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

489 Rating(s).

Posted on 09.12.2017 02:25 PM 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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58 Comments

Maurice Salama says on 09.12.2017 03:57 PM

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

Howard Gluckman says on 09.12.2017 04:35 PM

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

Maurice Salama says on 09.12.2017 05:34 PM

With plates is Ti=reinforced membrane needed?

Howard Gluckman says on 09.13.2017 03:56 AM

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

Tyler Binner says on 09.12.2017 04:05 PM

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

Howard Gluckman says on 09.12.2017 04:35 PM

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

narayan tv says on 09.14.2017 04:32 AM

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.

narayan tv says on 09.14.2017 04:32 AM

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.

richard martin says on 09.12.2017 05:22 PM

Howie,

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

Cheers,

Richard

Howard Gluckman says on 09.13.2017 03:57 AM

Rich you are the man with the ideas

Thanos Ntounis says on 09.12.2017 05:21 PM

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!

Howard Gluckman says on 09.13.2017 03:58 AM

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

Thanos Ntounis says on 09.13.2017 11:48 AM

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

Ehab Moussa says on 09.12.2017 10:06 PM

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

Howard Gluckman says on 09.13.2017 03:59 AM

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

Howard Gluckman says on 09.13.2017 07:37 AM

Thanos Ntounis says on 09.13.2017 11:48 AM

beautiful! Very difficult stabilization Howie! Great job!

Howard Gluckman says on 09.13.2017 07:37 AM

Howard Gluckman says on 09.13.2017 07:38 AM

Maurice Salama says on 09.13.2017 08:40 AM

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

Howard Gluckman says on 09.13.2017 03:35 PM

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

Naheed Mohamed says on 09.13.2017 01:27 PM

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

Howard Gluckman says on 09.13.2017 03:35 PM

thanks you

Fidan Kajtazi says on 09.13.2017 05:45 PM

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

Howard Gluckman says on 09.14.2017 02:33 AM

Thank you Fidan. I appreciate your kind words

PAOLO Mastrangelo says on 09.14.2017 03:11 AM

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

Howard Gluckman says on 09.14.2017 06:09 PM

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.

Jorge Campos says on 09.14.2017 09:12 AM

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

Howard Gluckman says on 09.14.2017 06:12 PM

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

snjezana pohl says on 09.14.2017 10:27 AM

Five stars, admiration and no questions!
Cheers
Snjezana

Howard Gluckman says on 09.14.2017 06:12 PM

thank you my dear friend

Bassam Rabie says on 09.14.2017 10:38 AM

amazing case and only can be found on this forum.

Howard Gluckman says on 09.14.2017 06:13 PM

totally agree Bassam

richard martin says on 09.14.2017 10:05 PM

Howie,

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

Cheers,

Richard

Howard Gluckman says on 09.18.2017 01:16 PM

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

yiannis vergoullis says on 09.15.2017 06:26 AM

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.

Howard Gluckman says on 09.18.2017 01:18 PM

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.

Manuel De LA ROSA says on 09.15.2017 10:17 AM

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

Howard Gluckman says on 09.18.2017 01:19 PM

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

Bernardo Mira Correa says on 09.18.2017 04:50 AM

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

Howard Gluckman says on 09.18.2017 01:20 PM

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.

richard martin says on 09.22.2017 07:51 PM

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

Howard Gluckman says on 09.26.2017 03:45 PM

CBCT 14 days post op

Howard Gluckman says on 09.26.2017 03:46 PM

3D Rendering of the case

Maurice Salama says on 09.27.2017 01:35 PM

Just LOVE the follow up CBCT.
Mo

Howard Gluckman says on 09.28.2017 03:52 AM

~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

Vincenzo Foti says on 11.26.2019 11:35 AM

Challenge case Maurice!
In my Country the BMP aren't available, as homologous bone.
So, according my technique, I would place a porcine cortical lamina soft fine 0.6 mm below the palatal flap glued by Tisseel until the residual bone. Graft autologous/collagenized heterologous 1:1 (sticky bone by Tisseel). Finally the lamina fixed always by Tisseel on buccal bone apically to defect (Rounded Box). Two-three S.E.I. sutures (Suspended External Internal) of Luca De Stavola to break down the tension of vestibular flap and horizontal mattress sutures. Healing time: 12 months.
Best regards
Enzo

Howard Gluckman says on 01.12.2020 09:51 AM

This case was finished in 4 months. No high cost of materials and little if any pain from either harvest or recipient site. I cannot see a batter way. I will show results soon

Howard Gluckman says on 04.17.2020 12:05 PM

Here are the latest finished products of this case
We opened the area up after 4 months and placed the implants and left exposed as the patient travels from Ivory Coast which is in West Africa. He came back and the implant crowns were placed. We cannot get any papilla here and I agree with he prostho not needed as the patient does not smile much at all.