Inadequate Bone Volume Case: Recommendations?

Remove 24 position implant without further damage to 23. A Bony augmentation in the defect made from removal of 24, place an appropriate membrane for the selected bony augmentation material. Place an abutment on 25 implant and provisionalise with ideal anatomic form 24 and 25. 24 will now be cantilevered off of 25. Evaluate over months, soft tissue discrepancies, bony discrepancies,and restorative challenges. Regroup and proceed with a more definitive plan, even if it dictates removal of 25 implant due to initial impression, vertical bony height requirement to adequately meet the patient expectation. You may spend more time with the compromised presentation but this approach may provide information valuable to help formulate the appropriate and definitive course of action. Just a thought.

Long term disaster for this 25yo female. Recommend you follow your first option and explant both fixtures. There is significant hard and soft tissue loss and both adjacent teeth 42 and 32 are at high risk of further soft tissue recession and periodontal compromise. Combination ramus block graft perforated with screw fixation and bone shavings with Bio-oss to increase alveolar bone volume.Large well mobilised flap required. Wait 6 months then do soft tissue augmentation with CT graft. Redo small diameter implants 3.0 or 3.5mm only for each tooth or a single regular diameter implant to support 2 teeth. Only other option is block distraction osteogenesis

This is a very difficult situation, With the implants in their current position the aesthetics will always be compromised. Restoring as they are using pink porcelain might be ok for now if the area is covered by a competent lip but.....the long crowns and Inadequate interproximal space will create a cleaning nightmare and I believe that it will result in later failure and potentially compromise 32 and 42. I believe ultimately this case will be the long road to restore the gingival profile before repeating the treatment. My judgement (for what it's worth) is this situation is all bad news. Sorry to be so gloomy :)

This is a tough case. The way I would treat the situation is to remove both implants. GBR using bmp2 is great for a case like this. The mini dose of bmp2 is about $950, plus the titanium mesh. I don't think anything else will come close to the results of bmp2 in a case like this. A soft tissue graft may also be required. regards, mwr

Seyed Jalil Sadr, DMD, MSD Prosthodontist January 26th, 2011 I would like to make some correction in my last statement. If we look and notice carefully the space is from one tooth Extraction, since she has tooth #24 (# 31) and also # 26 (#42). she has lost Just # 25 (# 41). For sure she had diastema in between. but her sergeon beside doing bone augmentation even without pre - surgical restorative / prosthodontics evaluation has inserted two very close implat and created a very difficult situation. With the implants in their current position the aesthetics will always be compromised. what will happend with her Midline and also long restoration.Restoring as they are and using pink porcelain might be ok for now if the area is covered by a competent lip but I personally do not believe on colored procelain because never give us soft tissue matching color and how about food impaction. The long crowns and Inadequate interproximal space will create a cleaning problem and it will result in later failure and potentially compromise 24 (31) and 26(42). Why everybody of dentist just think about insertion and surgry? For Xplant and bone grafting how we could have patient to accept? Dear Dr.Richard Vickers do you think even redoing the case with small diameter implants 3.0 or 3.5mm only for each tooth or a single regular diameter implant to support 2 teeth,will helps. Does the width of space let us better position for 2 implant? or what will happen if one implant be placed in middle of space? if every others codition were ok orthomay helped,but in radiographs the next teeth to space do not have good condition for movement, Just as a suggestion one could make dicision for # 26 and 24 and even 23 extractions and implant insertion for 26 and 23 and then restorative dentist ignore one of the exsiting implant and make a bridge for 23 - 26 with three implant abutment. Now with the existing situation from restoration fabrication point of view, how is it possible to make impression of such a closed adjacent two implant.it is impossible to put two Implant impression cap for opened or closed tray impression tchnique. What way(s) of soluation do you suggest?. As a last words: To fail the plan is to plan failure. We MUST learn that before starting to do treatment, to have good Diagnosis and consultation. God beless all of us with these cases. sorry for long statement and arasing Question(s) for Impression making and handdling road of this case.

For Dr. Vickers in NY: Do you really know something about the humane bone regeneration?

Is's a challenging case. I suggest 3 ways to manage it: Option 1: relatively easy and less traumatic, but predictable. Assuming the 41 implant is still in good restorative position Remove the 31 implant too close to and harmful to adjacent tooth. Put cover screw on 41 and well clean the perio problem around the region. When the perio condition is stable after 2-3 weeks,Perform a GBR on the 41 implant: to ensure the succes of GBR, the contaminate implant surface had to be clean(laser in this situation work the best, otherwise citric acid/ ultrasonic scaler help a bit) The use if Bio-OSS is advantage coz it had less resorption rate and provide good support to the soft tissue volume. Sof tissue augmentation is essential too, either with CTG or FGG.Soft tissue graft improve the both the quality and quantity of the soft tissue for both esthetic and OH. U can do it before, during or after GBR procedure, depends on your experience, confidence of those technique. I think this option is less predictable coz the the orientation of 41 implant may not be good enough for the final prosthesis. So, a diagnostic wax up with fixture level impression for 41 can help u to make the decision. Also, GBR on contaminated implant surface may be less predicable. Another problem is the existing bone resorption pattern. If the bone resorption limit on the buccal only, GBR is still favorable. But if both buccal and lingual are resorbed, poor result should be expect.A CT scan is helpful before U jump in

Option 2 , more predictable and still, relatively easy and less traumatic. Remove both implant, make diagnostic wax up and surgical stent. When the wound heal up after 1-2 months, insert a new 3.0 or 3.5 narrow implant in correct prosthetic driven position.GBR is probably needed and soft tissue graft is essential too. this is a more predictable option as the the implant position can be made ideal and the surface is clean for GBR. However, if the bone volume is highly inadequate, the grating with GBR is also compromise. Option 3 most predictable a, but more traumatic and long duration. Remove 2 implant, autogenous block bone graft and soft tissue graft. Wait for 6 month and implant with surgical stent. For optimal esthetic result, orthodontic/ veneer/ composite treatment can correct the space problem before implantation. I personally preferred option 3 if the patient accept the long treatment procedure and surgery for 2nd donor site. Otherwise will go for option 2. Block bone from Purous company seem work for some cases but I think autogenous block bone is still the gold stand are and higher chance of success. Hope this suggestion help

What a strange case - but what a mess. The lady only seems to have lost one tooth but has a gap of at least two incisor widths. Presumably she originally had a humungous midline diastema. Various contributors have suggested removing the implants followed by various exotic ways of building up the ridge before placing new fixtures. However this would be difficult. Even though your photo suggests that the implants have only recently been placed I guess they will be fairly firmly integrated by now. Removing them will result in the loss of most of what little alveolar crest there is left, and will also run a fair risk of wrecking the lower left central incisor. Moeover it would be very difficult to achieve adequate soft tissue cover over any hard tissue graft. I suggest the first thing to do is place cover screws on the implants and allow the gum contour to mature for a few weeks. Then you need to move into damage limitation mode and make it very clear to your patient that there's no perfect way out. Personally I would think about leaving both fixtures in situ and placing a two tooth "bridge" with pink gum work supported on just the right implant. This should be acceptable aesthetically so long as the lady does not have extraordinarily expressive lips. And so long as it is correctly contoured she should be able to floss around it without too much trouble. If and when the adjacent teeth bite the dust you could consider other approaches, but for the moment... The most important things are a)keep it simple, and (b)keep the patient fully informed of the problems. By the way Dr S, I love the concept of humane bone regeneration Good luck!

Many thanks to Mr. Townend Everytime some doctors believe that they do understand the bone regeneration. But who has research bones with the microscope?

The moment you restore this case you become part of the problem. This patient has been poorly diagnosed and treated to start with. She is only 25 years old. Clearly she needs to be informed, the implants removed, retreatment planned using CT scan and then treated. The most conventional fixed treatment here would be to remove teeth 42 and 32 as well; this leaves the height of the periodontal ligament adjacent to teeth43 and 33 in place. (International tooth numbers). Bone augmentation using your bone graft of choice and then implant, uncover, restore and finally maintain. Don't cut corners. Your challenge is more the temporary restoration during treatment. Start with the premise that there is no ideal and then decide which to use. The bone grafts you can use are dependant on your skills. If needed refer to someone who has the skills. Block grafts - autogenous or allografts can be used. Allograft blocks in the mandible have however, more complications than in the maxilla , and this should be considered. Particulate bone grafts can also be used but it lengthens treatment time considerably. Always keep the patient in mind and not just the procedure. This lady needs a better diagnosis and a more honest dentist than the previous one. No basic principles were adhered to in her existing mess.

i am just wondering......does ANYONE think THIS treatment plan would be acceptable/yield a good esthetic/functional result. 1. Extract implants ( i really love the term " explant" the implants....how elegant !! ) 2. Place bone and connective tissue graft....by someone who does ALOT of this type of grafting With placement of a flexible nesbitt for appearance while bone healing takes place ( 6 months to a year ) 3. Place a state of the art, all porcelain bridge, either 23 to 26 or 22 to 27. 4. Hope the patient doesnt sue for the rather amateurish, ill advised and doomed implant treatment plan. sometimes its better to cut to the chase, admit ( if only to yourself )that the work was....not good and give the patient something esthetic and long lasting ( yes, i KNOW she is 25 and will have to replace the prosthesis eventually AND yes i KNOW we would be using virgin teeth to do this ). This patient is probably miserable over this failed case....an offer of something with great possiblility of success, both clinical and esthetic, might be just what she would like and might just get her out of the dental funk she is probably in

OOOPS.... i just looked at the photos again after i placed my comment the implants ( 2 ) are in place to re place ONE tooth only 25 is missing what did the patient look like before the implant related work was done..?? i would like to see a pre op photo/xray....and know WHY the implant work was neccessary ( I really HOPE that it WAS neccessary ) Sorry about MY error

The ideal seems to be to remove both, bone graft and redo with smaller diameters placed with greater precision so that healthy living tissue can surround both fixtures to maximize gum and bone health, aesthetics and durability. But since the condition is already compromised and the patient probably wants the problem to be solved with a minimal of fuss, a suitable compromise is to remove the lower left fixture and replace it with a mini. The fixture is too close to the adjacent tooth and the adjacent fixture,resulting in failure in the formation of a healthy bridge of mucosa between the two fixtures. Remove this fixture, replace it immediately with a mini and finish it with a splint bridge. A satisfactory result in a bad situation..... all things considered... the oral problem per se, the patient's viewpoint and the dentist's viewpoint.

A tough case. Why would a dentist place 2 implants that look like 4 mm at least in diameter in tight spots like that. While, and if no symptomes on # 23 now, I would get both implants out, graft the site, and then go with smaller implants. If you have a good hand, then try 3.0 mm implants.

This is a tough area for two implants. I try to avoid these and talk patients into a fixed bridge. To treat this, I would put the implants to sleep and place a fixed bridge. You probably should of used two narrow body implants such as the UNO or MEGA GEN's narrow body implant or like I stated earlier, a simple fixed bridge and tell the patient that RCTs will have to pe performed.

Frankly, if you are not an expert, do not try to redo this case. Anything unexpertised would result in bigger failure. Tissue loss is simple but tissue increment would be complicated. Vertical bone augmentation?? Forget about it. Even bonecraft from iliac crest won't guarantee success. Therefore, acceptance for such scenario is the best. If the patient is so keen to have a more cosmetic result, just pass this hot plate to the specialist.

In this situation, where the patient is missing the right central incisor and has a diastema as wide as an incisor, and one implant is presently against the other central incisor, I would remove the implant against the root of the left central incisor AND the left central incisor which has been catastrophically compromised by the implant. The other implant has good distance from the right lateral incisor to maintain bone levels on the tooth. After the implant and left central incisor are removed (there is no longer any bone on the mesial of the left central and it has a poor long term prognosis) I would graft the implant and tooth sockets, allow the area to heal and then place a new implant in the position of the left central, spaced so there is bone between the implants and between the left implant and the left lateral incisor. I would then make a three unit prosthesis to replace the two central incisors and a pontic to fill the space of the diastema.

As the restoring dentist, you are now part of the inherited problem-- Why don't you just have the patient bite the bullet and have the 2 implants removed and then have a block bone graft placed for all the reasons posted above.. Explained in a way to her that since she is only 25 and needs to hang on to her teeth for at least another 75 years, this inconvenience now is small compared to what will happen down the road if it's not done right at this point in her life.

very good answer Dr. Richard Hughes.every time when i read some good comments, they are coming from you or from the rest of good doctors(mazor, horowitz,miller). putting to sleep the implant will prevent bone loss, and with a little tissue graft you can increase the hight and than do a fixed prosthetic brige with normal teeth an no pink porcelain.the resault after 2-3 month will be great.best regards