Crestal Bone Loss after Ridge Expansion & Sinus Lift

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Posted on By Maurice Salama In Bone Grafting

Patient presents after sinus lift and ridge expansion for 2nd stage uncovering. Crestal bone has resorbed at 6 months but implants are osseointegrated. What would you do? Remove implants and start again? Bone graft? What type of bone graft? Thoughts? Dr. Salama

Implants with exposed collars & microgrooves
Simultaneous Sinus Lift and OD

PA after Simultaneous Sinus Lift and OD
PRGF & Fibrin placed


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27 Comments

Difficult situation....looking for theories on why this occurred and what would you do? Dr. Salama


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Dear Maurice,
I think that after the split the bone walls were thin. I would perform a vertical/horizontal augmentation with allograft/autogenous bone chips and non-resorbable membrane.
All the best
Enzo


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Wow... very interesting.
What was the insertion torque in this case? Did you use osseodensification? How was soft tissue healing ?

Best regards,
Ehab


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Soft tissue healing was PERFECT!!!!


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Ehab, yes I used OD, insertion torque was not very high 35 Ncm. Keep up the discussion. Thanks Dr. S


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Hi Mo...on this case if Titanium is not contaminated I would have done, as you did, a GBR, using implants as tent poles. If you have a rigid membrane the better. Wish u good luck.
Regards
Jorge


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Maurice: I have a case like this that the whole thing failed. In my case, it was too many miracles at the same time. IMHO, in your case, as was mine, the removal of the lateral window and the ridge expansion at the same time with three implants in one surgery has shifted the remaining Autogenous Bone / Titanium Ratio into an unfavorable balance for an optimum healing. In my case, I removed the implants due to mobility and built the ridge width first then placed the implant at a second stage. In your case, I would try to regenerate the lost healed bone and maybe keep the implants.


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Preop CBCT plan...


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Post op PA radiographs...ALL implants at 68-75 ISQ at 6 months despite crestal resorption.

PA Immediate post Sx
PA 6 months post Sx note crestal bone loss


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Maurice, I agree with Salah especially after having seen CBCT. Have you may be underprepared implant sites?Additionally - this kind of surgeries take some time, assistance suctioning all the time and over-drying the thin bone. In orthopedic surgery care is always taken to keep the thin bone wet and not over-dry it.
What kind of provisional had the patient? Did she chew on this site? Vitamin D and Cholesterol values?
And for the treatment - additionally to Jorge`s proposal healing abutments on the implants to achieve even more tent effect.
Keep us posted (I am sure you´ve already treated it in the best way and we can learn again)
Thank you for sharing
Best regards
Snjezana


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Snjezana; Remarkable soft tissue healing, I did not under prepare the site and no issues with cholesterol or Vitamin D. The procedure went quite well with few issues BUT no denying that much going on in one procedure....Sinus Lift, Bone Graft, OD to gain implant stability in remaining minimal and soft bone quality....with the protocol created by Ziv Mazor and Salah. I have seen Ziv bravely speak from the podium at the Versah conference about performing these cases with minimal crestal bone through a crestal technique? Interesting and advanced discussion. Yes, I have treated the case and will display shortly. regards Dr. Salama


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Yes, Salah, Ziv and recently Chuck are very brave and successful with crestal sinus lift utilizing OD protocol. If one manage it, minimal invasive, flap-less crestal approach could have the best chances.


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Mo..perfect execution.The resorption might be due to the thin buccal plate and that could have been prevented doing a veneer buccal graft. Anyhow you managed the case beautifully using dense PTFE for vertical augmentation.
As for the crestal sinus approach- no doubt this will be the future and lateral window will become like an extinct animal..


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But Ziv...the bone resorbed 360 degrees around ALL the implants and not just on buccal aspect? I remain curious sometimes as I have seen this before....when I utilize OD for expansion. I know you have placed implants before with minimal (even just 1mm) crestal bone and utilized OD....have you ever experienced that? regards Mo


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I'm totally agree with Ziv Mazor on probably thin buccal plate after the split. There is scientific evidence on this event that can be prevented by simultaneous veneer graft. Congrats for the excellent management of recovery. Read above my first comment...
Best regards
Enzo


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Enzo;
Read above content to Ziv, "the bone resorbed 360 degrees around ALL the implants and not just on buccal aspect? I remain curious sometimes as I have seen this before....when I utilize OD for expansion. I know you have placed implants before with minimal (even just 1mm) crestal bone and utilized OD....have you ever experienced that?" regards Mo


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Do you have sagittal CBCT slices? Bone resorption 360 around all three implants, if removable prosthesis excluded, looks like consequence of bone expansion. Was the bone too cortical for expansion?
best regards
Snjezana


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Snjezana, no the bone was Type 2-3 and perfect for expansion?


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Thank you, Maurice, for sharing this case and triggering the discussion. There are several factors to consider for a ridge expansion with OD;
1- The most important is the volume of trabecular bone. Cases with a limited trabecular bone and thick cortical walls and crest are at higher risk for bony micro-fracture and crestal bone loss.
2- In ridge expansion cases, where steeply tapered design implants are to be used, please over-expand the osteotomy especially at the crestal 3 mm to prevent the implant thread from over-straining and compressing the expanded bony walls with a lasting compression. You may still get a decent stability due to the "Spring-Back" effect
3- The use of veneer contour graft with a membrane and full closure is highly recommended, especially in cases with low trabecular/cortical bone ratio and/or resulted in micro-fracture
The lateral window, in this case, may have acted as a large lateral bony fracture and may have added another variable for us to consider.
Maurice veneer grafting and the dense non-resorbable membrane with complete closure is a solid way to manage these cases.


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Good explanation and theory Salah


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Just wondering how many CC of bone graft were used to graft this area and to which walls was the membrane elevated. Seems that the graft loss can be due to insufficient blood supply coming to the graft. What's the thought about that?
regards



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Membrane always elevated to medial wall...2cc of bone and PRGF used. Dr. Salama


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Hi Maurice,
It looks like there was an overall loss of bone volume. I have seen this before on a patient I treated who had a history of hyperparathyroidism which was surgically managed who then developed a severe vitamin D deficiency. Earlier in the commentary you mentioned there were no vitamin D issues, I still wonder if there is some sort of underlying metabolic issue.
Mitch


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Hi Dr Salama Nice case the most important is how to manage the complication which you did very well, because complications happen in the best condition and sometimes without obvious reasons. In my opinion it might be the reaction to the surgical trauma which is performing many steps just in one go. The surgery was extensive left the bone thin on the buccal and palatal and mainly just cortical bone reducing the vascularity and by that reducing the chance of regeneration. Keep posting the nice cases.


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Thanks to all for the advice and comments.
Maurice, I learned more from this case than from the usual successful cases shown in most lectures. Well done!!!!
LarryJMeyer DDS


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Very interesting case , thank you for the post!
One question for Salah about the over preparation.when using versah burs I always had in mind that we shouldn’t underprepare. I normally go up to 3,3 for diameter 4 implants. What would you recommend ffor example for diameter 4 implants and “overpreparation”?
Thank you!
Margarita


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I have had a similar mandibular posterior vertical augmentation performed with allograft and ti/PTFE membrane. We had a very good result at membrane uncovery and implant placement but loss all of the vertical augmentation by 1 year
post op. Honestly don't believe implants stimulate bone anywhere near the effectiveness of the PDL if at all.

Regards Bob Scotto


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