Difficult Bone Grafting on young female patient

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Posted on By Carla Monteiro In Bone Grafting

Case Presentation:
Patient Presentation
22 y/o female
Chief Complaint: I would like to get my smile back
Med Hx: Hx of Drug Abuse & Hepatitis C; Anorexia, 90lbs
Past Dental HX - High Caries Risk - recurrent decay
Previous hx of orthodontics - with extracted maxillary premolars; blunted anterior teeth.
Class 3 Skeletal; small maxilla as compared with the mandible.

The patient first presented in March 2018 with heavily restored lower teeth with composite, decayed teeth on both maxillary and mandibular arch. She had previously had a diagnostic wax up at a dentist in California.

The case was discussed with colleagues and a treatment plan was formed for the patient.
Given the patients caries risk, it was decided that we move forward with an implant based plan. The focus being primarily the Maxillary arch to address the esthetic concerns of the patient.

The Original Treatment Plan - Extract tooth #4, #7,#8,#9,#10, #13 - with immediate implants in the sites of #4,#9,#10,#13 (non-loaded implants)

The patient’s teeth were prepared for crowns on tooth #3, #6,#11, #14 for a fixed temporary bridge while the sites were healing.
On the day of surgery, given the thin quality of bone, it was decided to remove the teeth and graft the extraction sites and evaluate 6 months later for bone quality and implant placement.

After evaluating the CBCT at 6 months post op, the bone was still thin in the anterior maxilla and the Oral Surgeon made an attempt to augment the bone w/ a minimally invasive Tunneling procedure. On the day of augmentation, he was able to augment the bone approximately 3 fold. After 6 months of healing, the graft was not successful only gaining about 1-1.5mm of buccal bone. The patient has since had vertical bone resorption in the transition zone and now has a “gap” that is visible. I believe we can correct this this Pink Porcelain. She showed me a photo of her touching the grafting site and may have aided in expelling all of the graft material.

Yesterday I had a discussion with the Oral surgeon and he feels that with the current bone volume, it may be possible to place 6 implants with Sinus augmentation on site #4 and grafting where needed in the sites of tooth #4- #7-#8-#9-#11-#13; with a thought of placing Pterygoid implants in the posterior for added insurance if needed. All risks were discussed with the patient and the possibility of the implants not working.

My concerns with this patient is that she is young and thin, and she has not responded favorably to the tunneling bone augmentation procedures. If we proceed with dental implants, my concerns are that if the implants fail, she may lose more bone making it more difficult to restore. Currently, we have her in a tooth borne temporary that can go to a fixed bridge at any point in time. The concern w/ the fixed prosthetics is her caries risk, she is decaying rapidly. Two options were presented to the patient with all risks 1)Fixed Crown and Bridge 2)Implants with her current bone status

The patient and her parents would like to exhaust all possible surgical options with implant dentistry. If that is no longer an option, then they will continue with fixed prosthodontics.
Thoughts? Advice, all will be much appreciated! Thanks in Advance!

Initial Presentation
Current State

Surgical TXP
Starting Bone Volume


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4 Comments

Carla; Tough case, sometimes the patient is a VARIABLE themselves in how they heal and respond to our therapies. Not sure what bone graft was used and how?? Surprised to see so much resorption of the original graft. I do not see the need for Pterygoid implants here as the molars look fine. My initial impression on a younger patient like this one would be FIXED bridge on remaining teeth instead of implants. I would obviously address diet and add prescription Fluoride to her daily regimen. IF her bridge fails down the line you could always fall back onto the implant option. regards Dr. Salama


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Carla, I agree with Maurice in all points. Could you provide us with initial x-ray, even better CBCT? Was it necessary to extract all incisors? And which post ex grafting material was utilized?
Thank you for posting!
Snjezana


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I agree with Maurice and Snjezana. Having said that , it would be interesting to know how her medical status is particularly with regards to here Vit D3, serum Ca, Pth levels and also considering her past history of substance abuse, if she’s on any SSRIs .


Reply

Hi Carla,
Shame to have lost those incisors. I would have gone with lots of fluoride, and crown and bridge along with 3 month recalls and diligent home care. I’ve done cases both ways, and I do crown and bridge if It is an option first these days.


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