Deficient Buccolingual Bone: Recommendations?

Refer to someone who has experience in grafting. This is in the esthetic zone- you do not want to experiment on this one. Your questions are very basic and it appears that your knowlege of grafting technique is limited. If you do a ridge split and you have layed a full thickness flap and you happen to fracture off the buccal plate- you are in trouble! Ask your OS or Periodontist if you can observe.

Dr A. In my opinion this does not sound like a clinical situation for a split ridge procedure. Clinical presentations such as the one you have described are much more amenable to particulate grafting as you have suggested to bulk up the buccal aspect of the alevolus and correct the soft tissue concavity. If, as Dr Schlesinger suggested, you are not comfortable with this procedure either refer it or perform it yourself in an 'over the shoulders' mentoring program. The esthetic zone is not very forgiving, and the most experienced of us have found this the hard way. "Experience is simply the name we give our mistakes" O. Wilde

Does the patient has a high smile line?. If not, then you might consider ridge expansion?. You need the "map" the area first, and have a good idea on how wide the ridge, the deepest area of the concavity. Make crestal incision, and only 1-2mm vertical releasing. I have been using the MIS ridge expansion kit, and it's been working well for me. If the area is really 5mm, then I think you can place a 3's something mm implant in the area. Please don't forget to angulate your osteotomy slightly palatal. Hope that help, good luck. Post some pictures if you decide to do it.

Is this a congenitally missing lateral case? If it is you will have a significant buccal defect apical to the crest. A scan will tell you exactly what is happening here. The procedure you discussed is not guided bone regeneration. Your procedure has no guaranteed results and it doesn't seem fair to this patient to expose him to this. I tend to block graft these cases, especially easy when in conjunction with third molar extractions. Your questions are so basic, as stated previously. This sounds like a good one to refer.

Dear Dr A, Apparently, you have sought a rationale , a philosophy for management and are clued into the technical etails of the procedures (techniques) themselves! So here we go, If you have a residual bone width of about 5mm in a young adult (as is your case), you probably would be well off doing a Ridge-Split (even an Expansion without the classical "Split"). I say this because, a Split or an expansion would give you the best chance of providing for a Labial Cortical plate and a Palatal Cortical plate around the Implant, whilst 'cleaving' a central area, representative of the deficient Cancellous component of the bone in the area. You may of course choose to either simultaneously place the Implant or graft the intervening expanded area with either a Cancellous Autogenous harvest or an Allograft (preferrably admixed with some early resorbing Alloplast), so that the Cancellous componenet may be generated and then you may place the Implant (Delyed) at an appropriate time. An Onlay would have been the relatively easier of the two procedures as a clean and minimally traumatic split would require a Piezo (or any similar device) to achieve the Micrometric cut at a frequency that would allow for bone to be preserved as much as possible during and after the surgery. An Onlay graft, would require the additional help of decortication of some sort to promote RAP (Regional Accleleratory Phenomenon)to help 'uptake'of the graft. This would then have to subsequently completely resorb and be replaced by native bone in the recipient area and only then would you be looking at the possibility of Osseointegration. Both the procedures would have the soft-tissue closure, be more cumbersome than easy, as the resulting increase in the width (Bucco-Lingual) of the augmented recipient site would find itself deficient of soft tissue. My own suggestion is plan wide exposures, involve a few papillae on either sides, go high along the alveolar mucosa tunnelling and freeing it from basal maxillary bone rather than making any relieving Periosteal or vertical release incisons. Dr Jeevan Aiyappa

Dr. Jeevan, I understand your train of thought. However, the dirty little secret is that onlay/block grafting is at best 50% successful. I know there are times this may seem to be the only option. I have taken a 2mm. wide ridge and expanted to 6mm. using Tatum's techniques. If you can split deep enough apically you will obtain a blood supply. You also have to protect the site with a surgical stent and need a most compliant patient. One also has to be patient when performing the expansion procedures.

The biggest problem with incisor replacement is the typical lack of facial cortical bone and apical concavity. Any time the bone is not of ideal contour, the overlying soft tissue will be inadequate to allow for truly esthetic restoration. The most reliable method of properly reconstructing the missing buccal cortical bone is a cortical onlay graft. In the hands of any well trained surgeon, the success rates should be in excess of 90%. There are too many factors to discuss here, but case selection is obviously important for all the procedures we do. Once the proper hard tissue contours have been established, suitable soft tissue grafting can be done to supply the needed attached tissue. Proper placement of the implant in all three planes will assure that the restoration can be constructed to emerge in a natural manner. I am not inferring that no other method works but simply that when cortical bone is missing, it is best to replace it with cortical bone. Really a pretty simple concept that will serve you well in your planning and case completion.

Google Dr. Daniel Buser. His group in Switzerland have published extensively on Implants in the Aesthetics zone. He has SAC classification Simple, Advanced, Complex. This case is probably an Advanced case (bone block repair) and is not the place to start for you. Take a good bone grafting course and buy some of Buser's books.

Nobody has mentioned soft tissue biotype. I have found that this makes a huge difference to your choices of augmentation. Very thick soft tissue is most forgiving and in the right circumstances some expansion and particulate will suffice. Take a CBCT if you want to be really sure as on occasion both cortical plates can fuse and then you wont be expanding anything! Thin tissue and a high lip line always makes me cautious and think long and hard a bout a block graft and probably some connective tissue grating (see Buser references as above). Send your case photos to a mentor pal for another opinion and good luck.