My first case on XP forum is Khoury bone augmentation.

190 Rating(s).


Posted on By Domagoj Grabovac In Bone Grafting

Hello XP family, I wish you all best in 2017!
My first case on forum is bone augmentation in anterior mandibula applying Khoury technique. Bone blocks, sticky bone and PRF membranes are used. The patient is 57 years old.
Treatment plan:
1. Bone graft in Khoury technique
2. All on four or implant supported over-denture.

Looking forward to your comments!
Domagoj Grabovac (Croatia team:))

left bone braft

right bone graft
provisional implants


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32 Comments

Dome, welcome!
I like especially cutting off a narrow top of ridge and using it as a Khoury plate. And I appreciate your service to the patient (and to the augmented area) by placing a provisional implants. And I envy you for the fact that you need a half of hour to complete this kind of surgery. And I am proud of you!
Warmly
Snjezana (hm....Dr. Pohl:))


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Domegoj. Beautiful work and treatment plan! The minis for graft protection are an essential yet often overlooked component for successful augmentation. Have you had the opporotunity to try Densah burs yet? I suspect this treatment plan would work well with Densah ridge expansion and simple veneer grafting? I look forward to seeing more of your work! Best regards. Chuck


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Thank you so much for your kind words and comment.
I am a big fan of Densah burs! However, the bone was very hard, all cortical, just a very narrow spongiosa and I didn`t dare to densify it. Perhaps I need more training with Densah:).
Best regards
Domagoj


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Domagoj. Your are wise in your Diagnostics and decision making. However, a staged Densah protocol has been shown to be effective for dense bone expansion. Best regards. Chuck


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Domago

Exceptional clean surgery. Did you get the plate ( graft ) from the cutting back the mandibular ridge?

Autologous chips? Perfect fit... Are the 3 screws for temp over denture.

Really nice job

Rocco

Sorry I would not have asked the questions if I had read Snjezana's Post


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Thank you very much.I see that you're doing great with animals.
Best regards
Dome


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Bravo Domagoj! Great skills and such a clean surgery. I'm so proud to be a part of team Croatia! Looking forward to a productive year ahead of us!
Matko


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Hi, Domagoj !

As usual with team Croatia members here, you are a very talented and skilled clinician ! I hope others from your team will soon follow you and Mia and start to post more cases.
You clearly show that you had a great mentor ;)

About the case
From where have you harvested the plate ? 1 side or both sides ? Do you have a preop cbct image ? Why not try smth in the lateral mandible in the future also?

Thank you !

I wish you all the best !


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Hi Cristian!
Thanks for the compliment!
A bone graft is taken from both sides.
Today I put preop CBCT.
Usually I take lateral side , but for this case I took grom frontal part.
Best regards
Dome


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Cristian, I jump in for Domagoj, he works today in our other clinic.
Preoperative CBCT is an impressive one. In cases like this we use to cut the top of the ridge and use this bone plate as Khoury plate. Piezo, thin Lindemann, saw...everything works. Especially easy in Domagoj`s hands:)

Thank you for your kind words, I enjoy so much my young people around me!

Warm regards
Snjezana


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Hi, Snjezana !

Very impressive slices of the CBCT. I would have started my presentation with the CBCT pics :)
Bone so thin crestally tends to resorb during healing because of blood supply loss when elevetating both flaps, buccal and lingual. So in the end i ussually have a ridge that is 2-3 mm short. So, your approach is very smart, cutting that upper part of the bone off and using as plate.

Thank you for your reply and clarification.
Best regards !


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Welcome Domagoj Grabovac. As you can see from the ratings your post was very well received by our global members. We hope to see more of you on the Forum in the future. Yes, I agree regarding OD in very dense Type 1 Bone, it is very challenging an can cause ischemia IMHO. I like your choice of techniques, how thick do you try to make your Khoury plates?? Dr. Gluckman prefers quite THIN plates but I see yours are a bit thicker? Great result and please keep us updated on the progress. regards Dr. Salama


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Thank you very much for your support !!
I appreciate it !!
There will be more cases in the future !!
A case I personally like to have a thicker plates for stability, and because bone resorption !
I will put updates on this case and its progress In the future!
Best regards
Dome.


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Dome ( blame Dr Pohl)

Very solid case and display of prowess- love the utilization of local bone-
And welcome to the forum - Team Croatia is University of Alabama football - endless supply of talent-
Few questions- First from a prosthetic standpoint I suppose or assume preoperatively the patient was wearing a complete mandibular denture which you used as a guide to maintain the vertical dimension? Did you utilize the same denture and relined to pick up abutments to maintain the same vertical and base the height of the temporary abutments on that? Once healed will this be Zirconia framework?

Now let's talk about the meat- preoperatively what was your goal and final diameter of implants and with this beautiful augmentation do you think that you could've placed your implants at the same time and position a temporary implants in between? it appears that your khoury plates are about 4-5 mm in vertical height and have the curvature of the anterior mandible-how did you determine what height you were going to cut ?how did you cut this with the Piezo ?reciprocating saw ? Did you remove the top of the ridge and then split it with Microsaw or Piezo and use the anterior aspect of Both? How far posteriorly did you extend your cut and did you reduce the vertical height in the molar area to prevent a step? And lastly how did you manage the Floor of the mouth? and avoid positioning Wharton's ducts over the ridge periosteal flap?

To post this as your first case is like being called up from the minor leagues and hitting a homerun with your first at bat from here on out nothing but excellence (just kiddin)

Cheers,

Richard



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Thank you very much for the kind words and encouragement for furture work !!
I am honored to have a discussion with you.
As you are able to see a CBCT on the upper part of the ridge is a tough and poor circulation, so I used it for the plate . I used Piezo and Lindeman for taking graft.
Tretment plan is made with dr. prosthetics which is burdened with the patient's dentures.
Thank you for the questions!
Best regards
Dome


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Hi, Richard, Jagoda here, I am doing prosthodontics for this patient. You guessed everything. The patient`s mandibular denture was used to maintain the vertical dimension and was relined to pick up abutments.
Metal framework will be done. We let it do in additive proces (laser selective melting, since I know you love modern technologies:). Normally, our technicians scan the model, design, and send it to be melted. But when I am just thinking about it – I`ll done IOS and avoid old fashioned impression taking.
Happy New Year
Jagoda


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Dome & jagoda

Thank you for your response - it must be great to be able to work both the surgeon and prostho In The same clinic -very few of us have that opportunity as far as iOS still a little tricky scanning full arch but it is coming

Overall impressive first case . I think I posted a case a while back where are used the mandible to graft the maxilla ( plates were thicker ) so always keep this in mind if doing a combination case and you can sacrifice some of the edentulous mandible to Khoury plates the maxilla

Cheers,

Richard


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Richard,I remember your case, I liked it. Don't waste anything is the message.
You can't imagine how long the communication ways in one clinic can be....
4 days
Snjezana


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Dome,

Exceptional skills shown here. I commend you on everything in this surgery my friend. Could you tell me how you managed the mental nerves during release of the labial flap? Also where did you harvest the autogenous chips?

Thank you for sharing this beautiful case.

Ehab


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Moussa,
I'm sorry they later answer.
Thank you very much for the kind words!
Graft is taken from the frontal ridge.
Best regards
Dome


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Great surgery. Nothing to add here. I too love using the immediate provisional implants from time to time. Did you give any consideration to placing the final implants immediately with the bone graft between your IPI's?
Thank you for posting. Regards Naheed


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DoME,DoME,

last but not least:)

Standing ovations...applause..firework..u name it..
u deserved it!!!!!!

Warmly,
Miaaa


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Thank you so much Mia !!
It's nice to have your support.
Best regards
Dome


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Excellent job dear colleague, especially knowing that Khoury technique is very challenging and demands very wide knowledge about not only dentistry and implantology.
Can just say: go for it!
Nenad


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Nenad,
Thank you very much colleague.
I agree that I Khoury technique demanding, but work is very good results with this technique.
Cheers,
Dome


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Continuation of my case..........
Results after 4 months, the 6.5 mm reef width was obtained. Four implants were placed on the patient and provisional implants were provided.


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Dome,
I would be tempted to place one more implant on the lower right
for better spread. You have plenty of bone there due to the excellent surgical techniques. I understand that real life and patient's finances
play role in your decision making.
What kind of final prosthesis being planned? Fixed, removable?
One more comment if I may. If temporary implants were placed in the triangular fashion one in the front and one on each side it would warrant better temporary denture stability.
Congrats,
Mike


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Mike,
Thanks for your questions and compliment!
Provisional implants have a role to play in the stability of the prosthesis and make it easier for the patient!
It is not necessary to add the implants!
There are enough 4 implants for this type of work!
Thank you for your interest!


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Sorry I only got to this case now but it is perfect in key way. beautiful post beautiful pics. one question did you use xenograft or just autogenous chips. in this case. Well done if this is your first then you are already at master level. Wow


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