Soft and hard tissue augmentation after implant spontaneous exfoliation

357 Rating(s).


Posted on By snjezana pohl In Implants

Patient presented for implant placement 6 months after spontaneous implant exfoliation #left central incisor. Patient didn`t have any information about the implant # right central incisor that showed dark crown margin due to very thin buccal hard and soft tissue. Smile line is low and patient doesn`t care about aesthetics, wants to keep that # 11(#8) implant.
My first idea was to perform Khoury technique but at the same time I didn`t want to elevate papilla and buccal tissue from the adjacent implant. mIVAN technique was performed, defect grafted with dentin autograft, care was taken about displaced mucogingival junction.
The second surgery included buccal sliding palatal flap, implant placement, GBR, CTG, guided soft tissue augmentation.
The final result is not ideal but exceeded patient`s expectations.
What XPerts think, was it possible to achieve an ideal result with a different approach?




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24 Comments


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A masters` work ,wow thank you for sharing aryeh


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Thank you, Aryeh!


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My dear friend Snjezana, Wonderful work as usual with you. Very interesting you used a dentin graft. What is your experience on the resorption rate with this type of grafts? What machine are you using? I really like your management and result. The connective tissue makes a great difference in this area of treatment. The tall healing abutment, as suggested by Salama gave you a nice soft tissue profile. How much time did you wait from the first surgery to the implant placement surgery? Beautiful case and result, congratulations and thanks for posting. Best regards Manuel


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Hello, my dear friend Manuel,
First of all, thank you for your kind comment and for taking your time to catch all treatment details.
I use KometaBio, it means non-demineralized dentin. Our Forum friend Rocco Mele inspired me.
Recently, we started to partially demineralize dentin with EDTA. According to the literature partially demineralized dentin is superior to the demineralized and non-demineralized dentin.
Dentin resorption rate is very slow and accordingly the ridge volume maintenance is outstanding.
Attached are some images out of >80 sites that I documented and CBCT fusion was done. Interesting is that in average there is a gain in the buccal and lingual wall hight.
Warm regards
Snjezana


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Snjezana; Just remarkable staging and augmentation of bone and tissue. Did you ever consider ortho extrusion of central incisor? thnx for sharing. Maurice


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Dear Maurice,
thank you for your nice comment.
Central incisor is an implant and we don`t know which implant system. This was the challenge in this case.
Best regards
Snjezana


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How long does it take to treat and grind dentin before it’s ready for use? Can you use residual roots , dentin and cementum alone, for that purpose? Do you mix with IPRF for better handling and cell induction? Does it become 100% bone given enough time?


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It takes about 15 min. One can use teeth without root canal filling, or remove it completely. Enamel I utilize for veneer grafting only. Sometimes I mix it with iPRF, always for veneer grafting. No one has done histology after many years after grafting with non demineralized dentin and we don`t know how long it takes to become 100% bone. Histologies show graft particles ankylosed to the surrounding new bone, no fibrous incapsulation.
Thank you for your questions, Laurent
Best regards
Snjezana


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Incredible work. The sequencing of the treatment is phenomenal.
Just a thought. Would orthodontic movement of the left lateral into the space of the missing central be a possible option?
perhaps Maurice can throw some light.


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I like this idea very much, smart Udatta.
Good point to keep it in mind (although for this patient it wasn`t an option). Back in Germany I had great collaboration with one ortho colleague and after Zachrisson courses we moved the teeth a lot, it was my favorite bone grafting procedure.
Cheers
Snjezana


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Snjezana, this is spectacular management of soft and hard tissue for a site with compromised healing potential.

I had faced similar situations with certain xenografts in contact with an implant. I have moved away from using this biomaterial in direct contact with implants for many years now. This was just my personal observation.

Ioannis


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Agree 100%. I use a layer of xenograft only to protect the underlaying autogenous bone (Misch, sandwich:)
Thank you for your input, dear Ioannis
Best regards
Snjezana


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Tough question Snjezana. Improve this? Hmm.
Only with another 3rd surgery when you add tuberosity on buccal...but it´s just a guess. You know. Just to feel important sayings something else... not really sure.
Love the results in this conditions.
Important was not to worsen right implant tissues!!
Thanks for sharing!
Regards
Jorge.


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Yes, Jorge, tuberosity CTG would may be improve the outcome.
It is interesting that despite GBR and CTG I couldn`t get more tissue volume on the "old" implant. Somehow "non-responder" case lol

Thank you for your input

Snjezana


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Snjezana, What a nice outcome for a mess! Well done! You show your stile here, it's 100% Snjezana! ;)


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Thank you so much, Andoni, what a wonderful compliment!
Best regards
Snjezana


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Woooow...what an awesome case.
With an implant in #8, this result is more than superb. My compliments !!!
The first graft with dentin, you didn’t place a membrane ?

Thanks for sharing,
Ehab


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Thank you, Ehab. Exactly, there is no membrane. I’ve done some cases with and some without membrane. It seems that dentin autograft doesn’t require any membrane. In contrary, comparing CBCT sites with and without membrane there is better volume maintenance if no membrane was placed.
Thank you for your input
Cheers
Snjezana


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Great Job!


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Thank you, Stefen!


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