How would you manage this vertical defect?

122 Rating(s).


Posted on By Maurice Salama In Bone Grafting

Patient presents with failing posterior bridge in the maxilla. The desire of the patient is to be able to remove or reduce the amount of artificial gingiva in the current restoration. What techniques would you suggest? Many roads lead to Rome. Dr. Salama

Vertical defect
Artificial Gingiva

Vertical block graft & Sinus Augmentation
Panorex after 4 months


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18 Comments

Why not a ctg first state and in second stage a ti mesh.?!


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Hi Dr Salama,

Would love to see CBCT or radiographs here.

Regards,
Ehab


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On the first image it doesn`t look like a big vertical defect. It looks like pontics are "oversized".
Like Ehab I would like to see CBCT.
Does patient insist on implants?
Thank you for sharing, looking forward to see case progress!
Best regards
Snjezana


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The simple and yet predictable alternative is soft tissue grafting (connective from tuberosity) then a pontic with provisionalisation for contouring. Sometimes i do also a bone grafting for ridge contouring, even if i will never place an implant there. The tunnel bone grafting and/or soft tissue grafting is a great minimal invasive technique. Implants may work too (after CBCT of course), but if it were my patient or my mouth, i would go for a pontic.

Best regards,

Mihnea.


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the depression apically didnt play a roll after the block .I assume particulate was used in the void area between the block and native bone. Membranes ?


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Very little particulate was need around block other than in the sinus graft which was accessed laterally. As for membrane ONLY Fibrin and PRGF. regards Mo


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This is way too complicated for a lateral site between two already prepped teeth. If any complication occur, the bone defect will be much bigger. Anyway in your hands it can become more predictable.


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Mihnea; I actually agree with you. I believe in a similar situation in the future I would try tenting Screws and GBR with Lateral Sinus Approach like I did here...


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Dr Salama , very nice result !

I like your corticotomies you did in the bone block.
Do you see any difference in healing when you do corticotomies for better vascularization, like how you did here, compared to when you dont perform them ?


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Cristian; Great question. I am unsure. It seems to be to allow for blood perfusion through the graft early on in healing but I have no real clinical information on it's true virtue yes or no? regards Dr. S


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Cristian; Great question. I am unsure. It seems to allow for blood perfusion through the graft early on in healing but I have no real clinical information on it's true virtue yes or no? regards Dr. S


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At first glance, I would likely treat the defect with a titanium re-inforced ePTFE membrane. However i am a big fan of autogenous cortical plates and the khoury box technique. I love your management and the results are amazing. Was there any gap between the plate and the crest? If so was what was the sandwiched graft? Any consideration of using a scarper to harvest bone from the sinus window to sandwich around the cortical plate. Only thing I may have done different is I would have likely submerged the implants deeper to prevent the risk of crestal resorption of the plate over time. How thick was your bone plate? Still always learning from the master :) Regards, Naheed


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All good questions....no bone sandwiched between plate and host. Yes, I like bone scraper and or utilization of lateral sinus window as bone graft material. Perhaps subcrestal placement is a good idea. We never know about latent resorption following loading. Dr. S


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Thank you for sharing this.
Minor periodontists and pulpal malady regularly cause comparable showing up injuries in the periodontium. Effective treatment relies upon amend finding, which is once in a while troublesome. Some hard deformities caused by pulpal ailment require surgical debridement notwithstanding standard endodontic treatment. With one special case three-walled intrabony periodontal deformities talked about in this report were overseen by surgical debridement with no kind of embed or unite. Long haul perception is required to decide the estimation of strategies utilized as a part of the treatment of intrabony periodontal imperfections.


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Interesting case Mo, as usual. And well managed. What would you be your best 2nd choice of treament? I would do the same, with a CTG on the uncovering stage. Thanks for posting.
Jorge


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Thanks Jorge. Fall back 2nd option may now be my first option today, ti-mesh reinforced GBR with tent screws followed by CTG at stage 2. regards Mo


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Interesting to see how do we evolve, and take different options to the same problem as knowledg, sciences, develops. It´s like PET...a new scenario in wich we have to take into account to make treatment decisions.
See you soon!
Jorge


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Thank you for shearing this information. Really it’s totally helpful when you suffering for your own vertical problems.


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