Re-Establish Lost Palatal Portion after Failed Bone Graft?

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Dr. C. asks:

I placed a mineralized freeze dried bone graft and titanium reinforced membrane over an alveolar ridge deficiency and facial defect #9 area. After about 5 weeks, the membrane became exposed on the palate and eventually I had to remove it.

The labial plate appears adequate, but there was a vertical defect on the palate and the palatal tissue has lost a significant amount of bulk. I would like to re-establish the lost palatal portion of the ridge. I’ve also run across this problem in periodontal patients with large palatal osseous defects but adequate labial ridge for good esthetics.

I’ve not seen anyone address how to handle this problem if dental implant placement in a situation like this has been planned. What do you do in these situations? Any advice would be appreciated.

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5 Responses to “ Re-Establish Lost Palatal Portion after Failed Bone Graft? ”

• Bruce June 27th, 2007

  
  

  Without seeing the case it is hard to figure out the solution, but I think I got a handle on your situation. If the area is not think enough to place an implant and the deficiency is truly palatal, then I perform a suspended onlay graft. What I mean is that I harvest a strip of ramus, and use that strip as the most palatal dimension of the reconstruction (and set it in the proper y plane (cephalad-caudal). I then use either my 1.2mm titanium screws or the newer screws from STOMA 1.0mm (not avaiable yet in the US-but coming soon I hear), and drill through the buccal plate and the engage the strip. Now if the defect is large enough, the strip will be suspended palatally a few millimeters from posterior portion of the buccal plate. (you will see a space between the two bones — the indigenous one and your new “suspended” strut. Since I usually have left over ramus, I crush that up very small and pack within the defect. Advancing the palatal portion of your flap is tough, so for tissue coverage, since your at nine position, I use the pedicled connective tissue flap, swung over from the premolar region. The best description of that is by Dr. Sclar and his VIP flap. The way I do it is very similar and I think his way is easier than than the Pikos way. In that manner you have a flap with its own good blood supply under your mucosal closure. I don’t use a membrane here as the volume is firmly contained by your strut, so the use of titanium reinforce PTFE or titanium mesh is not needed and with this method, you won’t need the extra volume to accept your membrane or mesh.

• satish joshi June 29th, 2007

  
  

  Just redo grafting with PARTICULATE and membrane fixed with suturing to periosteum on palatal and tacs on labial and more than enough TENSION FREE labial flap. NO REMOVABLE PROSTHESIS.YOU MAY NEED TO DO VESTIBULOPLASTY LATER.

• King of Implants July 8th, 2007

  
  

  I agree with Satish. Redo with paticulate graft, and make sure your non-resorble membrane is fixated. Passive primary closure is imperitive, so the pedicle technique, suggested by Bruce, works really well in these situations. To find out about this pedicle technique look up the author Fugazzotto. When proper technique is followed very good and PREDICTABLE (supported by literature)results can be obtained in this manner. Good Luck

• Marvick Muradin, MD DMD July 13th, 2007

  
  

  If using a cortical plate as a graft rigid fixation is a must as well as good soft tissue coverage. With ramus bone good volume will be the result. Particulate bone is useful and less is lost when dehiscence occurs, but you tend to get less volume when not using titanium inforced membranes.
  A very useful flap in frontal cases is the “bucket handle flap” or in more lateral cases a Buccal Fat Pad flap might be useful in some more complicated situations. Both flaps were first described by Peter Egyedi for closure of palatal fistula in cleft patients.

• Gregory J Gosch August 30th, 2007

  
  

  Could someone give me a source to purchase a Stoma screw kit?

  thank you,

  Greg Gosch

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