A Novel Approach to Repair Severe Damage in the Esthetic Zone

Case submitted by: Dr. Gerald Rudick and Arta Prenga.

Case Description
(Case photos are beneath the description)

A 40-year old male patient, a heavy smoker, presented with a mobile and sensitive upper right central incisor ( #11).

The preoperative radiograph revealed that this tooth had been treated endodontically, had a post and core, a crown and evidence of a possible root resection. He was given a local anaesthetic, and the tooth was extracted; however, a large portion of the root remained in the bone.

A full thickness flap was opened, and the remainder of the root was removed, and a lot damage to the buccal bone was observed. The soft tissues were approximated, sutured, and a plastic denture tooth was bonded to the adjacent teeth to act as a temporary replacement. A period of five weeks was left in order for the site to detoxify and clear itself of the deleterious tissues.

Prior to re-entering the site, four vials of PRF were drawn and centrifused for 8 minutes at 2700 rpms. The tubes were opened, and the PRF was withdrawn and pressed to obtain membranes.The exudate of fibronectin and vitreonectin were used to wet the grafting materials which were Cerasorb M, Osteogen, Osetodemin with a sprinkling of Metronidazol powder.

The soft tissue was reflected and with a piezo scaler, denuded the labial plate in the area of where the implant was to be placed. Selected an Adin 4.2 x 16 mm Touareg S implant; which was secured at the apex, and slightly on the sides, as the entire labial surface was exposed. A titanium mesh was cut to size and secured with the cover screw of the implant. The implant surface was rinsed with the PRF liquids, the grafting material packed on top of it, covered by two PRF pressed membranes, and the titanium membrane folded on top of it.

On top of the titanium mesh two remaining PRF membranes were placed, the soft tissue reapproximated and then sutured with sutures. The site was covered with Coepak periodontal dressing, which also secured the denture tooth. After 5 days, the periodontal pak was removed,and the denture tooth was bonded to the adjacent teeth, and left for observation. At 10 weeks, a decision was taken to open the soft tissues and remove the titanium mesh, and rebond the denture tooth to the adjacent teeth.

Four months after removing the titanium mesh, the labial tissue was reflected to expose the implant and it was observed that bone was developing on the labial surface of the implant, and holes were drilled in the adjacent bone to stimulate bleeding in preparation for a second grafting with Gen-Os which is a porcine xenograft, which was then covered with Evolution membrane. The evolution membrane covered the site and was sutured to place.

It must be observed that the implant was intentionally placed above the crest of the ridge, in order for the titanium mesh to generate bone above the height of the ridge . After four months the soft tissues were sufficiently healed, so that a titanium abutment was fitted on to the implant, and the temporary crown was totally implant supported. Post-op photos demonstrate excellent bone regeneration as verified in the radiograph, with the final restoration being a porcelain to metal cement retained crown.

16 thoughts on: A Novel Approach to Repair Severe Damage in the Esthetic Zone

  1. Gregori M Kurtzman DDS says:

    No mention of the exposed ti mesh at 5 weeks and worse at 10 weeks? I think you could have avoided the ti mesh exposure by placing PRF membranes over the ti mesh before flap closure thickening what was there . Also need to indicate that at ti mesh removal that some threads exposed on the implant and discuss why this occurred. Why use porcine graft material at this point? Why not more PRF and an osseous graft material.?

    • Dr. Gerald Rudick says:

      Dear Gregori K….I did use PRF over the graft and under the titaniu mesh, as well as PRF over the Titanium membrane. It is non unusual for stock titanium mesh to become exposed, unlike and individualized custom fabricated mesh from a CT Scan to a digital model.( available from Yxoss CBR, ReOss, Filderstadt, Germany). Additional augmentation to the implant surface was done with a porcine graft, because it gives excellent results…..I did title the article ” A Novel Approach….” because this was a different way of doing this sort of thing,and it worked out very well….

          • Gregori M Kurtzman DDS says:

            Gerald I think we should always look at our cases and ask ourselfs “what could I have done different or better”? I know I do that on my own cases. So many factors out of our control and cases are different patient to patient make things challenging grin Keep posting and learning and thanks for sharing your cases

  2. Paul says:

    Why not split the procedure into two phases, graft and implant placement. The question will remain if there is any osseous integration of the regenerated bone on the labial and the implant. There is also a question how much thickness of the labial bone is regenerated and will it last or resorb in short time. When done in two stages one can place the implant considering all the established dimensions and exercise the best control one has to assure the best prognosis.

    • Dr. Gerald Rudick says:

      Dear Paul….thank you for your comments………I do agree with you…normally it is best to try to regenerated bone prior to placing an implant…..however, when you look at the damage to the bone in the most esthetic of regions, as evidenced in the photos, I though I would try this approach, and the implant stabilized the titanium mesh in the correct location, and allowed to build a substantial labial surface of bone covering the implant….. at 10 weeks when the titanium mesh was removed, there was bone already growing on the surface of the implant, and months later, when a flap was reflected, the photos demonstrate new bone on most of the labial surface that required additional grafting with Gen Os to get a very decent result.

  3. Sam says:

    You’re a brave man. Nevermind the ignorant comments. These cases are unpredictable and your result is perfectly acceptable. Good job.

  4. Dr. Gerald Rudick says:

    Dear Sam…thank you for your comments…I will take “the brave man” as a compliment…….this was a very challenging situation because of the severe damage, and the fact that the patient was and is a smoker, and this delayed the healing process…. however, this case was completed a few years ago and shows no evidence of bone loss…….

  5. Gregori M Kurtzman DDS says:

    Biotypes can also make or break a case or at least add issues or go smoothly. Sometimes with thin biotypes nothing you do is without complications and those cases with thick biotypes seem that you cant go wrong with them no matter what you do. grin I suspect and may be wrong (I am at times grin) that this was a thin biotype and that was one of the reasons that the mesh got exposed.

  6. Dorian Hatchuel says:

    For what its worth I think that the Pak over the initial closure of the lesion may have been the cause for the necrosis of the flap. No space was left for swelling which is a natural part of the follow up to the trauma of the surgery. Without the Pak, you may not have had the problem if the flap was passive and you had good suturing technique.
    Best Wishes.

    • Dr. Gerald Rudick says:

      Dear Dorian, Thank you for your comment…I won’t argue with you, perhaps the reason for the exposure was caused by the CoePak, however, periodontists have routinely been covering surgical sites with a periodontal dressing for more than 60 years….and are still using it…so it cannot be all that harmful….Gerald

  7. Yosef Kowalsky says:

    Very nice case . Brave . Novel . Titanium membranes are problematic especially with a thin biotype . Very nice result thanks for sharing .

    • Dr. Gerald Rudick says:

      Hello my good friend Yosef…… thank you for your comments….and yes titanium mesh is not without its problems, however the late Carl Misch always found a positive to a negative, when he came out with the expression “RAP”….Regional Acceleratory Phenomenon….. because the irritating factors speed up the healing process between two and ten times….. so irritation does work for us, and as mentioned above individualized specific three dimensional titanium mesh is available from Yxoss CBR, ReOss, Filderstadt, Germany…..however I used a piece of titanium mesh cut from a stock sheet…..so uncovering of the mesh does occur somewhat

  8. Dr. Bill Woods says:

    That is an amazing case with a remarkable result. I’m of the mindset that I could not personally be as successful doing so much at one time and a staged approach certainly fits my skill level better. Combining the width of the defect apically with the implant foot, volume of graft and mesh would seem to tax the blood supply to the center of it all. Smoking didn’t help either. In time, though, it all progressed to a healed state following the return of the blood supply to the center. Great case. Bill

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