GBR or is the bony defect too great?

This patient presented approximately 10 weeks ago with a debonded post core crown #11 [maxillary left canine; 23]. The root had suffered a fracture on the buccal aspect and the prognosis was hopeless. We decided to extract the fractured root after discussing the alternative options for the resultant space. The buccal plate fractured during removal with periotomes and as the patient was not definite on an implant we could not justify GBR  [Guided Bone Regeneration] at the time of extraction. The patient returned recently expressing an interest in placing an implant in #11 site. The CBVT scan shows a significant bony defect on the buccal aspect of the proposed site.

The patient has no significant medical history and is a non smoker. My initial thoughts are implant installation with simultaneous GBR. Is this a predictable treatment plan or is the bony defect too great? Would a block graft followed by delayed implant placement be a more suitable approach? The patient is not concerned by aesthetics.   I feel comfortable with GBR but I would refer this case out if block grafting is needed.

UL3-ct-scan

12 thoughts on “GBR or is the bony defect too great?

  1. This defect needs to be grafted first, I would have done it at extraction by placing a reinforced teflon membrane tacked in place, particulate bone with or without PGRF. You’ll get a labial plate back or at least some thickness to work with. Others may use a block graft or use the implant itself, I have not had experience with those techniques. Be careful stating that the patient doesn’t care about aesthetics in this area, they will when the site heals with an exposed implant that is difficult to restore. You can also go back and use this technique post op just currette out the old clot. If the site is properly prepared in the long run it is easier than hoping an iffy placement will heal. Don’t feel bad about the fracture and loss of the plate, it is quite common with old endo fractured tooth. I usually treatment plan for this at extraction of these hopeless teeth.

  2. Looks like a block graft to me,
    there is loss of the entire facial plate of bone down to the apex.
    It would be nice to post some more slices of your CBCT so we can get a better idea of the volume of bone necessary to restore this area.
    Additionally, you’d be surprised how much a well executed socket preservation graft can do in cases like this, even with bone loss from extraction. If a patient is not decided on an implant yet, a socket preservation will make life easier for everyone in the future if they decide to go ahead. I’ve found it’s worth the time to talk to every patient about socket grafting.

  3. Thank you very much for the expert advice, I have decided to refer the patient to a local surgeon to manage the bone defect.

    • It really depends on the bone level on mesial and distal tooth. If it is fairly intact , then GBR would work!

  4. GBR works well but you are probably better planning to augment first, then implant placement later with some GBR as required. The critical factor with implant placement is having adequate bone width around the crestal part of the implant to help prevent later crestal bone loss and exposure of the root of the implant. A knife edge crestal bone margin around the implant is a guarantee of future bone loss, peri implantitis and eventual implant loss.

  5. Looks like an ideal situation for bone expansion using Dr. Tatum osteotome technique with no grafting needed.

    • Sorry but there is nothing to expand, no buccal plate to push out. If you fill it in first with bone then at implant placement expanders are great to push out vs drilling away what was grafted. ;)

  6. Good move Gavin , there are many years to tackle the more complex cases and if not totally confident of success then best to do what you have done .
    It would have been nice to see more images to get a clearer picture of the adjacent areas.
    Peter

  7. When working in the esthetic zone, one must be very aware of the fragility of the buccal plate……… periotomes and elevators are too unreliable and unpredictable in trying to preserve this very fragile, and most important bone…when it is lost, it is almost impossible to restore to the original shape, regardless of the grafting technique.

    It is for this reason, I developed the “TanGer Technique” for Atraumatic Root Removal in the Esthetic Zone ….published in Implants News & Reviews September/October 2012 Vol14 No.5.

    In this article I described how predrilling a shaft in the root to be extracted, and fitting a Dentatus Screw Post ( Preferable a minitransitional implant because of its length and that it is reusable) into the hole, and with the use of a sterilized common vice grip ( found in any hardware store), gently keep downward pressure once the screw is tightened and fastened by the vicegrip, to tear the ligament and extract the root. If the root is fractured, then the Dentatus screw will aid in pushing the fragments apart, thereby expanding the socket gently, so that fine periotomes can be inserted to bring the segments out….this technique does not work in every situation, but when it does….you will shout :” Hallaluyah”….no damage to the buccal plate.

    For further information on this technique , please contact me

    Dr. Gerald Rudick Montreal Canada

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