A tricky bone situation. How would you treat this massive anterior defect?

423 Rating(s).


Posted on By Howard Gluckman In Bone Grafting

This patient was referred to me from Chad which is ion West Africa A long way from SA. He wanted 2 implants in the extraction site of the 22 and the 21. All looked good until we took a CBCT which then showed this massive destruction. So my question to the panel. how would you reconstruct this case.




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47 Comments

Howie; Surprising considering the overlying soft tissue looks quite good? My first hunch would be to move the right central incisor orthodontically into the place of the left central incisor bringing along the bone and tissue and creating a manageable horizontal single tooth regenerative site for the left lateral incisor only.
Knowing that is unlikely I would consider Khoury Plates or Ti-mesh and BMP-2.
regards and thanks for sharing Mo

Plates
Collagen Membrane


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true a good option. I think most would use cytoplast with titanium reinforcement. Which would work well.


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With plates is Ti=reinforced membrane needed?


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Sorry No MO not at all. Its just another option that I think Most people would be comfortable with


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Pay for his flight to Ibiza and let Juan Alberto deal with it.... ;)


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He does these in his sleep. Its us mortals who struggle


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Hahahaha.If you are counted among the mortals, that would make the rest of us what??? :-). Great case and handled exactly as I envisioned you doing it. Trademark HG. Loved it.


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Hahahaha.If you are counted among the mortals, that would make the rest of us what??? :-). Great case and handled exactly as I envisioned you doing it. Trademark HG. Loved it.


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Howie,

You know I love this- 3 Khoury plates... What is cause of defect and what is your interim prosthesis?

Cheers,

Richard


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Rich you are the man with the ideas


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Wow! I would like to know more about the mesial height of bone on the canine. My feeling is to approach it with GRB with autogenous/xenograft and dPTFE membrane with Ti.
Looking forward to other comments! Thank you for posting Howie!


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Thanos the bone is there but it is thin. I think most people would use a titanium reinforced membrane and would most likely work quite well here. How long would you wait for healing before placing your implants here


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I would wait 6-9 months according to Urban protocol...


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Wow, very unexpected CBCT image compared to clinical. I think several
methods would work. Personally, I would prefer mesh here. Defect anatomy I believe makes it more convenient to use a mesh/membrane vs Khoury plates. But then again, I've said that before and you always pull the plates off :)
Looking forward to your solution my friend !!

Ehab


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Ha ha Ehab I agree with you one hundred percent. No one way is right. There are many roads to Rome.


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beautiful! Very difficult stabilization Howie! Great job!


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Applause....great way to get the correct curvature by harvesting from parasymphysis region. Not an easy harvest though as typically a fully cortical cut? Would you reconsider incision design here to extend to distal of canines on both sides which would have allowed coronally repostioning and possible treatment of recession....Really amazing skills here my friend. LOVE THIS. Mo


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I thought long and hard about the incision design. However I needed the most passive closure and that I could only achieve with the direct extension releases. I believe it was the right decision when I got closure as the releases really closed well and slid over each other so nicely. The recession I can treat at implant placement or at exposure. So maybe just one miracle at a time


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Wow I love this !!! Simply amazing!! Love the curved plate :)


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thanks you


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No way better than this way. Love the result so far. Bravo Master Howie 🥇


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Thank you Fidan. I appreciate your kind words


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Top made and pictures, congratulations! Few questions: the origin of the defect/age? which saw or piezo for cuts? prf in any cases of gbr? do you use mostly simphisis instead of ramus/posterior mandible (Khoury...) and why...any problems? as provisional ..? from cbct it seems a 3 class patient...scheduled ortho? Thanks again with admiration


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Thanks Paolo. I hope I can answer all the questions. I mostly harvest from the ramus not the chin. however he still had his wisdoms and the chin had plenty of bone. I prefer not to harvest from the chin but this was the best choice in this case. I try and use PRF as often as I can but it won't help the bone healing. I used the new Mectron bone tips they are .3mm in diameter and they cut on three surfaces so try easy to cut with.


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Howie:
Love the case, and the treatment plan! I´m sure will be a success! But I´m wondering about what you´ve said: incision design. I would choose from distal of both canines and horizontal cut of papillas. Don´t you consider would have good pasive closure this design?
Regards
Jorge


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Thanks Jorge. this is a great question and one that took me a while to decide on. I could not choose between the two. In the end I prefer the passive closure I get with the direct extension release. This case is dependent on that. I could also angle my cuts in such a way so as to keep them away from the bone plates. But at the same time get excellent passive closure as can be seen in the last pic


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Five stars, admiration and no questions!
Cheers
Snjezana


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thank you my dear friend


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amazing case and only can be found on this forum.


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totally agree Bassam


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Howie,

What is your interim prosthesis ? Couple more weeks healing and you can scan and digitally wax in the teeth and print...

Cheers,

Richard


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Thanks Rich. I used a temporary acrylic partial denture here. IF I scan do I not need a program that allows me to build the teeth


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Howie, that is out of this world...it is amazing how easy you make it look in your hands. Respect!

The palatal aspect of the defect was treated with particulate chips only? or did you place a plate there as well?

Thank you for sharing your great work.


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Thanks Yiannis. I only used chips in this area but I did place a membrane there just in case although I don't think I needed it. What did pop into my mind as you as I read you post was the possibly of putting a small block custom fitted into the defect to block the palatal area. Next time.


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Howie, Bravo! Simply amazing what you can do and teach always. Great case and fenomenal learning in th best forum in dentistry.
My deepest congrats and respect,
Thanks for sharing
Manuel


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Thanks Manuel. I really appreciate your kind words my friend.
Lots of love


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AMAZING case management Howie! Thank you so much for sharing it with us!!!
Did you split the bone block in half? or did you you get the second bone plate from another area?
Once again fantastic outcome!
Bernardo


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Thanks Bernardo. I did split the block in half as I wanted the thinnest plate to hold the bone in position. This bone is not important at all in the long run. Only the autogenous chip is the important stuff here.


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Howie,

Yes you would need a program in one of the digital applications to build the teeth but you are there now man you are very familiar with digital file design sky is the limit !

Cheers,

Richard


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CBCT 14 days post op


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3D Rendering of the case


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Just LOVE the follow up CBCT.
Mo


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~Thanks Mo. it does look great but 4 months later will be more important. I have the 14 day post op helming pics as well showing excellent soft tissue closure. Im quietly optimistic on this one


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Brasseler
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