Large Anterior Defect

Maurice,

Quick analysis of case reveals- what appears to be traumatic loss of teeth? evidence of anterior open bite,
possible periodontal defects-mobility-Thin buccal plate on cuspids. Also is there is a posterior maxillary defect (L)?
Age of patient? Panorex avail or broad overview of dentition and bone.

My thoughts would be to consider orthodontics to stabilize the dentition - Consider holding on to hopeless teeth as long as possible for bone maint. If this truly a 3D defect- then would consider gaining as much vertical and horizontal volume by using mesh crib or curV- ( w/rhBMP2) wrapping around- to palate in the 7-10 area ( ext 9 after ortho utilization) the 10 defect area appears good vertically so could use it as a vertical scaffold guide and just use crib to gain horizontal in that area- Would also consider large CT grafts or Alloderm to thicken tissue- I would wait 9 months before secondary surgery- if you cannot achieve adequate bone at first surgery - could graft again or consider distraction- ultimately this is a massive defect that at the end of the day if implants are stable in the 7 & 10 position consider "planning for pink" as you and Christian are well aware of.

Thanks,

Richard

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Dr.Richad
what about atotally horizontally defect with traumatic occlusion &pathologically migrated teeth?

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Safinaz,

In my response I mentioned evaluating the periodontal condition of the remaining dentition- and utilization of orthodontics to stabilize occlusion as well as to "grow" bone

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To me regenerating alveolar bone is not only a matter of the amount of bone we miss but also the "envelope" we have to obtain the possible regeneration (envelope= soft tissue).
Being the parameters to consider:
Arquitechture of the bone defect, adyacent teeth, occlusion, general health status of the patient, medication... and of course Soft Tissue.
Please, send info in that way.

Regards
Isaac

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Patient age, systemic health condition, soft tissue coverage & biotype, patient economic state....all this are co-factors in treatment planing & prognosis.
Evaluation of the periodontal state of the teeth adjacent to the defect (Rt & Lt canines and Lt central) i.e: mobility degree, tissue coverage "recession amount" to determine the prognosis of these teeth either to keep them or to be extracted.
This 3-D defect better to be restored either by autogenous coticocancellous bone block harvested from illiac crest, mandibular chin bone, retromolar region, or even from the palate, with particulate bone & membrane coverage and reevaluated after 6-9 months to determine the bone gain. if we cannot achieve adequate bone at first surgery, we could graft again.

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As i think if the patient medically free, and the teeth with no mobility ,vertical grafting can be done by autogenous block grafts covered by PRF and Alloderm (the type which dont need to be all covered,and may need multiple block surgeries,
Tenting technique may also work in vertical bone grafting with PRF and covered by Alooderm same type.
distraction osteogenesis may be used in such case also.


Best Regards
Ghassan Habash

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what about orthodontic extrusion of hopeless teeth prior to extraction as a method of vertical bone gain ...i think it would be invaluable and would help alot

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Dear Dr Salama:
Can we have some cross sectional views to check the possible spontaneous fenestration of the bicuspids at the level of the apexes?
Mobility and Soft Tissue status. MGJ line?
I agree with everything Dr Martin says.
I would suggest extract the hopeless or use them(OFE) taking advantage of orthodontics to correct occlusal anomalies and other issues. If needed increase the width of keratinized tissue by using autogenous or allograft soft tissue graft as a free gingival graft to ensure good quality of the soft tissue for primary closure.
Screw tenting technique with autogenous, allograft and xenograft material plus rh-PDGF seems to be quite predictable if is well performed and following the biologic rules. Also PRGF or PRF work excellent on these type of cases and I strongly recommend ePTFE membrane Ti reinforced to gain vertical ridge augmentation.
9 months later I also recommend the use of Soft tissue allograft at the time of implant placement, or CTG taking advantage of the palatal flap already raised.

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I am very pleased to see this radiogram here.

Even this case is a challenging, I just thought about minimally invasive surgery for this patient.

I posted treatment progress at dental forum.

Due to limitation of number of photos for uploading, I am sorry not to show you full story of this case.
You can click at

http://www.waups.org/sub_02/sub_01_view.php?startPage=1&c=p&cs=03&find_key=user_name&sort_key=user_signdate&sort_value=desc&idx=506&cs=03
for the full story of this case.



Thank you
DS

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