Large Labial Concavity: Best Treatment Option for Implant Placement?

very challeging case. in the premaxilla 9 out of 10 cases you're going to use some degree of angulation . i would augment 7 and 10 and use pontics in 8 and 9 , that will make my life much easier...

8 teeth exracted vs. 4 implants inserted for periodontically compromised patient with bone deficiency? Prosthetic component is rather debilitated, especially without crown splinting. I would not risk it, the failure is inevitable. To my mind, only seeing this clinical situation on the whole is it possible to give you a good treatment option.

SITE DEVELOPMENT!!!!!!!Atraumatic extractions, develop deficient sites, tenting screws will probably be helpful for concavities. Then place implants.

This is a relatively common situation. With a decent modern connection system and a custom metal connection / Zirconia emergence it is quite acceptable to angle the implant to fit within the existing bone volume. This is simpler and safer than attempting augmentation over a perforation. As for concerns about accentuated trauma leading to breakdown, this is disputed and controversial, except during early healing

Graft or augment the sockets, or what's left of them. Then consider placing the implants where the bone is and using either an angled stock or custom as stated above. If your esthetics trouble you in the temporization stage then move to a hybrid. That might be where you end up anyways since the maxilla is far from where it started before the periodontitis. Your crowns maybe be too long.

I agree with Dr Hunt and Dr B above - you appear to have ample bone for most common systems if you prep more parallel to the Palatal bone. The slow and hand prep technique of Bicon will help you avoid a perforation, or at least a void a large perforation such as your current plan would cause. That deepest part, the "A" point in Ortho work ups is programmed to eat facial bone and you'll end up with an exposed apical section. John

Consider a very successful implant from Souther Implants,Irvine, CA. The CoAxis implant has a 12 degree angle built into the implant. Lingualize the platform so you can screw retain the case. Center the implant in the ridge and you'll end up closer to where you want to be. Possibly save a bone graft. A clinical presentation will be given at the AO mtg in phoenix.

Hi. You would need a scan taken with a radiological template so you can see where the teeth go. It is easy to duplicate existing partial denture in acrylic-barrium mix. Then you will really know what you have. It does not look so bad. Planning with a planning software, with radio-guide so yousee the teeth would make you morse certain of your choices. this is what I would do in my own mouthj, just to be sure. good luck.

One answer would be site development, wait for new bone formation and place implants. Another answer would be to place the implants and graft around the exposed apical area at the time of implant placement. The safest alternative is the first. Please also consider the size of the implant in the lateral position. Don't try to squeeze too large an implant, as a regular diameter 3.7 by 11-13 mm long should be adequate in that position generally.

This is a routine case , now we scan much more and thus think too hard about the issues .When looking at the maxilla this situation is very common , so angle the Implant ( there is sufficient bone width for a 3.5 as Carlos stated ) and then graft buccally checking if any threads are visible at the thinnest area. Always place the implant at the time of graft as bone preservation is the key to long term success . Site management can be riskier in the long term. Work with the body and keep it simple . In the aesthetic zone the thinner implants are always the best as it is the bone we need . Always graft the entire buccal area and peri-implant as you can lose the bundle bone which is a critical area aesthetically. Peter

Ramus and/or chin block grafts! Chin will give a thicker block usually. This will greatly help reduce the angles of the implants. And splint the crowns.

Having not used Autogenous for the last 8 years , I have forgotten what it is like to have a patient in Pain the following day let alone months later! Peter

Francois, this is a cbct scan image. What you see is a socket on the ridge with a template already in place. The teeth are no longer there ! There are two options. 1) keep the implants within the ridge and accept the use of angled abutments. The surgical side is simpler and there is no need for grafting. Not all the implant companies supply stock/ prefab abutments greater than 22 degree. A hybrid or customised abutment would be necessary as mentioned by Dr b. Due to the vertical loss of bone, there is more room to play with esp. with regard to the emergence profile. It is possible to move the incisors inwards and reduce the overjet and overbite (shorter teeth), if the effects on the lip profile and smile line are negligible. 2) Placing the implants at the correct angle would entail perforation of the labial cortex and the use of grafts. This will increase the surgical risks and morbidity to the patient. Correct angulation of the implants supposed to load the implants along the long axis and provide stability to the final restorations (Morton). This will also reduce bone loss and provide better emergence profile. The restorations are in the anterior esthetics zone. I find both options are feasible in the short term. Do not have any idea about the long term esthetics in option 1.

All of you are wrong and hasty. This site needs to be developed first and then if the desired bone width is there, implant can be placed. Everyone is trying to do too much at once now a days. Be patient and do what's best or the patient, most predictable

Dr schwartz you are correct. Develop the site by a variety of methods, then place said implant.

The posted single CBCT image shifts discussion away from reviewing the described treatment plan, which is weak from prosthetic point of view.

I believe that when we are dealing with implants in the anterior (as in this case), and when you place 4 implants all next to each other and in close proximity as it appears, you will inevitably lose some of the interdental bone, and with it, the interdental papilla. Why don't you do the extractions first, use a Valplast partial during the healing period and then wait until the tissues have remodelled and then see where you are. I had a similar case on a 65 y.o.woman and did a 4 unit bridge from 12-22.It worked out well for me.

This can be done quite predictably using bone expansion techniques. The ridge appears to be about 4-6mm wide. If you drilled an osteotomy and planned to place a 4mm implant you would only have 1mm of bone on the buccal and lingual at best. That is not a great long term fix. If you expand the bone using osteotomes, you could place a 4mm x 13mm implant and have nice stable alveolar bone for long term success. You would use some type of angulated abutment with no problems. Bone expansion techniques are taught by Drs. Tatum and Pedroza in Puerto Rico.

Nowadays, of course, we strive to place the implants in ideal positions; prosthetically driven dentistry. So instead of doing dental gymnastics with large abutment angles, invest in site development. I think the best options are block grafting or grafting with tenting screws. Looks like fun.

There are several options. 1. Do not extract. Splint the 4 teeth together with joined crowns. 2. If the patient insists on individual standing crowns, then try bone spreading and no bone grafts may be necessary. If there is any labial perforation, graft over those spots. 3. Extract the four incisors and place in minis. Temporize with splinted acrylic crowns until the bone has climbed.... I mean grown back. Then place in four splinted PFMs or if the patient insists,remove the minis and replace with regulars... will take longer though.

I would agree with a Dr Schwartz on the part don't get too hasty in doing all this implant decisions example trying to do so many things in a short time. But rather put ourselves in the shoe of an engineer whom is trying to build a house; that is of course laying down a firm ground work that is stable enough to insert pillars for the building structure. My own experience in the aesthetic zones until today have taught me to play safe and look into more predictable and long term results. Therefore, my advice is to establish a stable ground work for the implants in near future.