Dr. KV, a prosthodontist, asks:
I have a patient who is treatment planned for an implant and free-standing single crown in the maxillary left central incisor site [#9; 21]. He has a significant buccal concavity. I am considering two treatment options for site preparation with the objective being to graft and wait for bone healing prior to implant installation. One approach would be to use a tunneling procedure and graft with porous hydroxyapatite and allow 6 months for healing. The other procedure would be to graft with a mixture of allograft and hydroxyapatite particulates. Which of these two procedures has a greater chance of success? Would you recommend any other procedures?
Implant Patient with Significant Buccal Concavity: Best Procedure?
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Dr KV
In order to place the implant in a central incisor that is significantly deficient labially you may need a large enough graft that may not be possible with particulate graft materials, and may have to resort to a block graft from the ramus preferably. The chin is ok with slightly more morbidity associated with that area.
If you choose to do a particulate graft, I would use a graft that will be completely replaced by the host’s bone, and not hydroxyapatite. Unless new materials have come out that I am not familiar with, the hydroxyapatite products I have worked with in the past have all been non-resorbable.
I do not believe that you will get the results you need with a tunneling technique. A conventional flap with cortical perforations for bleeding and RAP and some way of tenting the soft tissue would be necessary.
Good Luck.
If the buccal concavity is a big as you say, this is a case for a autogenous block graft.
As an esthetic site, the more bone volume you create, the better your long term outcome will be. Your HA tunneling – allograft onlay suggestion is not a reliable procedure for this patient.
My recommendations:
Scan the patient
Know your defect
Put yourself in the patient’s position
Think long term outcome
Always raise a site specific flap here when placing so you can see the issues and be aware of any perforation of the buccal plate which will be thin with this size of concavity. I would then expand the ridge with whatever method you prefer and place the implant , possiblly 3.5 mm wide in the aesthetic zone.Then Graft over with BTcp and Caso4 to get a stable , cell occlusive yet vascular nano-porous graft site.
Done it hundreds of times sucessfully over the last 7 years or so and long term (6 years)shows no future bone loss.
Low pain option , would we do blocks on ourselves , no so sure I would like one.
I like to avoid HA so what we have is bone since the other products fully bio-resorb to leave the body as it was.
Will be seeing some long term Tunnel cases with Histo in a few weeks time in Zurich which should be fun.
Happy patient …..happy dentist.
Peter
Full thickness flap. Do not use HA. Freeze dried bone best with PRF and. Non-resorbalbe membrane. I di four of these in the past week and have done a hundred or so more with excellent results. If you have enough bone, place the implant along with the graft….
*Implant placement with simultaneous Autogenous block + autogenous bone shavings (bone scrapper) stabilised with a titanium re-inforced non-resorbable membrane.
*As the gentlemen above have mentioned..stay away from hydroxyapatite.
*PRF …not sure if current literature supports its usage.
*Do consider DFDBA + bovine derived particulate grafts in case donor site morbidity is an issue.
Monocortical Block Graft,either ramus or symphysis. No if’s and’s or but’s. This is an autogenous situation, and there are no short-cuts. If block grafting is not part of your protocal, refer it to someone that does.
In a single maxillary incisor site a particulate graft will always work well if done properly and there is no donor site issue to consider. Suggest use an allograft such as mineralized cortical/cancellous bone covered with either a resorbable or non-resorbable membrane with tension free primary flap closure. Its also important not to have pressure on the graft from a temporary partial denture.
You need a cone beam CT , or at least bone mapping inorder to make a good & precise Tx planning.
-If you have more than 6mm bone place the implant such as 4.3×13 or 4.3×10 (REGULAR PLATFORM)would be ideal.
-If less than 1.5mm bone ramaines on the buccal side , GBR should be performed w/ releasing periosteal incision to be able to close the flap completely ,and remote flap design extending to distal of canines.
-If the threads are exposed, yiu need a sandwich technique ,ie; 2mm of autogenous bone graft + 2mm of bio oss + collagen res. membrane.an FRC as a temp, 6 months later proceed to prosthesis.
-If no part of the fixture is exposed , but the buccal bone is less than 2mm, do a sussage technique of GBR ie; mixture of 60% autogenous bone particle &40% bio -oss,to be covered by a res. collagen membrane,the prosthesis will be done after 4 months.
The autogenous bone can be taken from nasal spine , chin, ramus or max tuberosity, depends on the amount of bone you need.
During uncovering stage a connective tissue graft can help if needed.
-If there is 4-6mm bone available you can place the implant and perform GBR (sandwich technique),or augment the area w/o placing the fixture, and place the implant after 6-8 months,depends on your skill.
-If less than 4mm bone width is present just do the GBR by using sussage technique or of course using PRGF AND TITANIUM MESH, w/c is the best , but expensive.
Be very careful if your pt. has a high lip line.
good luck.
Dr. Danesh from Iran.
In addition PDGF growth factor (gem 21) w/ titanium mesh in a sver atriphy and resorbed ridges do a greate job.
ANYONE EVER ENCOUNTER A LINGUAL CONCAVITY IN THE PREMAXILLA?
Consider expanding the ridge with osteotomes. Make a crestal but to expose the crestal bone then using a 700XXL carbide break thru the cortical portion. error to be closer to the palatal so that the buccal is as thick as possible. Then using a very thin blade osteotome while pinching the buccal and palatal to prevent overexpansion and fracture of the buccal plate gently tap the osteotome in to depth. remove and repeat with the next size up blade repeating till you have a gap that is 2-3mm thick. next using a D shaped spreader (or a round pointed if D is not available) start with the smallest size and repeat the process slowly expanding the site till the ridge now measures 6mm from palatal to buccal. fill the gap with graft, suture across the soft tissue and allow to heal 6-8 weeks. at that time go back and after using a pilot drill use round osteotomes to develop the site to less then the final diam of the implant. the implant is then used to do final compression. Should there still be a residual defect on the buccal you can make a flap with no releasing incisions pocket out the area and fill with some non resorbable or very slow resorbable graft material. The result of all this is a site that has native bone as a buccal cortex whereas block grafting sometimes the graft doesnt fully “bond” to the native bone at the site
Dr KV.
If you are going to choose ONE of two graft as you mentioned, it’s better you use allograft and hydroxy-apatite particulates cover with resorbable membrane. However, AUTOGENOUS (symphgsis) block bone graft is the best option for your case. Hopefully help.
Dr Vaziri from Iran Tehran
One, if they have enough skill can do several things. 1) Expand the bone and place a singlr tooth blade implant from Park Dental or Pacific Dental Implants. 2) Expand and place “The Skinny” from American Dental Implant Inc. You may have to direct towards the lingual. 3) If real severe and you have adjacent teeth then simply treat with a fixed bridge. We do not always have to place implants.
i have a similar case and i prefer to use a 3.3 13mm implant placed with allograft rmtbg aand bovine graft with a resorbable membrane and wait for 6 mos ,if iam wrong please correct me
tunneling procedure ? i dont think its a good option to augment a very huges buccal concavity, and second one allograft mix with HA inaway yes it could but were dealing a very large concavity….. the best rational approach you can do is to harvest bone ( Bone Block) the use bone screw to stabilized the block then particulates to filled the voids around it ….. and if your thikig how to the graft stabilise used membrane to give you peace of mind that it will mature ad become bone, may be after 9 mos check do a xray and see whats goin on with garft you did , i Bet its a vital bone and the area is ready to received Implant………..BTW your option is good but always bear in our minds how big is the defect we are dealing with
DR K V ,
1. SIGNIFICANT BUCCAL CONCAVITY— LOSS OF BUCCAL PLATE ??? ( MOSTLY )
2. WIDTH OF THE BONE INADEQUATE —-
A. CONSIDER GBR WITH AUTOGRAFT OR DFDBA ( ALLOGRAFT )+ GTR OR TITANIUM MESH.
B. SPLIT IT IF WIDTH OF BONE IS 3 mm ( IF CONCAVITY DOES NOT CONTINUE APICALLY ) WITH PLACEMENT OF IMPLANT & BONE GRAFT AROUND .
C. IF CONCAVITY CONTINUES APICALLY THEN STEP A.+ WITHOUT SIMULTANEOUS IMPLANT PLACEMENT.
first consider the level of concavity by CT SCAN evaluation.2] never do any tunneling approach 3] i strongly deny to have any form of bonegraft artificial as u hv damn probability of enbloc recession palatally.4]always prefer a direct graft from ramus which will have much superiority of osteosynthesizing in this type of area.5] choose ur implant carefully 6] depending on thickness prefer 3.3, 3.7mm , 15mm implant. more over ur drill shuld take incremental approach. sucess is inevitable as several cases over ASIAN N AMERICANS conducted by me yielding good result after 5 years, hope u gain from this discussion