After 2 failed ramus grafts and GBR, what would you do?

226 Rating(s).


Posted on By Maurice Salama In Failures

After 2 failed ramus grafts and GBR, what would you do? Patient is in her early 20's and wants to improve her esthetics and have permanent teeth. regards Dr. Salama

CBCT
Preop

Left side with granules emerging thru flap
Concavity of ridge


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17 Comments

Tough case Maurice. Before planning another attempt I would analyze what had caused the previous graftings to fail. Was it a “Kiss of death” from a flipper or too much tension on soft tissue?
Could be a good case to try Dr.Foti’s fibrin sealant or/with sinus plates.


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Not sure my friend....both blocks failed and then GBR as you can see sequestered through flap.


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Khoury technique, PCTG and Emdogain for the left central incisor...orthodontic extrusion. Maryland bridges...later implants. Or alternative ridge augmentation and bridges.
Tough case due to missing papila on the left central incisor. How does bone look like on the distal root surface?
Best
Snjezana


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Snjezana; You have a great eye....diagnostics is KEY!! Bone on distal of Left Central an issue....Dr. Salama


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Very difficult case Maurice on site 22! The regeneration of distal papilla on 21 is unpredictable or impossible because there is lack of the bone peak. How to regenerate this peak? Maybe orthodontic extrusion, as suggested by Snjezana Pohl. Khoury technique is predictable also for new bone peak on a tooth? Alternatively, after soft-tissue stability I would try a rotated pedicle palatal graft and after 3 months a CTG by VISTA. My prosthetic rehabilitation would be a Maryland attached only on central incisor.
Best regards
Enzo Foti


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What a case Maurice.
Orthodontic extrusion, Soft tissue graft and then GBr


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Any cbct availabe?


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The 3D is from the CBCT....but nothing really changes with sagital sections here...


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1st SOFT TISSUE reconstruction.

Palatal pedicle harvest
extended graft


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Soft Tissue grafting right side

SECTG
SECTG


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Day of Soft Tissue Sx sutures & After Soft Tissue Grafting.

Sutures day of Sx
1 month healing


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Before & After Left side

Preop
1 month healing


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Omid; Yes, which sequence?


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Excellent result after the right soft-tissue surgical management!


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Mo,

Nice work coming along beautifully few questions for you- 10 site would you consider bonding in a ovate Maryland bridge to help shape the mesial papilla ultimately you will most likely still have a little defect there however someo pseudo papilla could be achieved also a touch of pink prosthetics consider to manage number 9 when doing final on 10. lastly Maybe a touch of orthodontic intrusion then re-extrude to bring a little bone down ? and consider splinting 9and 10 together for stability
Just some thoughts

See you in January

Cheers,

Richard


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Richard; Good thinking my dear friend and happy holidays. Yes, we have more to do but eventually orthoor "pink" will be needed to get over the hump on Left side....Will see you in January in Atlanta and then February in Florida at XP. regards Mo


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Extrusion 6,8,9,11, move 6 and 11 into the lateral position and reshape 6,8,9,11/conservative veneers is necessary, implants in the cuspid areas.


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