Large Class 3 Vertical Defect in Maxilla Updated

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Posted on By Maurice Salama In Bio-modifiers: BMP-2 / PRGF

Large Class 3 Vertical Defect in Maxilla post Implant Failure. Horizontal and Vertical Defect present. Options and Solutions? My treatment method displayed. Great discussions. I have posted Sutures and Closure this week and now 16 Days post op Healing and radiograph. So far so good. Thoughts and other options please.
Dr. Salama

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59 Comments

Hi Maurice,
hope you are well.
Have you thought of using the Botiss Bonering for the 2 implants? It should work well with PRGF.
Will need soft tissue management at some stage


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Hello Dr. Salama.

Since there's a good height of interproximal bone, I would regenerate with DFDBA, PRF or PRGF and a slow resorption membrane such as Biogide, Zimmer Curv or a non resorbable one.
After healing time, A CTG and more bone graft (Bi oss) with simultaneous placement of the implants.
A lot of the success depends on the temporary the patient will wear
Great Didactic case.

Greetings from Costa Rica


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Jose and Kish; thanks for the great ideas and discussion. Really do appreciate your thoughts on treatment. Will display my treatment shortly.
Dr. Salama


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Combination ridge split - implant placement - particulate bone mixture (FDBA / DFDBA ) beneath titanium mech supported by tent screws and implants with extension caps - prf.
After healing place provisional bridge (one abutment on time) with CTG.
Easier said than done, but should work. Look forward to seeing your solution.
Chuck


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J-graft combines three-dimensional vertical and horizontal, bone allograft and soft-tissue grafting in one or in two procedures. In a second stage place the implants. One miracle at a time.
Regards Dr. Salama.


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Charles and Larrabe; Very creative suggestions and with a sequence of therapy. Chuck would you really suggest doing the implants simultaneously? Larrabe, J-Block from the Hip?? or Allograft?
Great discussion. Dr. S


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I think that allogeneic materials none can predictably regenerate natural bone to the extent of autogenous bone grafts. it depends on the tastes of the operator.
What to do what to do, Charles have good thinking.
Regards.


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Yes that is what I am suggesting. Very similar concept to what professor Sohn demonstrated in the posterior mandible. Should even work better in the Maxilla. In addition to supporting the mesh, the implants can be used to injure / expand the bone and therefore promote bony repair. The biological principle of injury and wound repair just makes sense to me.
In my opinion, exposure of the titanium mesh is more of a risk than placement of the implants. BTW Most likely will end up with hybrid prosthesis as has been used in the anterior region.
Thanks for posting such an interesting case to discuss.
Chuck



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Larrabe and Chuck; I agree that autologous bone works BEST especially for VERTICAL gain. Chuck, having done cases with simultaneous placement of implants, I do believe this a RISK!! If not successful, you RISK exposure of the top portions of the implants and must now manage this LONG TERM. If we go with HYBRID prosthesis as you suggest with PINK, where do we place neck of implant VERTICALLY? IT effects the DEPTH of placement? I would NOT go with SIMULTANEOUS placement here especially close to the Esthetic Zone. TENTING Screws do NOT commit us to implant placement. We can then RE-EVALUATE the success of the 1st Vertical Augmentation Result and make a FINAL decision as to Conventional or Hybrid PINK and the DEPTH of Implant Placement.
GREAT DISCUSSION. My case photos shortly! Maurice


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Mo,
Of course your approach makes sense and is safer, but I feel the benefit of ridge expansion would be a significant plus here. Could you please explain how you would alter the depth of implant placement for a hybryd prosthesis. Based on the simulation, it appeared to me you could go either way in this case.
Chuck


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Dear Maurice
what a great discussion,i think as you mentioned installing dental implants simultaneously is a huge risk.as charles said,spliiting can work too but i prefer to augment the case using tent screws(like the one by Neo-biotech) with titanium mesh and also soft tissue grafting. there might be a need for additional soft tissue grafting at the time of implant placement.the bone graft which i choose will be allografts(FDBA).
TNX FOR SHARING


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Very interesting case, Maurice!

I would take the decision of going for "natural" pink of for "artificial" pink in advance.

Biggest advantage of going for "artificial" pink is the simpler and thus less risky GBR-procedure. The implants would be placed far more apical than the neighbouring teeths' bone level (as displayed on Pic CBCT2) and I would just augment very little around the neck.
Biggest disadvantage of this solution is the difficulty of adequate hygiene between the two implants!

Biggest advantage of the BIG augmentation would of course be better esthetics and hygiene, but it is quite a risk because of the size. If I would go for this solution, I would avoid large GBR and splitting simultaneously. Two many miracles at a time.
The Botiss CAD/CAM allograft could be helpful in this case.

Still don't know which Tx-Plan I would opt for. I would definately involve the patient in the final decision.

Greetings from Greece


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Very interesting case and discussion also. What I would do in this case is to try to use the available bone and do distraction osteogenesis on the first place. Than do lateral augmentation of the alveolar ridge with autologous bone grafts with colagen membrane. The implants would come in the third stage.
Best regards.
Dime


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Gentlemen; Those that suggest ridge split or distraction, I ask you to review the photo of the "knife edge" crest of bone. It is roughly 1.5mm ONLY? Would you want to split that or distract it?
Dr. Salama


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Based on the simulation there appears to be approximately 3mm where the implants are positioned. If there is only 1.5mm then you essentially have only cortical plates with poor vascularity. In that case, I would augment with soft tissue and take my chances with a tooth supported bridge. Now I really can't wait to see your solution. Chuck.


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Hi Maurice,
Greetings from India !!!
Nice pics....if i get a case like this....with limited resources and as a beginner I would prefer to do bone grafting with Titanium mesh and then longer implant placement ....especially Dentsply Xive :-)
Regards
Dr Sandeep


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BEUATIFUL!
Chuck


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Fantastic :-)


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Nice comments! As far as vascularity is concerned in this case as far as I can see on the bottom right picture you rised palatal mucoperiosteal flap wich compromises blod supply. Doing distraction osteogenesis you do not rise palataly flap so you do not disturb the palatal blod supply and gives you an opportunity to distract even redge that is 1.5mm thick. It would be fine to show sagital cross section of that part from a CB-CT to se the thickness of the alveolar ridge. Even if you are scared of loosing the upper fragment you can first augment than distract.
On the other hand if you prefer to use titanium mesh you can consider using soft tissue expanders maybue to avoid mesh exposure.
Best regards.
Dime


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Dr. Salama, Nice job !!

Vincent


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very nice


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Great case and approach!!!


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Dear Maurice, very interresting case and result. Interproximal bone height looks okay, so Personally I'd like to recommrnd mesh assisted ridge aug. and simultaneous implant placement as I have performed for years. Key is tension free suture whatever we do for this case. thank you


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Dear Maurice, Did you use two mesh in this case? if yes, Did you stabilized two meshes with one conver screw and one mini screw? Thank you DS.


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Yes, Dr. Sohn, I used 2 mesh and secured them with one screw. Thanks for the comments. Maurice


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Hello dr. Salama
Very nice case , what brand is the tenting screw you use?
Did you fixed the mesh on top of the tenting screw with a mini screw?
thanks.


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Yes, Davide I did secure it and I utilized the Neobiotech GBR KIT. It is their tenting and fixation screws.
Dr. Salama


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You can also do it by taking the lateral wall of the sinus and put it with screws and then augment the area with granular bone, like khoury tech, or with blocks from the chin, but i prefere the first one because you are already in the area.best regards.


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Alexandru; Very creative suggestions. Which way would you secure the Lateral Sinus Cortical bone? Buccal, Lingual or Crestal? As this is a 3D defect? Chin was an option for sure but with much higher morbidity.
Dr. Salama


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at the picture "clinical 2" where we can see that you put the mesh palatal i would put it the bone(sinus wall or chin) on the buccal plate because it's more predictible for the closure and possible complication.in the palatal area you can't have the mesh uncovered because of the thick palatal mucosa but on buccal it's another thing...puting the bone is more natural for healing that area, but again, it's my opinion.


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Hi Dr. Salama,
Could you post a photo of the site after closure?
Thanks so much.


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Dr. Maurice,
This is exactly what i was looking for when i signed up dental xp...learning a lot from this kind of cases and discussions. I'd like to see the soft tissue closure of this specific case.
Thanks for sharing!
Sormani.


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Thanks to ALL: Really great interaction and exchange of ideas. I know there are many different solutions to a case of this type. I simply propose my solution here regarding low morbidity utilizing new tools (Neobiotech GBR Kit for Tenting and Fixation Mini Screws and the CTi Micro Ti-Mesh as well as BMP-2 from Medtronic mixed with autologous and Mineralized irradiated bone cortico-cancellous, MinerOss Biohorizons and Jason Pericardium Membrane from BoTiss) I will post the closure of the case and follow-up sometime next week.
thanks again Dr. Salama


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Dear Maurice,
I am very interesting to hear that BMP 2 requires longer healing period than convetional GBR. I believe that BMP 2 reduces healing time. I just started to use BMP bone graft.. Do you really recommend longer healin period.? Thank you DS


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Just Wow and Thank you!! amazing technical skill. You inspire me. Band


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Thanks Band. Just added photos of sutures and closure.
Dr. Salama


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Maurice. Impecable work. "I'm playing checkers while your playing chess" :-). Chuck


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Chuck; You are too kind. We are all getting better each day and this FORUM is doing it's JOB!! Pushing us all to improve diagnostically and through Group Treatment Planning.
Thanks for being so willing to SHARE!!!
Maurice


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Brilliant case discussion, its good to hear all the ideas. But to me Dr. Salamas treatment choice appears to be more predictable and well aims to achieve only one miracle at a time. Can't wait to see the final outcome of this case.
Prashant


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Dr. Salama,
Being an orthodontist, would you consider mesializing #5 into site #6 utilizing TADs and then implant #4 and #7 post-grafting. This treatment plan is appealing but I do question the replacement of the longest root in the mouth with a potentially inadequately sized premolar root. The biomechanics involved with the occlusal work horse of the mouth (max. cuspid) are significant, so this treatment option should be carefully planned. Thoughts?


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Charles; Very creative approach. As an orthodontist as well, I have performed that very approach many times. Yes, it works but we require a patient willing to go through orthodontics for 10-12 months.
Dr. Salama


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Maurice, Thank you for the update. Looking good thus far. Especially the soft tissue thickness coronal to the mesh. In addition, the augmented site appears to be doing well radiographically. I am curious to see how the adjacent teeth/PDL respond to BMP-2 exposure long term. This is a SPECTACULAR CASE to study! Thanks so much for sharing. Chuck.


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Thanks for sharing Maurice, so far looks grate.
hope to see the case as developed throughout.

Omar


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Hello Maurice:

After the interesting debate you promoted about bone remodelling, I want to ask you: how long do you wait in a case like this before implant placement? and if you would place the implant at the same time as doing the GBR, how long would you wait before second stage?
Thank you so much in advance and congrats for this outstanding case!!


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Ramon; I would wait 6-8 months here prior to loading or placement of implants. It appears that BMP-2 requires a longer time for healing, remodeling and biological repair/density of newly regenerated bone.

Here are my timelines;
1. Autogenous Block 3-4 months
2. GBR 6 Months
3. Ti-Mesh BMP-2 8 months
4. Allograft Blocks 8-10 months
5. Completely Pneumatized Sinus Graft 10-12 Months

regards Maurice


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Beautifull case for ideas interchange Maurice!
I would treat this case with a very conservative aproach.
1.- Block graft from Anterior nasal spine (same área) and GBR to horizontal resolution and vertical enhancement.
2.- After 4 months implant placement and if more vertical height is needed, Carlo Tinti´s technic, using implant´s heads as tent poles. Also a CTG is done in this stage.
3.- After 6 months mucogingival surgery plus...
This new mesh fixation screws opens new posibilities.
Thanks for showing us.
Don´t you think that the challenge here is to regenerate the interimplant bone for papilla support?
This is the esthetic challenge for me in this case and treatmente option.
Jorge


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I believe that the key to success is the tension free flap attained. Please describe, in detail, the technique utilized to attain the tension free flap. Please illustrate any points that will make tension free flaps a predictable part of a procedure. Please list any precautions.
thx


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Nice case for ideas interchange Maurice!
Sorry for beeing late at the Fórum.
I would treat this in a very conservative aproach with many stages but with "maximun" predictability.
1.- Block graft (donor site: Anterior nasal spine)
2.- After 4 months Implant placement and BGR (Carlo Tinti technic) using implant heads as tent poles if more vertical bone is needed.
Adding a CTG.
3.- After 6 months Mucogingival...
But this new mesh fixation screw opens new posibilities. Thanks for showing.
I think the toughest bone regeneration will be the inter implant peak for papilla support.
Don´t you think that creating there a papilla is the biggest challenge?
Jorge


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Jorge; I agree but do not think that block grafting for vertical gain of a ridge is "more conservative"?? 2nd surgical wound, donor site, and Potential early flap dehiscence is worse with blocks than mesh. Yes, papilla here will be challenging but i do like the Tinti approach at implant placement if further bone grafting is required.
regards Maurice


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Great dr my question was what s your opinion by using mineralized plasmatic matrix in case like this case under the mesh


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Mohammed; Not sure what "plasmatic matrix" is? Can you explain?


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Dear Maurice
Interesting case , and very professionally done , my question is .. Have you tried to do a 3D alveolar ridge augmentation utilizing only sandwich autogenous graft ( two cortical plates with particulated bone in between) of Khoury technique in such cases as another alternative treatment. and would you always prefer to use allograft materials with titanium shield.


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Emad; I have not yet utilized this technique in this situation. My concerns are the following are mobility of the thin blocks, early wound dehiscence and additional surgical site morbidity.
regards and look forward to seeing you again soon. Maurice


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Maurice; That is beautiful case and early result! What kind of provisional did you offer during healing time? (essix?)

Yiannis


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Yiannis; Yes, Essix is my typical transitional appliance to avoid tissue loading over the wound. regards Maurice


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Dear Dr. Maurice Salama;
Your surgical 3D management and reconstruction with the Ti-Mesh plus guiding tent screws is a real state of art!
I have seen a similar alternative shell boxing technique processed by KLS Martin SonicWeld RX bioabsorbable poly(D,L) Lactic Acid plates and screws but I think your technique with Ti-Mesh is mush more osteoinductive than just being preservative and it also assures a full protection to the vulnerable occlusal surface of the bone graft material.


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Saed; Many thanks. I have also utilized the Sonic Weld Technique for these 3D defects with excellent results and with less risk of wound dehiscence which is a greater issue with Ti-Mesh. Dr. Salama


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Nice case And very interesting discusion


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Cant get enough of this beautiful case, really.


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