3D Bone Graft Surgery...Plan B

202 Rating(s).


Posted on By narayan tv In Bone Grafting

68 year old lady, undergoing FMR with a prostho colleague, referred for vertical & Horizontal augmentation in 45, 46 region. Vertical defect ~5mm at the deepest, & Horizontal ~4mm. I thought the best approach would be a Khoury type cortical lamina with cortico- cancellous . All went well, till I tried screwing the lid on the box with the second screw (The first screw didn't feel secure enough. In hindsight, maybe I could have left it with a single screw) .As I tightened the screw, i split the plate wide open. Used the bone scrapings as the core material, with coarsely ground large particulate cortical chips from the broken cortical lamina, covered with a long lasting collagen membrane . I did think of dense PTFE, but my past experience with it in the posterior mandible has not been very good, particularly with older individuals,with membrane exposures even with tension free closure. I'm not sure what to expect with healing, though logically, it seems things should work out similar to if I had not deviated from the plan. Will know in 4 months. Would love to hear all your views

Pre-op
Pre-op

Vertical defect
Horizontal defect


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12 Comments

scraper on the block
scraper for cancellous


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This is when I broke it
large cortical chips on top, dense cross linked collagen


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I think you will still get adequate bone for implants. One thing to note, when doing these khoury plates with smaller blocks, always better to use micro screws either 1.0mm or 1.2mm to be safe and minimize plate fracture risk. I also noted on the buccal cortical plate, the medial screw is closer to the edge which also caused some splitting, since you're not placing implants simultaneously you can always place screws more towards the middle. I personally have found placing the screws the toughest part of these procedures. I have found I do get resorption when the plate is split but not too much if you cover with particulate and membrane as you have. One screw would also work on the top plate if the plate is stable and not mobile, I have also done it with great results. I think you will still have great results. One thing i can mention is if you still want vertical and you have a fractured plate, consider using a microplate across the ridge to tent the vertical space. I have attached a picture to give you an idea of what i mean. Great case. Regards, Naheed


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Thank you Naheed, for your inputs. One of those days when you are out of microscrews and you try to make do 🙂. The microplate would have done as well. Beautifully done. Thanks again .


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I think it will still work out for you....BUT for me, I prefer to address tissue issues prior to the bone work. In my hands, my Plan B would have consisted of bone grinder of split plate and then tenting screw for vertical with a collagen barrier. regards Mo


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Thanks ‘Maurice, appreciate your inputs. I figured the buccal laminate will do the tenting anyway. Will update the progress as time goes by. I have been away from this forum for a long time. Good to be back 🙂.


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Nice and very interesting case!
I really like this technique and do it quite often. As Maurice says I think your "Plan B" is going to work but there are Some things that I Would always keep in mind when performing this technique.
If vertical augmentation is performed in the posterior mandible, you should try tunnel approach, it will decrease you exposures almost to zero.
If you decide to do Khoury through an open approach, you should place a buccal and lingual plate and this is because if you place buccal and crestal (To be able to manage the lingual flap and get tension free closure) particulated bone will not be contained by the lingual periosteum (As long as It is detached)
So, tunnel; Crestal and buccal
open approach Buccal and lingual. Higher risk of exposure.

Thank you so much for sharing! Keep us updated!

Jose Mompell


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Thank you for your thoughts . I haven’t any experience with a tunnel approach for these situations- I find it challenging enough doing it with the open flap. Further, the mental foremen was pretty high up , and in the operative field. Will try and post a picture later today. I’m always caught up about the vestibular ppproach in this region. Could you share your thoughts on circumventing the mental nerve with either approach? Thanks again


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Hi! A couple of weeks ago we made two presentations about this technique and how to deal with every single detail. You have them in Dental Xp presentations.
Either with a tunnel or an open approach first of all the mental nerve has to be located in order not no damage it.


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Thanks. Will do


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BTI
Salvin