Lower Left Mandibular Reconstruction: suggestions for long term treatment?
This patient is a 66 year old male of Asian ethnicity that initially presented for a failing bridge from the distal root of the hemisectioned #19 through tooth #21 [mandibular left first molar to first premolar). There was insufficient bone in the #19 and 20 sites as per the CBVT. Block grafting from the lower left mandible was done in the #20 area [mandibular left second premolar; 35] followed by implant placement in the #19, 20 areas. The implants did not integrate and failed within a few months. The area was than regrafted using titanium mesh and overlying membrane, which became exposed and led to failure of the graft. Soft tissue contraction has occurred in the area, as well as additional bone loss in the sites with exposure of the root on #21 now. What are your thoughts and suggestions for the long term treatment of the area?
11 Comments on Lower Left Mandibular Reconstruction: suggestions for long term treatment?
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CRS
9/10/2014
There are several reasons why the treatment may have failed you would be the best person to form a hypothesis even though I have some ideas. However with two failed grafts which are high skill and risky techniques the blood supply to this area and regenerative capacity are probably compromised. I would do a bridge at this point. Now looking at the first periapical I would have used the molar root for one implant, and expanded the adjacent site with motorized spreaders and a small onlay graft. I would have seen what I got and perhaps just placed a single implant or two depending on how it healed. What I have found is that an area that has been edentulous for a long time resorbs to more cortical bone with less blood supply. I'm not sure why a hemi section was done without endodontic treatment. I think that molar is tooth#19. Why not remake the bridge originally it doesn't look that bad on the film just an open margin. I would be sure and document any rationale and discussions with the patient on the treatment plan.When these complicated grafts fail it can be ugly. Welcome to the world of Oral and Maxillofacial surgery, I feel your pain!
Alex Zavyalov
9/10/2014
In this narrow alveolar ridge case I would've considered a single blade implant form with two abutments (Linkow's).
CRS
9/11/2014
Not such a crazy idea, I just don't have experience with blades. In a small space like this seems like a good option.
Dr L
9/10/2014
Im not well versed enough in implant surgery to comment on the treatment, but why couldn't root canal treatment be done on the abutment(s) and a new bridge by made before it got to this stage?
Richard Hughes, DDS, FAAI
9/13/2014
This is not a blade case. The two root forms free standing or a four unit bridge are the best options. Blades are not designed for free standing use in most cases. Plate forms can be used free standing.
peter Fairbairn
9/14/2014
Good tunnel graft case , simple low pain , graft to increase bone with through incision anteriorly .
Place implants at 4 months take core sample for histology at the same time , use Osstell to check placement and loading ( in 10 weeks ) ISQs ...
Regards
Peter
Richard Hughes, DDS, FAAI
9/14/2014
The use of a blade requires abutting to natural teeth. Both adjacent teeth already have cast metal restorations. A fixed partial denture will serve this patient very well without all the invasive procedures and excessive financial cost.
Yes this is a tunnel graft or expansion case, if implants were selected as the treatment of choice.
ezgator
9/16/2014
I agree with the bridge comments but it appears to me that the extracted tooth was a 2nd premolar not a hemi-sected tooth. The root morphology looks like a premolar and that would explain the lack of a root canal being done. It seems to me that redoing the bridge would have been the simplest solution.???
Peter Fairbairn
9/18/2014
Bridges are a good solution , but in cases where they have failed before patients themselves are more reluctant to go down that road again ......
Will show a tunnel graft with Histology and Osstell readings as well as long term results this weekend in Porto Conference
Peter
JS
9/20/2014
It would be helpful to see a post implant removal CT of the area to access how much alveolar bone remains and if any significant defects are present. Just as a suggestion, I wonder if you could not have reduced the aveolar crest and avoided a block graft altogether; I think there may have been enough width for a 3.5 or 3.75 x10mm implant for #s 20 and 21.
If a significant defect currently exists (which we need the post-removal CT to confirm), then another onlay graft may be advisable and then replace both implants. If you want to save time, a 4-unit FPD with abutments that far apart may work, but long term prognosis is less favorable, and if either of those abutments fail, well...
David robinson
9/25/2014
Or even , pardon my obscenity , a brace of 2.5 mm minis .
Chap is probably fed up with grafting by now.
