First lower molar extracted one year ago, severe atrophy: suggestions?

I have a 28 year old patient in who wants to have missing #19 replaced [maxillary left first molar; 36]. Since the extraction was done more than a year prior to the visit, more than 50% of the bone volume was lost buccolingually. PMH is unremarkable. What do I start with on this type of case? What is the best implant diameter/length to use on this case? What do I tell the patient about the treatment time?


![]DENTOLOGY-MOLAR-IMPLANT-1](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2014/04/DENTOLOGY-MOLAR-IMPLANT-1.jpg)


![]DENTOLOGY-MOLAR-IMPLANT-2](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2014/04/DENTOLOGY-MOLAR-IMPLANT-2.jpg)


![]DENTOLOGY-MOLAR-IMPLANT-3](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2014/04/DENTOLOGY-MOLAR-IMPLANT-3.jpg)

66 Comments on First lower molar extracted one year ago, severe atrophy: suggestions?

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CRS
4/6/2014
Whew this one is a challenge, I would get a cone beam to see his much of that width is soft tissue or bone sound. How was the tooth lost, caries, endo, perio? This area needs a graft to rebuild the width either block or guided with the materials you are comfortable with. A significant amount of bond loss is this a failed graft? A bridge is an option but the width needs to be grafted regardless otherwise a nightmare to maintain in such a young patient. Rebuild the ridge, repair the damage first, see what you get then determine the implant size if width regained. If you are not experienced in this I would prudently refer not a case for a novice even if you are told otherwise.
DENTOLOGY
4/6/2014
CRS, thank you for the input. The tooth was lost due to profound caries. I did bone sounding it revealed 3 mm wide ridge 5 mm down vertically .I didn't get it , why should I graft the ridge for the bridge? It will resort without the implant anyway. Any suggestions on the future implant specs ?
CRS
4/6/2014
Here is the reason, the bone on the adjacent teeth and the bone under the Pontic will be replaced, easier for the patient to maintain. What I do is if I get enough for an implant then I place the implant. If Bio-OSS is used it will hang around and the ridge is preserved making it a cleansable under a Pontic.
DrT
4/8/2014
A bridge is NOT a good option. This kid is 28 years old. He could live 70 more years. You want to destroy two perfectly healthy teeth?! Look at 18 and 20 and give me a good reason why you want to remove ALL of the enamel from them. Graft and implant or make a partial but please don't ruin good teeth.
DENTOLOGY
4/6/2014
What do yo mean by "if there is enough bone" ? What if patient does not want the bridge? Will you tell the patient -" we will do your bone graft but I do not know if we able to place an implant after that"? How much do you charge for bone graft? Let's say $1000. So do you suggest $1000 procedure to your patient with unpredictable result ?
CRS
4/6/2014
Lighten up it is a very predictable procedure if you know how to restore the buccal plate, it's called an onlay graft. I like to restore what was lost, the best time to do this is at the original extraction. If you are more comfortable just doing a bridge then do so, my point is that if there is very little base bone you need to see how much bone develops. A second graft can be done after expanding the plate at implant placement. It is about knowing what you can accomplish with grafting. If you place a bridge over this without grafting, the Pontic needs to be modified, it works well but is difficult to explain in a blog.
doctored
4/8/2014
Unfortunately this tooth was removed without conservation of the buccal plate. If it had the situation would be less severe even given the time frame. At this point bone will need to be created where it was removed. I would perform an onlay graft with FDMB and a mixture of Fusion bone binder. I would use a Cytoplast PFTE membrane that would not require release and advancement of the buccal mucosa. Be sure to perforate the buccal cortex with a #2 round burr in many places to establish bleeding points before placing the graft material and placing the Cytoplast membrane.
DENTOLOGY
4/7/2014
CRS, Thank you for the enlightenment ! The onlay graft you referred to, is it a kind of block graft ? Does it need another site for harvesting? I am still under impression that you are not confident how predictable the result could be using onlay graft in such case. Is there any more predictable technique?
CRS
4/7/2014
It depends on what you are comfortable with. Onlay grafts with harvested block bone are one way to go. I use particulate with space maintenance either reinforced Teflon, sonic weld or osteowrap. What will help is the fact that there are healthy adjacent teeth to scaffold off of. Every case is different, a good flap with primary closure and space maintenance is key. Grafting materials are personal choices I use growth factors and allogenic bone. Don't get me wrong I am confident with my onlay technique I am just realistic in how much the patient will heal which as an experienced surgeon I am thinking about vs boasting about. Unfortunately there seems to be a lot of boasters out there vs giving honest advice.
Anton Andrews
4/8/2014
CRS thank you for your comments! Are you an OS or a perio? I wonder if any other pros on osseonews blog to suggest on this case?
CRS
4/8/2014
Thanks you are too kind, I'm an OMS and I am pursuing my ABOI to better serve my referring colleagues.
Majid SALAS
4/8/2014
Hi, You have a serious horizontal bone loss. Vertically, you have no problem with your expected future implant. First step, you should consider what type of treatment is considered as pertaining to horizontal bone loss and why do you have this loss. I think he has a controlled localized horizontal periodontitis. The horizontal bone must be restored. If the patient wants an implant then the solution is a guided bone regeneration with implant insertion in the same seance, and collagen membrane must be used in this case. This is a localized horizontal loss and can be controlled easily.
DENTOLOGY
4/8/2014
Majid, Thank you for the comment. What type, size of the proposed implant do you recommend on this case?
SALAS Majid
4/8/2014
Classical Titanium Implant would be the best of choice. The type depends on where you live, as i am here in France so we must be having different companies. Regarding to the size, bone volume strongly determines diameter and size of the implant. As you are going for guided bone generation with membrane in the same seance then you do not to be worried a lot. 4.2 to 5.0 would be the size of choice which may resist the opposite occlusal forces. The implant will succeed 94 to 99% at the condition of good oral hygiene and non smoker patient.
CRS
4/8/2014
This will work if you can get primary stability possibly by expanding the alveolus, the type of implant does not fix it, restoring the bone does. I would still stage it. The original extraction was probably not grafted, the comment on localized perio is interesting. If this patient did not heal well initially why would a riskier procedure work? If you place the implant at the same time and it fails you'll be replacing it probably for free. That's what I would do see what you get then place the implant.
Richard Hughes, DDS, FAAI
4/8/2014
This is a challenge. Most likely an onlay bone graft that is anchored with screws is the best way to restore. I have expanded these by Tatum's technique, which makes it a five walled defect, but it's difficult for a single tooth space. You also need a very compliant patient.
DENTOLOGY
4/8/2014
Majid, I think it's a great idea to place an implant and graft at the same time ! Can you post a case to demonstrate the clinical result where you were able to deliver using that approach. Here in the US doctors are not so confident to pull it in one surgery .
Gregori Kurtzman, DDS, MA
4/8/2014
When flapped this will not have any buccal wall to get primary retention to place the implant at time of grafting and will fail. this unfortunately needs to be staged to get success
Majid SALAS
4/8/2014
Hi, I will try to show you a case with with guided bone regeneration with implant insertion in the same seance. Give me some time to learn a little how to post photos on this website. You have also a new technology which is called Basal Implantation. Basal implantation is a revolutionary technique developed in Switzerland jointly with the European Community of Implantologists. It allows restoring the teeth (from 3 teeth) without the bone augmentation. This method uses the special design of implants, custom-fitted to the patient. The implants are installed in a single procedure with the abutment (it is a part of structural design of basal implant upon which the denture is installed). Depending on the condition and the bone size, the implants are selected that have a special attachment and structure for better fixation in the tissue. In addition, in areas of strong atrophy the additional implants can be placed at an angle where the bone allows ensuring the maximum stability of a dental structure that can withstand high loads and not get loose. On the third day after the implantation, the metal- plastic denture is installed. This is the final part of the dental structure, which allows the patient to chew using the new teeth in a week. The essence of the basal implantation method is to provide for the patients the ability to chew, so that in the process of chewing will stimulate the natural regeneration of bone tissue. Due to this technology, there has been achieved an aesthetic effect right after the implantation, and also it reduced the time of implantation in the dozens of times. Basal implantation advantages: It does not require the bone augmentation in most cases, the basal implants can be installed at a certain angle, so they can be securely locked in any size of bone tissue. It provides an individual approach, to restore the teeth the dentist-implantologist selects different dental structure in length, shape and design, so the implantologist can evenly divide the load between the implants and reduce the time of their engraftment. It favors the fast teeth recovery, the basal implants allow to fix the denture within 3-7 days after the implantation, and therefore, the entire treatment process takes about a week. It favors the bone tissue restoration, so due to immediate chewing load the implants allow restoring the blood circulation in the bone and improving the regeneration process. It causes the minimum number of contraindications, and there are only a small number of the patients who are refused to install the basal implants for the medical reasons. In addition, in many cases, the basal implantation is available, even if there were discovered some contraindications for the classical method. It provides the resistance to infections, the implants are installed in bicortical layers of the bone that are deep, so the probability of penetration of bacteria and germs in it is minimal, and thus it reduces the risk of rejection of the implant. It gives guaranteed result, the fast recovery of bone tissue provides survival of the implants within a short period of time, as well as an excellent aesthetic and functional results, and a full recovery of the teeth in a couple of months after the surgery. In order to prevent the atrophy of bone tissue, the patient must immediately be concerned with the issue of dental prosthetics after the tooth removal. However, the patient should give the dental implantation preference, as it is the most natural way to restore the missing teeth.
Gregori Kurtzman, DDS, MA
4/8/2014
In USA basal implants do not have FDA approval so cant be sold here. Even with basal implants one needs bone to place it into. placing a basal implant at this site would have the entire buccal half of the implant sitting outside the current bone and making the cuts into the remaining bone would weaken the current lingual plate which is the only bone present. This case as I said before needs to be managed ina staged approach with 1st phase being grafting then months later phase 2 implant placement
Gregori Kurtzman, DDS, MA
4/8/2014
Please provide literature (peer reviewed) that supports the statements you are making about basal implants. The little literature available I have seen is all from the company who makes the implant or the dentist who owns the company and speaks for them
Majid SALAS
4/8/2014
Can we post photos here?
OsseoNews
4/8/2014
Yes, simply click on the "Post a Case" link located either at the menu at top of the page, or at the left side of the title of every post.
Gregori Kurtzman, DDS, MA
4/8/2014
First did the molar have severe perio or endo issues that necessitated the extraction? This is a good example why at the least socket grafting needs to be performed so that the buccal (most likely to resorb) is maintained as best as possible. selection of what graft material will be determined as to when implant placement (time wise) is anticipated. Placement of the implant at time of extraction is often best but may not be possible due to finances or infection present. Now what is needed to treat this case now. if the patient is set on an implant this will require extensive grafting either with a cortical bone graft or particulate in a metal mesh cage. this will need to heal for 4-6 months before an implant can be placed. the other option if the patient doesnt want to wait that long, or undergo the grafting or the financial aspect is too high is a traditional bridge on the adjacent teeth.
txx
4/8/2014
"The tooth was lost due to profound caries." 
bigpoppa
4/8/2014
Gregori says- "the other option if the patient doesnt want to wait that long, or undergo the grafting or the financial aspect is too high is a traditional bridge on the adjacent teeth." This guy lost a tooth to caries at 27 years old. He's not going to be able to keep a bridge clean and then he'll have 3 teeth missing. Fixed bridgework is as archaic as bleeding people to reduce bad blood. Implant or leave it as it is. Doesn't anyone remember, "First do no harm!" ? Don't cut healthy teeth.
Anton Andrews
4/8/2014
Gregori, Let's imagine that your mesh technique worked fine and you will get the bone volume you satisfied with. What size of the implant would you then place to replace this lower first molar for the best long term prognosis? I do not know details about extraction, this patient came as is, I have not done that extraction. There is no any sign of inflammation or chronic infection around the entire quadrant .
Gregori Kurtzman, DDS, MA
4/8/2014
I think based on what seems to be available mesial distally your probably looking at a 4mm diam implant, placing a wider one may be a big challenge creating a wide enough ridge to house it.
Dr. Omar Olalde
4/8/2014
First a CT Scan, then I can suggest two implants of 3 mm diamenter and guided bone regeneration at the same time, but to be sure of this, a CT Scan.
Gregori Kurtzman, DDS, MA
4/8/2014
Why would you place two 3mm implants at a molar site, a site that gets high occlusal loads? 3mm implants have thinner walls and are more prone to crestal fracture when over loaded. Why subject apatient who is 28 and has hopefully 60 years ahead of them to placing implants that are too narrow to last their lifetime?
Omar Olalde
4/8/2014
Hello Greg, why over load the implants? Think about the area (square mm) that will have contact with the bone. An implant of 6x11= 66 sq mm Two implants of 3x11=33 x 2 = 66 sq mm of contact area Titanium-Bone. Two implants joined by one crown, good oclusal distribution. A good designed crown easy to clean, no periimplantitis. Titanium grade 5, stronger than 4 or 3, because of thin walls. The number of osteoblasts and osteocytes present in an onlay graft in posterior mandible mmm... But as I wrote, first the CT Scan, maybe a 3, 3.2, 3.7 depending on the Company.
Gregori Kurtzman, DDS, MA
4/8/2014
We have to look at the individual implants and a 3mm wide implant will have much thinner walls at the connector then an implant that is 4mm 5mm or greater and as we know under occlusal loading the molars take greater loads then premolars or anteriors so higher chance of implant fracture in a 3mm implant
Dennis Flanagan DDS MSc
4/8/2014
I agree with Greg K. This site would be best treated with 2, 3.2mm diameter implants with the ringbone technique. The small diameter implants have less displacement and may not block angiogenesis and osteogenesis as would a larger diameter. The ringbone would allow immediate implant placement.
Mahnaz syed
4/8/2014
If you are going to treat this patient as a restoratively driven implant retained crown. I think you need to make the hard decision for the patient a block onlay graft would work well to increase ridge with and then the adequate size implant can be installed. Thus is going to give the patient the best long term result. Narrow implants in this site is going to give a prosthesis with poor emergence profiles difficult to clean therefore opening this up to peri implantitis. You should be thinking long term for your patients. Block grafting is chalkenging and soft tissue management is important refer to an OMFS or periodontist if you don't feel confident to do this
Anton Andrews
4/8/2014
Dear Drs, Thank you for the great discussion. Please allow me to summarize here. The bridge is not an option - the patient is too young and the teeth are intact, besides that, she did not want it. So we have the implant replacement option left with 2-phase treatment to augment first ( Ti-mesh, sonic weld, GBR with membrane etc) and the second stage will be 4-5 mm implant to replace this 11mm wide first molar. It seems to me that we are so deep into discussion , (not even talking about a basal implant option:)) and I am ready to detonate at this point. I used "Russian AAA " technique to rehabilitate this . It is a simple, versatile surgical technique that allows simultaneous placement of wide diameter (7+mm ) implant and bone rehab . This case was completed with only ONE surgery. Russian AAA surgical technique could be used on any site - posterior , anterior, mandible or maxilla. Russian AAA is good for single or multiple implants . It can be used in extreme cases like the one presented and even in more extreme situations . There is simply no better alternative....
Richard Hughes, DDS, FAAI
4/12/2014
What is the Russian AAA technique?
Vipul G Shukla
4/8/2014
This is a good location for a wide platform implant, bone level or tissue level. However, from what is evident here, placing the implant as is would probably expose the top 5-7 threads on the buccal side. Does concurrent grafting work during placement so a separate surgery be avoided? For small defects yes, but something so deficient, I have to agree with other posters, a separate onlay block graft first, autogenous or allogenous, wait 3-4 months and place a nice wide platform (5.0 or 6.0 diameter) smack in the middle of the space. Make a beautiful screw-retained crown after 3 months. Avoid cutting two adjacent healthy teeth to make a fixed bridge. May not be justified in today's conservative world of modern dentistry. Especially in a young person like this. Someone above said this may have localized periodontitis, which is an amusing observation. Lateral buccal plate lost after an extraction in a young person is very common and typically is a result of thin buccal plate to begin with, whether or not that was maintained during the extraction procedure. Socket grafting during the extraction procedure is the best way to prevent issues like these, and I feel students should be routinely taught this procedure in all dental schools today. And I have strong reservations about the longevity and hygiene maintenance around basal implants, especially for a single tooth replacement. Two narrow implants in the space will open a big Pandora's box re: passive fit of framework around each collar and eventually one of the implants will start losing bone due to loading differential, also not easy for patient to keep clean. One wide implant is best here. 5.0 mm or more. Lastly, do not ignore the molar above, that is over-erupting each day. Synopsis: Onlay block graft(patient's own or cadaver), wait three months, single wide implant, crown after 3 months and upper molar adjusted a bit to correct over-eruption. Good Luck!
Martinez
4/8/2014
I would also stage being such little width. Another 2mm horizontal present, I would consider ridge split with immediate placement. Still difficult replacing one implant. Intended vertical release(of bone) on either side will also help. Then again.. Much too narrow ridge, as is. Searched Russian AAA to no avail. Please explain.
Anton Andrews
4/8/2014
Dr. Martinez, Please wait until tomorrow I will demonstrate the results of Russian AAA surgical technique to everyone .
Andy K
4/8/2014
I restored a lot of cases like this. I will first take CT Scan and most likely pt has plenty space to put Bicon 5x5 or even 5x6 (5 mm width, 6 mm depth). We still need to submerge the implant 1-2 mm then may need longer post to restore it. Perfect case for Bicon. No need to do bone graft most likely. If you want to get perfect result, you can do the block graft using Ramus mandible as donor site. Just use standard flap for third molar, it's better from the other site / #32 area. Use the surgical round / 557 to make "u" cut( about the same size like the defect), then fracture the block graft using chisel or even regular periosteal elevator. You might want to prepare #19 area first before harvesting the bone by making vertical incision in #20 area, then make a tunnel toward # 19 area (full thickness flap- make sure you touch the bone directly, not periosteum). By preparing #19 area first, you will be able to estimate how big the defect is and to prevent the bone block from staying outside the body for long time. At the end, after inserting the bone block to the defecting area, you just need to put 1 or 2 sutures only. No need matrix or membrane, just make sure you make a good tunnel. After 4/6 months you can do implant with any type/ brand. But I still prefer Bicon.
DENTOLOGY
4/8/2014
Andy, Your approach with the block graft is too aggressive . Bicon has disadvantage of creating black triangles since it is hard to parallel the implant axis with the contacts of adjacent teeth. Also Bicon has loosening problems in grinders . Russian AAA is only ONE surgery for everything , you place the implant (one per tooth, not two) you desire the best for the case , no additional harvesting site is needed, no blocks, no screws , no meshes that needs to be removed , Predictable, affordable, reduces treatment time and most importantly it decreases patient's suffering .
CRS
4/9/2014
Dear Dr Andrews, I took a look at your website Dentology. Just curious why you would post a case that you already treated. And would you be kind enough to explain what a Russian AAA procedure which is one step for everything. It is great that your implants never fail and everything can be done at once. Thanks
Anton Andrews
4/9/2014
CRS, Thank you for the compliment. The reason I posted this case was to confirm that by this date, there is no other reliable surgical approach to treat this cases with one surgical procedure. I posted only "before" images to stimulate the discussion. In my previous comments to other Drs posts I tried to bring attention to alternative treatment option such as Russian AAA technique and I posted links to my web site but osseonews removed those, including links to this case . I also want to bring to your attention that I do not say on my web site that my implants "never fail " . It is said "never fracture". I am happy to hear your desire to be "lighten up" with Russian AAA technique. I have plans to set up hands on course for that .
John Manuel, DDS
4/9/2014
You have several good options in Guided Bone Regeneration using the Bicon Short Implants: Single 4.0 x 8.0, 4.5 x 6.0, possible 6 x 5 or 5 x 6 if setting low, or even dual 4 x 5, 4 x 6 implants in the molar root positions. The obvious "hole" in the Buccal Ridge Crest is perfect for insetting a "finned" implant which does not require tight threading and which will help support the resorbable membrane. The Bicons, in this setting, would be placed at least 3 mm below that Lingual Ridge high point. The prep would start with a groove or channel against that lingual plate until sufficient bone width area is encountered to inset the apical 1/3 or 1/4 th of the Bicon implant. Then, normal site prep to obtain a secure, but fairly passive placement. The Buccal wall of the defect must be decorticated by at least 2 -4 round burs and then very carefully perforate with 330 or such along the cortical plate curving around the neighboring molar and bicuspid. I've used the granular SynthoGraft in this situation with great success. You have a choice on how much, if any regeneration volume in this case by varying the width of the implant(s). i.e., if the Lingual Shelf is deep enough, you could just put the two 4x5 or 4x6 Bicons deeply enough so that the implant top is below the available bone. Then restore as two separate bicuspids. If your patient is reluctant to undergo the ridge enhancement, in spite of that being the preferred path, this would work. I do this a lot on elderly where medical complications and patient resilience prevent large grafts. The hole you see is actually a benefit in that it becomes a three walled defect and the tissue curving down into that hole has the extra surface area to cover a graft when you evert that tissue over the graft/implant installation. Working that close to Lingual Nerve, Inferior Alveolar and Long Buccal Nerve, I favor simultaneous implant and graft placement.
Anton Andrews
4/9/2014
Bravo Dr. Manuel! So far only you were able to see the advantage where others saw the opposite! "The hole you see is actually a benefit in that it becomes a three walled defect.." But your choice of Bicon can spoil the whole project for the following reasons. 1. Since its not threaded implant system, Bicon has lack of initial stability sooo needed for this case. 2.That's why you have no choice but to use 4 mm diameter to replace the MOLAR! For those who is unaware , it had been realized that 6+mm diameter implants is the best choice to replace posterior teeth like this first molar. 3. Bicon has disadvantage of creating black triangles since it is hard to parallel the implant axis with the contacts of adjacent teeth. 4. Also Bicon has loosening problems in grinders . This case was treated with 7mm diameter implant 5.7 mm platform. Opss, I completely forgot to mention, Russian AAA technique does not require preoperative CT scan in 90% of the cases. Russian AAA is a versatile technique which could be used in situations where is no "benefits of three-wall defect" - on severely atrophic ridges to replace multiple missing teeth with dental implants in ONE surgery!
John Manuel, DDS
4/9/2014
Anton, It's difficult for me to view this Bicon solution as "impossible" since I've used it with great success for years. Perhaps it would be more advantageous for your product if you restricted your opinions of other technics to those of which you have experience.
Anton Andrews
4/9/2014
Manuel, First of all, I never said "impossible" replying to your comment. Secondly, you are right, I never used Bicon. It is a good system but it has its limits. it ,simply, does not fly with Russian AAA and and it has a number of serious flaws for reasons I've already posted. It happened, that Bicon's headquarter is in Boston where I am. I took several courses there, but decided not to go with it. I can continue the list of Bicon system disadvantages, but for the sake of this case, I've said enough. Thirdly, and finally, please do not take it offensive,because " Discussio mater veritas est!" . We are in the free country and I hope, in free world. I do not see why should I restrict my opinions? I am open minded clinician and I never stuck to a single technique or an implant system. Just the last year alone, I'd purchased two implant systems and this year, so far, one. The world is changing , so Dental Implantology is changing too, dear colleague. Those, who are stuck in the past , will eventually loose it.....
CRS
4/13/2014
This is starting to sound like an infomercial you already have treated this case and are promoting your technique. No one like to be mislead. Myself included.
Peter Fairbairn
4/10/2014
A tunnel graft will work well here.... Peter
Crs
4/12/2014
I have an even better technique it is the Triple Salchow Technique. It works every time unless there is a Russian judge! ;)
Raul Mena
4/15/2014
CRS You are in the right track going for the ABOI congratulations I would do simple block graft by making an incision lingually to the crest and tunelling toward the apex. Place a block graft with Rocky Mountain Blocks. You need to do RAP of the buccal plate and insert the graft and suture. No need to use any screws. I have done this technic with high success rate. do not wait for more than 4 month to place the implant because the grafting may start resorbing without the implant in place.
CRS
4/15/2014
Thanks, you are very kind. Are you splitting the ridge and placing the graft in between?
Raul Mena
4/15/2014
CRS, In some cases I split the ridge, specially in the maxilla, but in the mandible I usually decorticate or RAP and then place the block graft, and in some cases place Irradiated particles around the graft to prevent sharp edges. Histology demonstrate that we obtain from 50 to 97 % of new bone withing 4 month. What state do you practice in? Now responding to other comments, In my opinion Tunneling is an ideal option for this case. Personally I like Irradiated blocks from RMTB better than allogeneic grafts, I have grafted with autogenous hip, cranial and fibula, and the bone remodeling of the block has been ideal, plus you eliminate the cost and morbidity. Regarding the use of Bicon implant, I see no reason for not using it in this case. it is a very good implant and with fantastic results, much better than must other brands. I have no affiliations or economic involvement with Bicon, on the contrary, I am the president of Quantum Dental Implants, so they could be consider competition, but fair is fair. i am posting for scientific reasons and not for marketing purpose. Regarding implant size, I agree with both Dennis and Greg, 2) 3.0 mm will do the job, the other choice wold be a 5 or a 6 mm implant Raul
CRS
4/16/2014
A couple of questions what is RAP and do you have more information on the tunnel technique . With a lingual/crestal incision and tunnel to the apex do you go past the attached mucosa to get primary closure? How do you stabilize the graft? I see your integrity in your posts and appreciate the information. I use a combination of expansion, prgf, particulate and a fixed membrane to maintain space. I am always looking for simpler techniques. By the way I'm in Chicago.
CRS
4/16/2014
Dear Raul with a tunnel technique do you go past the attached mucosa for release and primary closure? How do you stabilize the graft without bone screws and what does RAP stand for? As you see I'm intrigued . Any article or photos of technique? Always like to learn new things Thanks.
Richard Hughes, DDS, FAAI
4/16/2014
QUANTUM IMPLANT: this implant system is very innovative and well thought out. It offers several platforms in one implant. It is somewhat like Bicon but is also threaded. It offers a lot of prosthetic flexibility. I think it's the implant of the future but should be one for the present. The genius, Dr Mena's developed this implant!
Raul Mena
4/16/2014
CRS, RAP is "Regional Acceleratory Phenomenon" It is basically decorticating or using a round burr and drilling holes through the cortical bone to stimulate bleeding and the release of BMPs and others. When doing tunneling usually the soft tissue holds the graft in place. Provided that there is no object moving the graft such as to tongue or a prosthesis. In the case under discussion, doing a tunnel from the crest should leave enough tension to hold the graft in place. I will look for a picture of a similar case. I have done premaxilla tunneling and one side was fixed by one screw and the other by the periosteum, after 4 month obtained 2 cores from each side, and both demonstrated from 57 to 94% of new bone. A simple suture at the crest will provide for nice closure. My favorite membrane for grafting is the patients own vital periosteum. My best success has been with Irradiated Cancellous Bone from RMTB. with its proper use i seldom use autogenous bone any more..
Raul Mena
4/16/2014
I Forgot to answer part of your question,. Yes I go pass the attached mucosa the only place to be concern is over the mental foramen..
Richard Hughes, DDS, FAAI
4/17/2014
CRS, RAP is the regional accelerators phenomenon. I suggest you google the tunnel technique. There is an excellent paper on that in on line by Heller and Rutkowski. This paper was published in the JOI.
Richard Hughes, DDS, FAAI
4/17/2014
Even though I'm a big believer in dental implants, I would treat this patient with a three unit FPD.
CRS
4/17/2014
Thanks for info.
peter Fairbairn
4/18/2014
Hi Raul I can see you have done few of them , a tunnel graft can work very well here and can place a4-5 mm wide implant at 3-4 months material and host dependant . As you said the periosteum is the key as it induces BMP production ( Stromal cell derived factors ) in " bone injury " site as well about 85 % of the blood supply. I too take cores and have been interested by the high levels of new bone formation. I always use Alloplasts and have had great results. This route is the least traumatic for the patient and as I like my patients so prefer less invasive solutions. Peter
Raul Mena
4/18/2014
Peter, I am glad that we are in agreement regarding how to perform the graft, if implant treatment is going to be performed. Richard Hughes choice of doing a 3 unit bridge is also a viable choice.
Richard Hughes, DDS, FAAI
4/19/2014
Thanks Raul. I always consider the conservative treatment first.
John T
5/9/2014
Gosh. 64 postings on one little implant - and still none of us have the faintest idea what the Russian AAA technique is!
Gregori Kurtzman, DDS, MA
5/9/2014
Well Russia does have issues with drinking too much vodka so.............

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