Inadequate Bone Volume Towards the Apical Direction: Best Way to Handle?

I see 3 practical options for dental implant placement. 1) You can augment bone (GBR), wait for bone to heal then place implant. This would be the most predictable. 2) Place your implant and augment the fenestration defect/exposed apical implant thread with bone/membrane (GBR) at time of placement. 3) As you stated, you can also split the ridge and expand the bone with an osteotome or chisel, then place an implant.

use piezosurgery deep about 7 mm. bone expand, implantation. bone augmen la aspect.pisitroj

John Kong is correct. I'd try to place implant and graft at the same time. Inform pt. that you may not be able to and that grafting may need to be done first.

Question. If that is a cross-section of the #8-9 area, that small portion of bone to the posterior looks like part of the palate, in which case we are looking at the incisive foramen. I'd like to see a few slices mesial and distal to the one you have there and see what the ridge looks like.

Great call, Dr. JS... John

The only thing that I would add to the previous comments is that you really want to have at least 2 mm of bone buccal to the fixture.

The easiest and most predictable way to handle this would be to use osteotomes to manipulate the bone. The diameter of the implant would be determined by the M-D width of the space. If you have an 8mm space, you could place a 5x 17mm Tatum Tapered implant with minimal problems.

As previuosly mentioned , grafting the site first in this case is probably the safest and most predictable way of doing this case . The grafting is quite simple with a super prognosis after 4-5 months . You can easily gain 2-3 mm of bone in the middle section . i would then go for an implant of no more than 3.5 mm diameter . i think the research is now showing that thinner implants are better for the maintenance of the buccal plate and healthier tissue. Otherwise go for the expansion after a pilot drill using osteotomes or the Meisenger expanders ( Even better ) . This area can easily be expanded . Again try to expand only enough to get a 3.5 mm diameter implant in.Good luck .

I agree with JS regarding the incisive foramen - distal to this is plenty of bone. However, given the measurements shown, the 'narrowing' is about 15mm apical to the crest. If you cannot place more distally than at this slice, just use a 12mm (x 3.5 or 4.0) and you'll have no problems. Incidentally, I believe the need for minimum 2mm bone labially really only applies to the gingival area, where you need bone to support soft tissues. If an implant has less near the apical area there will not be a problem unless a fenestration occurs (and even some of these are asymptomatic.

Looks like plenty of bone for a 3mm X 17mm MILO implant. Could be placed in the same way as a mini implant in bone like this (no osteotomy like a 2.5mm mini implant). Could even be loaded with a temp crown to contour of the gingiva in preparation for the final restoration. No graft needed.

Splitting the ridge for a single tooth is impractical. This is why nobel or whoever invented the tapered implant , or one of the reasons. I agree with placing implant and augmenting the fenestration with gtr. Primary closure in this case is a big no no, In my opinion. Use real bone please. You need two thimbles full of morsalized bone max. . Pretty simple, thank god for cbct tech.. Bvinci

BV, as a novise I just wondered if you could list some pros/cons wether to close this primarily or not?

Assuming there were no incisive canal, this is a standard place and graft simultaneously for the Bicon system. Pull a flap from just palatal to the crest down Buccally and flared base, place implant size that does not violate the crest width while having the Buccal flap tied out of the way. Small vent holes in the depth of the cortical plate each side of the Buccal perforation where that boney depression sits, then close with or without resorbable collagen membrane. Salvage pt's bone, without saline contamination/dilution, vigorously whip that into Synthograft with pt's blood from socket. A localized, deep depressed site with tight periosteum surrounding could hold graft in place without the collagen membrane. If worry of membrane migration, stitch it to peristeum at base of flap with 5-0 chromic gut. Bicons can be uncovered and loaded in 3 months. Check "Webcast Replays" on Bicon.com John

OMS resident, There is a huge advantage in protecting any graft and/or membrane from intraoral contamination of saliva, food, and all the crazy things ppl do to your beautiful surgery site. I have had ppl actually dig the collagen membrane out and scrape the bone graft particles out!!!!!!!!! And then come in to complain about how hard that was since I put all those sutures in the way! Treating an active infection might require some open site, but you'd not want to graft in an infection. There is little difference between a bone graft and a blood agar plate - that is my mantra in that... John

I think that the most predictable, fast and inexpensive is to OPEN A FLAP, place a Narrow Platform implant, I´m almost sure you´re going to do a fenestration and then graft that apical area and place a membrane. You are going to solve with the prosthetic abutment the wide of your crown. Agree with BV maybe you can place a second healing screw in the same surgery. Good luck.

Dear resident, remember the five principles of surgery? Primary closure is never water tight, this is why we go thru the neck for big recon cases. Lifting the flap enough to get primary closure, destroys the random pattern and oxygen tension. For single tooth cases , that already have enough bone, a partially raised flap is going to feed the particulate bone graft better than a fully raised flap , or one with vertical releasing incisions. The most important principle that I am alluding to is , keeping ur flap base as broad as possible. This has worked for me. I use a small resorbable membrane with tension free closure( 2ndary). Just one surgeons opinion. 7 failures In 20 years. Most of which have been salvaged. Granted , I'm very picky as far as who i call an implant candidate. Bv

Hey resident , did you learn anything at the meeting. There were a lot of Parkland speakers. I'm sure there were some other good lectures. Or did you just chase Barr bodies? Bv

Resident , I have had one case get infected with this technique, and it may very well be because I'm essentially leaving the sight open. I encourage tailoring the membrane with exacting nature, so that it rest passively under the buccal and liqual and or palatal side, loose closure with 4-0 gortex suture, left for 14 days. Yes, this is relative old school gtr, but I still do my bssro's as per obwegaser( with epker tweaking ). Some things continue to work. Now as far as block grafting, that is rigidly fixated, as per first scenario, primary closure is necessary , with absolutely no tension, and a faster resorbing membrane , if I use one at all. Bmp comes with it's own membrane essentially. I use prp in most of these cases , primarily for graft handling and soft tissue management. Those principles of surgery, always apply. Do you play any sports. When things go south , go back to principles and basics. As you said before, you are in a hospital , with essential endless resources . Use all of them. Don't put anything cheap, in anyone. Autogenous bone is still the gold standard. Use your time becoming proficient in tibial. Calvarial and icb grafting. This best source, thus far, in my opinion is RIA bone (Stryker), harvested upon reaming the femor, as per IM rodding. One pass provides a coffee cup of beautiful cancellous bone.hope some of this makes sense. Guess what, I just got called on a panfacial trauma case, that a plastic sturgeon refused at another hospital , because it had a mandibular component. Night, night. Bv

BV, thanks for all the brilliant comments! And yes, it makes sense. I really like that you stick to the basic principles and use well documented procedures. It gives hope to a young OMS (to be). There seem to be so many "quick and easy" solutions out there, espescially in the implant biz. I see that a lot of guys on this site are "infected" with a lot of these ideas. Some comments are shockingly crazy in my book. Haven't done any RIA bone harvesting yet, but I really want to learn the technique. Done some hip, tibia, calvarium though. The meeting was great by the way, but I didn't get tickets to all the clinics/lectures I wanted to attend. Acted too slow I guess, or maybe I was busy showing off my poster to the Barr bodies. Good luck on the trauma case! (Plastic surgeons seem to be a strange breed in my experience...)

Flipper is the best option.... NOT!!! There are tapered implants that narrow to 2.8 at the apex. Also, if do not raise a full flap and do not perforate through the periosteum, you'll be safe if you have primary stability. However, if you are still unsure, the earlier suggestions are most predictable and safest options. Full flap and graft at the same time. Choose a flap design that will lead to the least recession in adjacent teeth.

I agree dr. Dan, in 2011 , there is almost mo indication for a flipper, especially as an interim device over a fresh graft or new implant. We encourage a thin Essex, or snap on teeth. I beg the patient to go with nothing, but sometimes , this is impractical. Bv

Baker- What I sometimes do, instead of an Essix retainer, if it is even possible, but in particular for anterior teeth if immediate loading is not possible, is to take an exact mold of the tooth or use the actual tooth and bond it to the adjacent teeth and keep it out of occlusion. I find that most patients who wear an Essix retainer find them to be uncomfortable. Is there a way you make yours fit, feel, and look good?

I agree , have and do the same sometimes. It ,is a little more difficult to clean, but certainly looks much better. I'm not very good at doing it, in that the only time I use composite is for exposures or cranioplasties. So , obviously the restorative guys do a great job with this . Bv

By the way , the reamed out femur is not intramembranous bone, at least, I don't think it is . None the less , it doesn't matter because you will only use that as particulate. Bv

I'm just guessing that there is a pretty well defined dished-out area between the two adjacent incisors. If there is adequate interproximal bone adjacent to the edentulous site, in my hands a very predictable treatment would be a ramus graft to get adequate buccal bone for a regular platform implant (3.5-4.5). I'd wait 4-6 mos for the graft to integrate (mortised into the adjacent bone and held in place with 2-3 screws and covered with something to plump up the tissue). Open it up and enjoy the simplicity of adequate base for your future implant and the tissue around it. I am afraid of inadequate buccal plate in this part of the mouth. If I dehisce by placing the implant into minimal buccal bone in this cosmetic zone post placement, I have severely handicapped the patient. I'd temporize with a bonded pontic protected by an invisalign tray 24/7. Thanx for sharing.t

Dr. Manual, are you suggesting that primary closure is going to protect your graft from infection. Certainly you can't be serious. In twenty years I have seen one graft sight get infected, with gtr protocol and dissolving membrane. Maybe 17 years. But whenever they came out with the resorbable I started to use it. That only way you can keep a graft sight free of contaminants is via extraoral grafting , and that is even questionable. This doesn't apply to this case, however. I believe infection rates go up with less blood supply. Ie. Lifting a flap a greater distance than necessary. Just my opinion. Bv