Patient with Low Lip Line: Best Treatment Plan?
I have a patient who is a healthy, non smoker, regular attendee.  Patient has a low lip line, that is it does not strictly fall in the aesthetic zone. I extracted #5 [maxillary right first premolar; 14] 3 months ago following a failing post and core crown. Periapical radiographs taken after 3 months reveal a defect in the buccal and palatal alveolar bone. Is it better to place the implant at the level of interdental bone and do Guided Bone Regeneration with BIo-Oss with a submerged implant approach, or should I place it at the level of defect and compromise the aesthetics with a longer crowns? What do you recommend?
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13 Comments on Patient with Low Lip Line: Best Treatment Plan?
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CRS
11/20/2012
Grafting with membrane at the time of extraction is best there probably was no huccal plate due to the failing post and core.I would repair the defect first by a full thickness flap alloplastic human bone, bio OSS is grainy to drill thru, and place a restorable membrane across the defect palatial-buccally.repair the defect first then place the implant. Next time be sure to graft at extraction since this defect was probably there initially. Primary closure let it heal 12-16 weeks. There will be less trouble down the line if the repair is done now vs hoping for the best Good Luck
Tyler
11/23/2012
100% agree. This problem is best managed at the time of extraction. At this point, grafting and placing your implant at the same time leaves you guessing on the final level of the crest, and can certainly complicate your result.
Also, if you were to place the implant "at the level of the intercrestal bone" you'd be right at the CEJ, which would make your emergence profile very flat. Remember that the ideal location for the fixture platform is 3mm apical to the final restorations gingival margin (not the CEJ as commonly cited).
Baker k. Vinci
11/29/2012
Tyler, my best suggestion is to google BMP and neck surgery. 1/2 of all the complaints are excess ectopic bone formation, the other half are swelling from the recruitment process. These ectopic bone issues are with infuse only and of course the carrier. Sorry it took me so long to respond. Bvinci
CRS
11/30/2012
Also google Bmp,Amplify FDA approval.Interesting.
ttmillerjr
11/25/2012
You actually have an advantage now in that you wont have to score the periosteum to get primary closure, this will leave you with more gingiva. I tend to agree with the saying, "One miracle at a time".
Baker k. Vinci
11/28/2012
You don't have to have primary closure for the ridge preservation graft or the implant, in most cases, if you know how to use your membrane appropriately. You can get more consistant passive re-draping of the attached mucosa this way. Bioss is possibly the last material you would use, unless you are trying to gain buccal contour, buccal to real bone. Look up Mike Block's explanation of this. If you are not comfortable harvesting bone, then use min. or demin. bone and a well tested membrane. Bvinci
Baker k. Vinci
11/29/2012
One caveat of scoring the periosteum is, you are blindly cutting the random pattern blood supply and depriving your graft of a lot of its nutrient resource. BV
DrT
11/27/2012
I agree with the above posters. I do have a question about the M-D dimension of the edentulous area that you are dealing with. In the second x-ray it appears that you do not have a great deal of space mesio-distally. Perhaps this is a product of the angulation of the film...or is it?
DrT
CRS
11/28/2012
I see this lack of grafting at extraction a lot upon referrals. You do have some windows three weeks after extraction is a good rule of thumb but why not do it right the first time. At extraction there can always be surprises so I have several options ready such as bio-active modifiers (prgf) Teflon membranes and good quality allografts. Also if the technique and materials are poor it has to be redone, my niche. I'd rather do it correctly the first time. That said I did a very lovely case where a one week post op the patient lost the graft even with primary closure! Very humbling! That made me a lot less judgmental! When I regraft this guy I'm tacking down the Teflon membrane let's see if he can pick that out! That's my control issue! And yes "one miracle at a time!"
Dr. Alex Zavyalov
11/28/2012
If a mesio-distal space is really decreased, the best way for the patient's rehabilitation is to use a Ribbond-type single-visit bridge technology.
Peter Fairbairn
11/30/2012
Yes CRS , the bigger the company the more wary practitioners should be , you would be supprised how easily "bad" research can be buried .
But that is life.
As for this case again always place the Implant at 3 weeks ( to get sof tissue closure but prior to hard tissue loss ) , preservation is the way of the future and the Implant is the gold standard graft . A colleague has done some very interesting work with a synchtron CT ( the one in Grenoble ) which really shows the effect of the implant on the surroundimg bone which will be published soon .
Interesting stuff.
Work with the body to encourage healing , cross species methods may not be the future .
Peter
CRS
11/30/2012
I agree with your plan I use the three week rule with ungrafted cases referred to me or failed cases. So far as big companies please google BMP, Amplify FDA approval, Medtronics. I was shocked and am no longer using this product! I personally have not had much success with synthetics even with combined with autologous. My recipe works well in my hands and it took some time to develop. The Infuse issue may become the next Bisphosp issue there is a huge following with this very expensive product and I noticed that the reps are not calling.
Richard Hughes, DDS, FAAI
11/30/2012
Why BioOss? It's just a filler. You will get a better results with a synthetic, like OsteoGen etc.
