Maxillary Ridge Expansion and Graft Case: Any Advice?
Dr. I asks:
Please see the case photos below.
I am looking for some practical advice on how to treatment plan this case. The patient is a 65 year old female with no medical complications. She has been wearing complete dentures for about 20 years and has significant bone resorption in her maxilla. She also has a shallow palate. I am placing implants in her maxilla so she can have an overdenture with increased retention and comfort. I took a CBVT scan without a stent to assess the pre-operative at the bone levels. I advised the patient that bone augmentation would be necessary because of the lack of bone necessary for primary stability and osseointegration. My original treatment plan was to place 4 narrow platform implants in her maxilla – 2 on the right, 2 on the left. I tried to expand the maxilla and found that the bone was very poor quality and splintered. I was not able to achieve primary stability. I have a great deal of experience in splitting and expanding and grafting and have enjoyed considerable success in this. In this case I placed Bio-Oss [Osteohealth] and covered with a membrane.
I have a number of options, I have considered and would like to get feedback from the Osseonews users on these different options. Here are the options:
1) Another attempt at a ridge split with Meisinger kit [Salvin Dental] or a piezotome?
2) Hip graft would be an excellent solution but the patient declined this option.
3) Block grafts from the ramus of mandible but this may be too far a stretch.
4) Bilateral sinus graft with bone graft and then wait 9 months for healing and then re-attempt implant placement. Consider using 2 individual bars – one on each side.
5) Re-make the maxillary denture and not place implants.
6) Refund what she has paid and refer her to another dentist.
25 Comments on Maxillary Ridge Expansion and Graft Case: Any Advice?
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Bruce GKnecht
12/21/2010
The best thing I would do is shave down the bone to get a wider platform adn then Osteotome lift the sinus. Once you are in the medulary bone the osteotome will expand adn compress the bone and infracture the sinus all at once. I do not like Bio Oss and I would mix curasan with PRF adn cover teh area with PRF. Good Luck!
Dr Benz
12/21/2010
consider straumann roxsolid 3.3mm only need to prepare 2.8mm sink it by couple of millimetre. you can still use intial bone expansion drill to improve stability
sherman
12/21/2010
Have you considered Imtect hybrid implant 2.8 mm. Place 4-6 from canine to canine, and totally avoid the sinus. If your pupose is just for denture retention, this would be adequate. Also, if the patient is on bisphosphonate medication, minimally invasive procedures are better.
S Dharmar
12/22/2010
Another option that one could consider is Zygomatic implants. The need for bone grafting and use of thinner implants can be avoided
Mr. X
12/22/2010
The best thing here and for everybody in every situation:
Do not use unresorbable Bio-Oss from cows with biological risks.
Do not support the lying lobbyists!
Richard Hughes, DDS, FAAI
12/22/2010
As per the above mentioned case. You can osteocompress with a 3.75 implant from AB Dental or one like the MIS 7. Place osteogen into the osteotomy to increase the bone to implant ratio. Also put the patient on calcitonin for a couple of months. Place more implants. One can always use blades and MAX SUB with a combo of the O'RARK and NORDQUIST method, you have to be alot better operator to do this.
alistair
12/22/2010
interesting Dr Hughes - i have used osteo-compressive implants a long time ago - as well as blades ( went off these due to a nasty failure)
Where could i find out about o'rark and nordquist method ??
Dr Dharmar -zygomatic implants are an option - but not one that i have had any experience with.
Alistair
peter fairbairn
12/22/2010
There is enough bone to keep this case simple. Can us enormal 3.5 mm by 10 or 12 mm implants and use bone expansion when preparing the osteotomies with an Osteotome ( we have a nice expasion tool which we developed about 20 years ago) . The ridge looks reasonably good and just a bit narrow at he top which will suit this technique , but always remember to use graft particulates when expanding. Minis are always a risk in the maxilla and Zygomatic implants are not warrented here as there is ample bone.
As to the distal inplants you could place in the zygomatic bone spur thus avoiding sinus augmentation (although I prefer sinus route ) if the patient so desires.
Thus you would have 8 implants and could have a cross arch fixed restoration , result very happy patient.
Often scans I feel make the picture look a little more desparate than it really is when you raise the flap , just my opinion.
But good luck
Dr morales schwarz
12/22/2010
I agree with you Peter, I dont really see the complication to place enough implants for a fixed solution, id go for four anterior implants, the two distals maybe tilted, and for posterior you can go either for bilateral sinus lift or for two tuber-pterigoid implants, zigomas will also be an option but in this case a favor the last two.
A bone condenser or expander certainly will help a lot as well as a reliable 3.3 diameter implant like straumann Roxolid.
Using a tc based planning software will help a lot in cases like this, since it will assist you to find the best areas to place implants, guided surgery will also be an alternative you should consider.
Mr. Truth
12/22/2010
Dear Dr. Schwarz,
you are from France. I get the advice that I should go in contact with Dr. Hilt Taturn (University Lille) because of Bio-Oss problems.
Bio-Oss is only a lie of a pharmacy (?) concern. Bio-Oss is an unresorbable product with biological risks from the cow! A filler, nothing else and never living bone. Money for the opinion leaders! The result leads to patients suffer.
How can I get in contact with him?
K. F. Chow BDS., FDSRCS
12/23/2010
Dear Dr I,
Dr Sherman is correct in recommending minis though he called them hybrids from Imtec and others like them.
The practical advice is to avoid unnecessary surgery whenever possible. The whole surgical world is moving towards minimal invasive surgery as far as possible because of all the accompanying advantages. Ridge splits, hip grafts, block grafts, sinus grafts all involve quite extensive surgical procedures with its accompanying costs in terms of finance, healing time, pain and swelling plus more chances of complications. It should be avoided if possible....and at 65 years of age, your patient will be so grateful.
Six minis with 0rings and housings will allow adequate denture stabilization. An additional four minis and you can have a fixed bridge. And you can refund half back to the patient as a Christmas gift.
Happy Holidays!
Dr. Morales Schwarz
12/23/2010
Implanthology is moving towards minimally invasive procedures, but also towards fixed implant supported rehabilitations, a removable device will never give your patients the confort, confidence and long term succes that a fixed bridge will do, that is true specially in the maxilla.
Rob Dunn
12/23/2010
This is an ideal case for the use of 3M/Imtec mini implants. There is evidence of good cortical plates, and primary stability can be achieved by bi-cortical stabilisation. Mini implants placed in the maxilla, where poor bone density is present, will require the denture to be soft relined for a minimum of 3 months before placing the housings in the denture, but an excellent result can be achieved with these smaller implants when denture stabilisation is the desired result
peter fairbairn
12/23/2010
Hi David I agree patients are always happier with a fixed result and the amount of work with bars and attachments can sometimes be more extensive than we would like. I meant tuber-pterigoid area to place the distal implants thanks for pointing that out.
65 is the new young now...
As for "Mr Truth" you made your point now lets be constructive on this forum
Ken Clifford
12/23/2010
I would love to see this case done with 2.5mm MDL implants and a fixed bridge as advocated by Dr. Todd Shatkin, Dr Chow, Dr Gordon Christianson, myself, and many others. There is a plethora of bone for mini implants, and 10 mini implants with a fixed prosthesis will keep everything stable with plenty of surface area. If you're nervous about fixed, try using the existing denture relined with PermaSoft over the mini implants for a few months until you are sure you have good integration.
Kaz Zymantas
12/24/2010
With the limited amount of info it looks like a fairly conventional case to use bone expansion and osteotomes from the Tatum system. Looks like you could place at least a 5x13mm implants in all of the cross sectional areas and you may need sinus graft with a couple more implants in that area. Check out Tatum implants on the web.
Gregori M. Kurtzman, DDS
12/28/2010
I was taught by Hilt Tatum. He would make a crestal incision just enough to see the crestal bone then using a scalpel he started the split (today can use peizo) then went to increasing wider osteotomes. But the key is you need to compress the boen there and to do this you create a space with the osteotome then put graft in and continue to compress while holding the plates with your fingers. He has a D shaped implant for these situations (www.tatumsurgical.com) But sometimes this has to be staged, expand and graft wait 3 months go back expand further and then place the implants and allow to heal
Greg Steiner
12/28/2010
Dr. L I assume the radiographs that are presented were taken prior to the ridge splitting attempt. Would it be possible to update us with what the maxilla looks like at this time? Also for those clinicians who would do fixed in this case how do you maintain proper facial esthetics if you don't regenerate the alveolar ridge or use a flange to support the facial tissues? Mr. X and Mr. Truth I suggest you respectfully question the authors understanding of a particular material and their rational for using the material if you want to engage in the discussion.
Dr. Samir Nayyar
12/29/2010
Just go for 4 mini implants from any system u like in the anterior region & fabricate an overdenture without extending it to the palate. Patient is wearing the denture since 20 yrs, so she'll be hpy to wear this denture.
Just don't forget to split the maxillary plates & then place implants after widening the osteotomy with osteotomes.........
Dr. Ahmed Halim
12/29/2010
Simply go for bone splitting and expansion using non traumatic threaded expanders... do not use oteotome just the expanders with screw movement
then place a tapered implants after the bone expansion... this is a straight forward case..
Holly
12/31/2010
The first question should be, "how far and to what expense is the patient willing to go"? This seems like a lot of extra surgeries and expense if there is a high probablity of failure. If any of these options are chosen, what does the patient do in the meantime. Will she be able to wear her existing denture, or will a new tempoary on have to be made? That will also incrue an extra expense. At 65, I would imagine that funds aren't inexhaustable. I know wearing detures for that long of a time is hard for anyone, but I would think her best option would be to remake her a new denture, make sure that if fills out her face better and skip the implants. I think this will make th patient happiest in the end. Less surgery, pain and expense.
dream dds
1/1/2011
With the caveat that I would put this into an application program and would have had a radiographic guide to select the abutment emergence postions. There appears a great amount of bone to use for either fixed or removable. This is an ideal case for All-On-4 implant postioning: 2 anterior would be 3.5 x 10mm nobel with 17 degree abutments and the angled implants would be 4 x 13mm with 30 degree abutments. This would set this up for either a fixed or removable with a great A-P spread that eliminates need for sinus graft and any other graft fill would be simple allograft. This would typically be a flapless surgery.You can make any modifications to the surgery that you want, ridge split, alveolectomy, graft. At a more sophisticated level, this would be an All-On-4 with immediate fixed placement at surgery. I was skeptical about this surgery until I became trained on it and now it is so painless for the patient and routine and predictable that I will no longer do this type of case without guided surgery which means CT, radiographic guide, surgical stent,surgical kit, availability of abutment angles. But the case can be done even without a stent if the experience is there.
yossi kowalsky
1/4/2011
If all you have is a hammer everything looks like a screw, or something like that. Look into basal implantology . See Scortecci book with Misch as second author . You can place pterygoid implants with disks anterioly .. Load immediatly as long as you have full arch metal fixed stabilization . Disks are made by Victory from France. If you want to go with small diameter implants i like arrow press from alpha bio . They are one piece or two piece with an available 15degree abutment . Try to place them with apical cortical engagemnt and as parallel as possible.
abdusalam alrmali
1/7/2011
I think you will have problem if you planning for FULL ARCH implants.And you donot give us additional information on the anterior region, but generally if you plan to do overdenture you can put 2 implants in the canine area and minimplants beside them .
David R Powers
1/20/2011
You might want to consider a full arch roundhouse mini implant bridge. This could keep you from having to do any bone grafting or bone manipulation. I have had great success with these cases and highly recommend you consult with Dr. Todd Shatkin and Shatkin First Lab in Buffalo NY, good luck
