative view. 1b The bone defect showing a bucco-palatal perforation. 1c later, the definitive screw-retained resto-
Twin-block grafts placed and secured at the recipient bed. 1d Primary closure attained. ration was placed (Figs. 7c, 7d, and 8c).
The patient was followed for 3 years af-
ter cementation. The bone and soft tissue
levels were stable (Fig. 7e).

Discussion
Although augmentation of deficient
alveolar ridges has been done predict-
ably over the years, no single pro-
cedure has been shown to be better
than the other.2,4,5 Autogenous bone
from the mandibular symphysis was
used to augment the large defects in
the cases described above because of
the high success rate associated with
bone grafted from that area.2-5,7,8,11
This high success rate has been attrib-
uted to faster revascularization and
better incorporation in the maxillo-
facial region attributable to similar
proto-collagen, higher bone morpho-
genetic proteins (BMPs) and growth
factors;5,11 higher number of bone in-
duction cells; lower resorption; and
minimal reduction in grafted volume.
FIGURE 2 Case 1. 2a At the time of reentry, well-healed soft tissues were observed. 2b Grafts integrated The fact that the quantity available is
at the recipient bed. 2c Osteotomy performed using bone expanders. 2d Implant placed.
sufficient for areas of two to three miss-
ing teeth has been the biggest advan-
for replacement of his missing canines. The patients history tage of using these grafts. Another advantage is that it
revealed that he had impacted canines that were extracted requires only conventional access because both the donor
3 years previously. Clinical examination revealed a three- and recipient areas are in close proximity, resulting in re-
dimensional bucco-palatal ridge deficiency in the area of duced operative time and local anesthesia. Also, because
tooth #6 (Fig. 5a). The treatment plan was explained to the it is a single-day procedure, the patient can return home
patient, and written informed consent was obtained. Full- after the surgery, unlike in cases requiring extraoral
thickness flaps were reflected, and the ridge was visualized grafts.5,7,8,11-14

184 Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 The Sandwich Bone Augmentation Technique
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The technique by Khoury and

Khoury2 was not used in the first case
described because the amount of
bone available in the mandibular ra-
mus area was insufficient, attribut-
able to the presence of impacted
third molars, and the mucosal thick-
ness on the palate was inadequate to
harvest a VIP-CT graft to cover the
augmented area. In the second case,
the patient did not agree to an additional
surgical site because the bone from the
ramus would be insufficient and the
need for a particulate graft would neces-
sitate a third surgical site. Technically,
it is possible to do the Khoury and
Khoury2 technique using a block har-
vested from the symphysis. However,
the block has to be thinned outside the
mouth, and the chances of losing the graft
to breakage/scatter and operator injury
while using the saw are high. Hence, it
FIGURE 3 Case 1. 3a Final abutment placed. 3b Final restoration on the day of cementation. 3c Final was decided not to proceed with this ap-
restoration at the 3-year recall. 3d The patient in full smile at the 3-year recall. proach. The conventional approach is
also easier and less clinically demanding
and has fewer risks involved when com-
pared with the Khoury and Khoury
technique.2
Although it is easier to harvest a J-graft
from the mandibular ramusexternal
oblique ridge area with minimal postop-
erative complications, the J-graft9 was
not done because of the patient-
specific factors mentioned above and
because the bone harvested is cortical
and has fewer cells and BMPs and thus
needs more time to revascularize, un-
like a corticocancellous graft from
the symphysis.
The GBR procedure with a titanium-
reinforced membrane was not under-
taken because the defect size was
large, and it was important to hold the
shape of the ridge both buccally and
palatally.10
Although the use of grafts from the
symphysis may be associated with com-
plications, such as altered sensation in
FIGURE 4 Case 1 radiographs. 4a Preoperative. 4b Twin blocks held with fixation screws. 4c the mucosa overlying the area, loss of
Implant placed. 4d Final restoration on the day of cementation. 4e Final restoration at the 3-year sensation of the mandibular incisors,
recall.
and occurrence of a ptotic chin, the au-
thors preferred the site because it offers
In the cases described here, the block grafts were fixed2,5,15 the best possible amount of cortical and cancellous bone
with the cancellous surface in direct contact with the recip- graft to augment the defects of the size mentioned above,
ient bed to facilitate faster revascularization and cortical sur- and the complications were minimized by following a proper
face forming the ridge outline. The space between the blocks surgical technique as described previously. No complica-
and the recipient bed was filled with autogenous corticocan- tions were observed in the aforementioned cases through
cellous particulate graft to create a sandwich.5,7,8,12 the 3-year follow-up.2,16

Kulkarni, Thakur, Kamath Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 185
C A S E S E R I E S

observed.3,4,8,12,14 This occurred de-

spite using oversized grafts, layering
of the blocks with anorganic bovine
bone mineral on the surface, place-
ment of a collagen membrane, and
passive primary closure.17 The reduc-
tion in the grafted volume in the first
case can be attributed to the fenes-
trated bed and thus the time lag in re-
vascularization and, in the second
case, the pressure from the overlying
palatal mucosa. Other factors result-
ing in graft volume loss include inad-
equate primary closure at the surgical
area,2,4 premature membrane/graft
exposure,17 soft tissue invasion of
the graft, architectural differences
between the donor and recipient
bone, the amount of cortical thick-
ness, adaptation of the graft to the re-
cipient bed,11 and the time duration
between augmentation and implant
FIGURE 5 Case 2. 5a Preoperative view. 5b Buccal concavity defect. 5c Palatal defect. 5d Occlusal view placement.3,4
of the defect. PRF was shown to enhance graft in-
tegration and healing so it was used in
both of these cases.18 However, it is in-
appropriate to infer from the case
reports that the bone regeneration ob-
served was attributable to the effect
of PRF.
In both cases, the grafts integrated
with the host bed and facilitated im-
plant placement. Although the qual-
ity of bone was poor, undersizing
the osteotomy with expanders aided
in good primary stability of the
implants.19
Temporary restorations placed dur-
ing the second-stage surgery pro-
vided ideal soft tissue contours, and
an optimal emergence profile was
achieved. The final restorative out-
comes were esthetically pleasing and
very well accepted by the patients.
The cases were followed for 36
months, and the hard and soft tis-
sue levels around the implants were
FIGURE 6 Case 2. 6a Block graft placed on the buccal aspect at the time of grafting. 6b Occlusal
found to be stable.
view of the palatal block at the time of grafting. 6c Integrated buccal graft at reentry. 6d Occlusal Corticocancellous block grafts
view of the graft. can be successfully used in the
sandwich bone augmentation tech-
A reduction in the volume of the graft at the augmented nique to reconstruct lost alveolar bone to eventually
site is a common occurrence. In the cases presented here, facilitate implant placement and achieve optimal
a 10% to 15% loss of the augmented bone volume was outcomes. n

186 Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 The Sandwich Bone Augmentation Technique
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FIGURE 7 Case 2. 7a Ridge width at the time of implant placement. 7b Implant placed. 7c Final
abutment. 7d Final restoration on the day of cementation. 7e Final restoration at the 3-year recall.

FIGURE 8 Case 2 radiographs. 8a The blocks with fixation screws. 8b Implant placed. 8c Final restoration.

Kulkarni, Thakur, Kamath Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 187
C A S E S E R I E S

Summary
Why are these cases new j Their demonstration of the use of twin corticocancellous block grafts
information? placed buccally and palatally in the treatment of large bone defects in
the anterior maxilla with optimal outcomes

What are the keys to successful j The use of autogenous corticocancellous block grafts stabilized with
management of these cases? fixation screws
j The use of cancellous particulate bone between the blocks that aid in

faster revascularization of the grafts

What are the primary limitations to j Achieving primary closure on the augmented site
success in these cases? j Quality of the regenerated bone

Acknowledgment CORRESPONDENCE:
Dr. Sudhindra S. Kulkarni, Department of Periodontology and Implantology,
The authors report no conflicts of interest related to this SDM College of Dental Sciences and Hospital, Dharwad, Karnataka
case series. 580009, India. E-mail:drsudhindrak@gmail.com.

188 Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 The Sandwich Bone Augmentation Technique
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augmentation: A human study. Int J Periodontics Restorative Dent

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Kulkarni, Thakur, Kamath Clinical Advances in Periodontics, Vol. 6, No. 4, November 2016 189