Buccal Cortical Plate Has Resorbed: Which of the Three Treatment Options is Best?

Simplify, I say 8 and 9 implants and cantilever.

cantilever 8 and 9 ımplants ...

need more info. Smile photo, probing depths, cosmetic needs, lip line. Papillae are a big problem here.

Agree with cavekrazi. There is insufficient info to say what is the best option. Simplicity is implants in 8 & 9 with cantilever, but it might not give the best cosmetic result. Without further details, I would tell you that 3 implants with fixed provisionals made the same day will give you the best cosmetic result longterm as it will give you the best chance of shaping the tissue properly. You may require grafting #7 first and then placing implants at a later date.

I agree with the 2 posters who recommend implants in the site of the 2 centrals and a cantilever pontic for the lateral. However, there are a few other considerations that I would point out before you proceed with any implant placement. The picture of maxilla that you include shows that there is some loss of vertical bone height in the area of the centrals. There also appear to be significant osseous concavities apically. In addition, there is loss of bone around tooth #7 both vertically and horizontally. So I would strongly suggest that you consider some site preparation in the areas of the centrals at least in the form of vertical ridge augmentation. You can deal with the apical ridge concavities at this time or at the time of implant placement, or at both times. You should also augment the ridge in the area of the lateral, either via hard or soft tissue replacement or a combination of both, to allow for an optimally esthetic pontic. Please do not jump into placing the implant fixtures too quickly. Otherwise, I suspect that you will be posting pictures on this site in a few months asking how to manage such a poor esthetic result.

Cavekrazi asked the right questions. It is difficult to comment without having all the facts. There are different ways to attempt to rebuild the bone in the premaxilla......all of them have their advantages and disadvantages and no one techique can guarantee 100% satisfaction. My advise is to inform the patient that you will attempt to rebuild the bone, and depending on how successful this attempt will be, then further plans can be made at such time. In the meantime, build a comfortable provisional removable appliance that will be functional, esthetic and will allow you to work behind the scenes. Gerald Rudick dds Montreal

Simplify is good! Sequence the treatment - it could take multiple procedures to obtain the optimal results. Make sure the patient knows that this is not a one shot slam dunk procedure. A challenging case to be sure.

Yes the lip line is important and could make or break this case . if the lip line is reasonable then I would take out #7 and try to put some graft material over the socket just to prevent total collapse of the area for esthetic purposes and do 2 implants 8 and 9 with a cantiliever . I DEFINITELY wouldn't do 3 implants !!

The way you pose your question shows that you ar not adept enough to do implant placement in the aesthetic region. As it has been shown by the work of salama and tarnow definitely do not place imps in both central incisors because you will not have predictable Aesthetics. Forget neighboring imps in the aesthetic region. Plus your treatment planning is really poor. The lateral needs both vertical and horizontal augmentation. That should be done either with a block graft or with a putty alloplast like novabone putty that can stick to the place u put it. Just graft, use a membrane over that and wait for 5-6months. While you do that you can have the imp on the central site placed. 5-6 months later go in and place an implant In the lateral. The graft if u know how to do it is a very predictable solution. Then u can make a 3 unit implant bridge which is the treatment of choice in such a case. Ιdon't know how the soft tissue situation is on the case ,but u probably may need some pink porcelain on the lateral site.

When we're talking about cosmetics in the anterior we're talking about how the papilla will fill in the area after next to an implant. It is well known that the worst papilla will be between two adjacent implant. You can only gain 3mm from bone to interproximal contact. Therefore, 3 adjacent implants in that are will look the WORST! On the other hand, you can get the papilla between the pontic and implant tooth can gain 6mm of papilla. That is better than a natural tooth, because with a pontic you can train the tissue so well. The second best papilla will be between an implant and natural tooth. These facts are well documented, so I am surprised to hear all of these less esthetic treatment options. The best option would be to graft #7 area to an ideal ridge and place 2 implants, #7 and #9. This gives you two ideal papillas next to the pontic, and 2 seconbd best papillas next between the implant and natural teeth. This is AAID exam stuff.

Just saw DR. G's comments. I agree 100%

This patient looks more like an ALL ON FOUR candidate long term or full denture/RPD. Poor px if past dental hx is to be considered. Some patients can change miraculously though, if this patient has an undiagnosed systemic dz,maybe I would insist on a full physical , possibly a stress test and blood work. If all the perio dz and bone loss is due to poor oral hygiene, poor diet, stress....is that going to get better?

All On Four??? OMG give some people a hammer and everything in the world looks like a nail!!

I would guess that 8 and 9 were lost to hyper-mobility due to pernicious bite habit or perio and 7 went the same way.The remaining molar on the right has a bifurcation involvement.I bet she doesn't have much buccolingual bone at 8,9.I would be more comfortable if this were my if discussing alternative treatment plans the pros and cons you know.

Take the new implant kit away from the all on four guy. Your kidding correct. The treating doctor is asking about replacing incisors in an area with severe atrophy. Best option, would be to have a thick ridge of bone . Block bone grafting has excellent success rates, and are suited for the guy that can do this. Intramembranous bone ,by the literature, and personal experience is the greatest source. Chin/ calvarium, with rigid fixation and particulate bone and prp to fill voids. You will loose some of the bone so timing is essential. Primary closure is also a must in my hands. You can also take the buccal plate , as per intentional buccal plate fx in bssro. You could go ahead and place the implant in the socket at the lateral, as this will help preserve what you already have. Why would you consider cantilevering or splinting? If your going to take that approach, just do a simple ridge preservation graft and place a bridge ( take implants out of the equation). The patient is healthy. Is his perio arrested, and is he ready to change his habits, because if not, he ought to just buy a fine sports car! Bv

How about exo #7 and a simple 6 unit bridge from #6-11. If esthetics is a failure due to asymmetry, short or missing papilla, or long uneven teeth, but the implants you place are perfectly covered by bone and functional, the case is STILL a failure. For an anterior case to be successful, it should be both esthetic and functional. I don't care how long you've been placing implants, you cannot be sure exactly how this case will turn out even if you placed the implant perfectly (just look at the bone level on #'s7,8,9 compared to the bone level on #6 & #7. It has to be at least a few mm difference). That said, implants can be done (pls use platform switch implants if you're planning on implant #8,9 with #7 cantilever)...but if this patient is high strung or has a very gummy smile, I'm also pushing a 6-unit bridge.

I bet if you were to adjust the destiny sensor when reading the scan, he probably has a little more bone in real life! At least I hope so, because I'm not 100 percent certain the implant could be placed at graft time. Bv

I agree with Dr. G. I would further suggest that in the cosmetic zone rhBMP-2/ACS (INFUSE) be used to insure a more predictable result for the hard and soft tissue. When expectations are at a premium, the cost of INFUSE is well justified and probably essential. This is not to say that allograft onlay grating is not an excellent option,I believe it is and have had many sucesses. In these instances I am convinced that adding more needed BMP-2 to up regulate healing is a relevant and protective choice in the sensative cosmetic zone. By leveraging are already great anterior grafting techniques and surgical princilples with rhBMP-2 technology, a whole other level of care is open to us.

Dr kong , that is way too practical! Oh , I get it ,you are a realist. Refreshing! Too sarcastic for some of you? To bad. For the guy suggesting edentulation, frankly scary! Bv

I think they require any further information regarding the level of bone, as we bone width and height of these depend on placement of implants, supports the soft tissue and estectica this is the basic principle for a good treatment plant. To make judgments about the best treatment we need more information for this case. For me best option : extraction of tooth 7 ,immediate placement of implants 7,9 ,bone graft, immediate loading implants with temporary abutment ,placed temporary bridge from 7 to 9 , with ovoid Pontic in number 8 to create papilla and preserve soft tissue and get best estectica.all depend of bone level.

I agree with the bridge crowd on this one. Graft #7,and place a lab prefabricated temp bridge, form the papillas then transition to the final bridge.

Dr f. , I've been using infuse for 9 years , and absolutely agree that it is a great option. I have not had a Lot of success with it for small defects like this one, however. I scanned a 91 yo surgeon last week that I treated for radionecrosis/ continuity defect in 2002 and he is completely healed. Stlill think fine crushed autogenous and a block of intrmembranous bone rigidly fixed , is way to go. The biggest complaint I get from my restorative guys is, that there is too much bone. They seem to appreciate the fact that we can trim it back. Bv

BV great comments as always. What do u mean by placing the implant in the lateral's socket as this will preserve te bone??u obviously know that immediate imps do not preserve the socket!!I think that an immediate is out of the question but I'm with u on everything else. PS please Mike C , all on 4 guy, do ur patients a favor and start referring to a periodontist!!!!!!!! This patient is maybe an all on 4 candidate but not earlier than in 20years from now!!!! Double omg

Look at the Sonic Weld for GBR! Great results for width and height and no secon surgical site

Was there a cosmetic waxup? What is the patient's goals? That is huge. Have you figured out where implants even need to go yet? That is first, along with the final planned outcome. The either isnt enough info or all the right questions havent been asked yet. What does the central papilla look like, because it is often different from all other papillae if it is very thick with CT and has been sitting there awhile. It could take implants next to each other. Also, its hard to plan for just those front teeth without thinking about what is in the posterior and how it relates to the lower arch. And what does the lower arch have ot offer? Is there active perio? Are those posterior teeth stable? I would work some provisionals out first and get the patient to see where you need to place things restoratively and THEN scan it and plan from there so you can see what is required. Just some thoughts. BIll

Bone ring technique with 3 individual implants could be an option as well which I think wld be better

Dr,G , I beg to differ. I have cases where implants aren't even loaded that are greater than 18 years old, still perserving bone. Even though, they are not technically loaded, they are stimulating the bone. Why do you say this doesn't preserve bone. Retained broken roots retain bone? This is why I'm on the site. Please respond. Bv

I'm not suggesting immediate loading, however. Bv

I think I'm looking at number 6! Bv

Dr. Levine, With all do respect, the sonic weld polymer causes inflammation as it degrades, it's not a good material for GBR.

I have to agree with j Knox. . Tell steve o. Hello. Bv

Dr g , waiting on a response. Very curious about your philosophy, in that Is one of my biggest selling points, when I am " pitching a case". Or any other responders that agree , that implants don't help preserve the socket. Should I qualify my request? I'm not being sarcastic. I may have just misunderstood! Thanks bv

I am very sorry about the late response BV but I do not check the forum on a daily basis. Here is your answer: first of all the root retention concept was the first concept introduced to retain the inevitable ridge resorption that follows teeth extraction. It has been efficient in doing that when traditional pros has been employed and the sites are used as pontics. But this only works because by retaining the root your retain the periodontal ligament thus you keep your buccal plate blood supply. On the contrary when you extract the root or even worse when you raise a flap to get an immediate in then the buccal plates blood supply severly deteriorates. So ridge resorption occurs. Approximately a 40% of the total bone volume resorbs. The difference is that when u have an immediate placed the resorption stops after the initial 40% because the implant presents a stimuli to the bone. Moreover if u graft and use a membrane when placing the implant the resorption will be around 10% instead of 40, because u actually did a ridge preservation technique! As far as literature is concerned you can check J clin periodontol 2011 Blanco et al . " immediate placement with or without immediate loading does not prevent the amount of bone resorption that occurs following a tooth extraction without immediate placement" J clin periodontol 2005 Araujo et al "the placement of an implant in the fresh extraction socket clearly failed to prevent the remodeling that occurred in the walls of the socket" There is also an ITI consensus statement on that , if u r fond of the ITI thing. Probably your claims are based on the first papers on immediate placement like Schropp 2003 where they thought that immediates preserve the extraction socket, but all the research since then shows otherwise! Hope I helped BV!

Dr G. Embarrased to say I'm not familiar with the iti study, however am getting their kit. I guess I understand some of what you are saying , but not certain if I can completely concur . The implants i find most difficult to uncover are the immediate ones , in that I find myself removing bone from the cover screw on 25 percent of them. This leads me to believe that the socket is being preserved . I am raising a full conservative flap on both sides , to provide room for the membrane and closing with no tension . Now , for the case at hand , I would be raising a full flap, with essential adjacent tissue transfer , Which would render the blood supply of the flap more compromised . In this scenario,Your argument does , in my opinion carry with it some significant credibility. Again this is why I'm on the site. Thanks for the thorough response . Bv

Well BV thats what the forum is for!I do understand what you r saying, but bare in mind that when you do immediate imps you probably placing them 1-2mm subcrestally + you are grafting and placing a membrane, so you are doing ridge preservation. According to the literature when doing ridge pres you can limit the coronal resorption to 1mm or less, so if you went 1-2mm subcrestally, having the imp covered with bone that does not mean you got full socket preservation! Moreover if you could check the bone width pre n post extraction you would observe a resorption of up to 3mm each time. Do not be tricked by the optically perceived width of the area, because even though the bone is resorbed the soft tissue gets more width so it is not apparent. In any case you have a CT scan of an immediate case where you had full socket preservation or augmentation I would really love to publish it with you!! Glad if I could help you this time BV, you are an asset to this forum since you seem to be helping most of the folks around.

Ok,gonna get some postop scans and measure. If they support my argument, I'll submit them , if not they will get lost , I'm sure. Get back with ya. Bv

About implants maintaining bone..... I was of the understanding similar to Dr G. However there are two scenarios. Are we talking about preserving bone in immediate extraction site or "long-term" edentulous sites. I think the latest and greatest is that implants don't stop resorption, the only limit it in immediate/extraction sites. Hence they only partially preserve bone..... (bio-oss is another story/scenario) In longer term edentulous ridges, I think implants can preserve bone (or it seems to)...However, who know if most of the remodeling has already occured anyway. I am on this site to learn and exchange ideas, so feel happy to agree, disagree, comment or correct me....

Dr. Ham, there are lots of studies that support implants halt atrophy of the edentulous maxilla or mandible. Two to three implants for the atrophic mandible ,is the absolute "work horse" of dentistry and probably the most cost effective service I provide. As dr. C suggested it also prevents socket resorpion to some degree,when grafting is done at same time. There is absolutely no doubt about the above. I rarely say absolutely. As far as bioss goes, I am out of the loop,in that I don't use it.However, I can almost assure you ,it doesn't cause trigeminal neuralgia. Also, might suggest you investigate the limitations associated with using putty type materials,when trying to gain real volume,especially vertically . Bv

Totally agree that putty grafts have limitations as far as vertical aug goes. But using them as adjuncts so that I can minimize the amount of autogenous bone using thus minimizing post op discomfort works great in my hands. I love the way the putty embraces the autogenous block or stabilizes the autogenous particles and maintains the space better than any particle graft. The novabone putty that I use has the perfect viscosity and gets to the site directly from a syringe so I need literally one minute to graft the whole area. That saves time , makes the patient happier that he will finish sooner and minimizes the discomfort that is associated with the time that the flap is open. It had really been a great addition to my surgical armamentarium for two years now. PS. BV in a nose membrane question I had done in another topic in the forum u suggested me studying some articles. I haven't been able to find them. Neither can I find ur contact mail so u could send em. Do u have any link? Thanks

Sorry dr. G. , the best description of the nasal mucosa ,as it rest in the base of the nose( piriform aperture) is , in my opinion "Epker , wolford, l. Fish" text on management of dental/ facial deformities. Any section describing lefort one osteotomy. Any maxillofacial surgeon that does orthognathic surgery has this and would let you borrow it. If you can't find it , I will email you the chapter . There is also a pretty good article in JOMS . I will try to find it for ya. Bvinci

Dr G , I do not think this would be a case where nasal lift would be applicable, unless your gonna place 16 mm implants. If this were my case and if it got to the point of being ready for the implants and the patient was demanding the longest fixture, I would simply do the lift only and not worry about grafting into the nasal floor, unless it protruded more than 2 mm, as per the previous sinus lift query . Bv

Dr. G., in brief, the only difference between the approach described in the Epker text is, you acces through a crestal incision, obviously, instead of an incision at the junction of attached and unattached mucosa. The only challenging part of the operation in my opinion, is when you get to the piriform rim, you have to dissect inferiorly in order to get to the nasal floor. You will also need to disengage the septum. This sounds like a big deal. You can actually cut out a few mm of the septum, on the floor. You will not create any kind of nasal deformity, unless pt has had a previous injury or nasal surg. Involving septal resection. A good history will determine that. Getting one of our residents to look up article for you. I'm not very tech. Savvy . Hope that helps a bit. Bv

Very helpful BV!thank you!I have petersons textbook and ill check there as well. If u find it please send!! PS not talking about nasal lift for this case. No need to. Just referring to a topic I had posted earlier when I entered the nose while extending a flap and u had replied. Thx

I remember promising to pull an article, and never doing it. Bv

Google -dental implant articles; ridge splitting nasal lift for implants . Fair description , out of argentina . Bv