Periodontal Bone Loss Case: Best Technique for Increasing Bone Height?

Shave off #9 & 10 about 3-4mm incisally. Then, extrude #9&10 using invisalign (rx in script to move them 2X slower than default setting). Intrude lower anteriors (which invisalign does very well) to correct the severe overbite and level&align #7&8 along with any other teeth that need it. The bone should follow coronally the forced eruption of #9 & 10. Once invisalign is finished, place an implant on #9 and hang a pontic #10 off Implant PFM #9. OR you may want to exo #8 (which looks to have 40-50% boneloss on mesial) as well and place implant #8 & #10 for 3-unit bridge #8-10 and veneer #7 for symmetry.

This case should be referred to an orthodontist or a GP well versed in fixed orthodox tx. The cuspids have been dumped after the 1st bi extractions, the mandibular arch has collapsed lingual (tx should stay within the fct matrix), level the curve of Spee. The pt may lose the max centrals and laterals. Restore any edentulous areas(space permitting) with fixed bridges. A ceph and lateral photos would be a great help. Notice the distal lesion on the max 2nd molar. This needs addressing.

This case also needs perio tx.

Similar cases (implant supported or conventional ones) can’t be treated successfully without increasing a vertical dimension for at least 3mm, which should be rested on molar/premolar area. The prostheses might be fixed or removable.

Dr. D: I cannot read the radiographs clearly, but if there is still alveolar bone around the hopeless teeth, you can do forced eruption with orthodontics to increase the vertical dimension of the bone. As you over-erupt the teeth, they need to be reduced to avoidcollisions with the opposing dentition. Contrary to Dr. Kong's opinion, this is not an Invisalign case. Invisalign has good intrusion control (pushing forces) but poor extrusion control (pulling). There are things you can use to compensate, but you need the control of the archwire and the brackets for cases like this. Plus you would need more than 3 or 4 millimeters of reduction to gain enough vertical bone. At the end of the orthodontics you need 3-4 months of retention and will still need a ridge augmentation procedure. In this case the forced eruption will not increase the width and you will blow the bone away with your implant placement. Like Dr. Hughes said, make sure there is no active periodontal disease if you are attempting this. Good luck!

Agree With team approach, OMS ext 1,15,16,17,32, with planning for block grafting after fate of 6-11 evolves in ortho phase, trad ortho to correct occlusal collapse, (probably lose 7-10 in process) , periodontal maintenance and interim therapy, sacrifice 7-10, graft and removable provisional (snap on smile, flipper, ect.) implants only after successful site prep, is patient In for long haul? Tough case to achieve stability! Without utmost patient commitment, better off with dentures followed with implant support or implant fixed re-hab.

With that much bone loss especially between #9 and 10, I would question the amount of vertical bone that you would get with forced orthodontic eruption, especially if you cannot control the inflammation. You may just end up erupting the teeth out of the bone. Unfortunately, the PA seems foreshortened so the true bone level is hard to assess. Alternative would be some type of block graft to increase bone volume.

exo and block graft

This is a severely closed, high angle case with narrow max. While perio problems abound, the deep vertical is a major factor in her arriving To this point. Likely tongue thrust also. Pt. needs ceph analysis and consult with those know Edge able in orthodontics, occlusion, and perio. This EVEN if a compromise treatment is desired. The root causes of her condition need addressing. John

Forced extrusion, if possible, extraction with particulate bone graft (cortical,cancellous, irradiated)+collagen membrane+tenting screw.

extract #7,8,9,10...place 4 short implants...use Syntograft...now one doesn't need more bone height ,,,if you place 6mm implants..say Bicon..because the bone to implant interface will fill with blood and in 2-3 months there will be new bone...implants can be completed with abutment abd IAC crowns...

Drs Boudet and Manuel are on the mark. This is not an Invisalign case (I push Invisalign as far as possible). This case needs a good periodontist and fixed orthodontics for arch development. As I mentioned earlier, the case was dumped, which creates a periodontal situation between the mandibular second bi and first molar. Uprighting the mandibular posterior teeth ton the buccal and leveling the curve of Spee will help gain vertical. The maxilla may be constricted, but I don't think so. The maxillary incisors will most likely be lost. A dense HA particulate graftvwill help maintain the ridge. A 6 unit fpd will do nicely from 6 to 11. After mandibular arch development there may be space for root forms for #21 and 28, or two mandibular fpd's for replacement of the same. #15 needs endo and a PFM/cecr. This case deserves a classic orthodontic work up! Notice the deep bite and retrognathia. Then again perhaps only #9 &10'will have to be extracted. Either way, I do not consider this an implant case!

Some good points and some bad points made in this discussion. There is a term for the underlying major problem in this case: Posterior Bite Collapse. This has been hinted at by some above, but this is the actual diagnosis over-all. So, PBC, Chronic Adult Periodontitis, missing teeth, probable loss of vertical dimension, etc. Unable to follow too far along the path due to limited data. However, PBC is the fundamental. No implants should be considered until a proper diagnosis is made and the patient given options for treatment including full reconstruction. Treatment would naturally be interdisciplinary in nature and involve possibly several periodontal surgical treatments (including hard and soft tissue augmentation/grafting), orthodontics (and the suggestion to use Invisalign to accomplish what this patient need shows a clear lack of understanding of orthodontic principals), and etc. I mean, really, this is a very complex case that needs options for treatment that include all of this. Compromise may be possible such as splinting of teeth without full reconstruction, but the basics should be followed or the case will continue to fail as it is now no matter what implants you put in. Seriously, this is the type of case that should be referred to those trained in such cases (ideally, Periodontal Prosthesis) even if compromise treatment is chosen by the patient. To not do so would be a gross disservice to this patient and I do not need any more data to make this recommendation. This is also alluded to above.

er, uh, forget the missing teeth part. ;o)

To those who keep stating posterior bite collapse as the major problem in this case (Richard and musician), get yourself some loops and look at the intraoral pic again- its fine for this case. The problem you are referring to is the whole lower anterior complex of teeth from canine to canine has supra-erupted - follow the gingival plane you can clearly see whats happened. Max anteriors have also supraerupted. Enough with the misinformation already - its like a herd mentality...blind following the blind. Its true that invisalign is not so great at forced eruption as Carlos mentioned, but there is none better at intrusion than invisalign. If teeth have supraerupted, the easiest fix is to intrude those teeth and not open up the patients VDO even more. As for extrusion of #9&10 using invisalign, how much force does it take to move a tooth that has 80% boneloss at half the default speed? (have you even tried it for those critiquing?) Not much. If this doesnt work, you can make a buccal slot on teeth #9&10 and attach a button by the gingival margin #9&10and swing an elastic incisally over #9&10 and hook it to the lingual aspect of the aligner after making a notch (it will erupt). At best, you have intruded the lowers, aligned some teeth and extruded #9&10 and gained some bone vertically (maybe) in those areas. At worst, exo #8-10 and bonegraft and the teeth are setup for proper restoration using implant #8&10 or bridge #6-11 b/c you now have room to place teeth again. And yes, the patient has periodontal issues which need to be worked out along with exo of wisdom teeth along with #15.

My goodness. I will agree to my mistake. I was not aware of how deep the lack of education was involved. Wow. No kidding. This is not about bashing someone, John Kong. This is about advice for that is what you asked for. To the moderator, we are not attempting to wander into the zone of over criticizing someone. Some of us are very highly educated far beyond dental school and have years of experience as well to back us up. I for one, figured that this was an educational site for all of us but especially for those that need advice from others that have the advanced education and experience dealing with aberrant and difficult cases. If John does not want advice then why is he here? John, I do not need loups to see. I am trained in Periodontal Prosthesis and am well versed in the literature and very experienced in the treatment of these cases. If you were you would not have asked the questions you asked. If you do not want to learn from us, no problem. I don't know you and don't know the patient. I am just trying to help in a limited forum for these things. You are not educated in this type of case or you would not have even posted it for you would have known what to do. It is rather odd that you criticize those trying to help you. Go ahead. Treat this patient your way. If you have no interest in sending this to those that have experience and training for these type of cases, who cares? That is between you and the patient. Why would you ask questions if you knew what to do? And you talk about the blind leading the blind? Wow. This is a sad ending to a question: bash those you ask a question of because you don't like the answer. You loose, and the saddest thing is that the patient looses and neither you or the patient even know what has happened. Treat this case as you wish. It takes a long time for failure to occur in a case like this and with an attitude like what you wrote, you will probably never know and think what you did was appropriate. And that is OK because as stated above, We don't know you or the patient so who cares? The Max anteriors are supererupted, huh? No kidding Sherlock. That is what happens in a case such as this. As for loupes, you need to take yours off and see the whole case. It is always interesting when ignorance pushes a point. Those of us that can see what is really going on just shake our heads, chuckle a bit, and walk away... So, don't take our recommendations. No problem. Next time you ask the question we will say the same thing for no other reason than entertainment. But what we are telling you is accurate, supported by the literature, supported by extensive education and experience, and simply, the truth. You are indeed wrong, but one cannot teach when the person does not want to learn. Periodontal issues "need to be worked out along with the extraction of the wisdom teeth". Wow. You need to read the literature, John Kong. The periodontal issues need to be addressed at the beginning and are fundamental to this case. Fundamental to ANY case where it exists. Your latest post is a clear indication of your lack of education and qualification of treating a case such as this, and your post is scary at the depth of ignorance. Poor patient. Wow. No kidding. Oh, and I take back the missing teeth comments addressed above. The second bicuspids have been removed. Clearly a diagnosis of Posterior Bite Collapse. Missing this diagnosis, especially in the context of having been told, is a disservice to the profession of dentistry and especially to the patient. Understood due to lack of education and ignorance. Do not speak to us of being blind. We are trying to help. We have education and experience that you do not have. Learn from us.. reject at your and your patients peril. Personally? we don't care. We just are trying to help. You don't want it? Cool. Again, who cares. Personally, I am trained in Periodontal Prosthesis, University of Pennsylvania, Advanced Periodontics, Advance Prosthodontics, Advanced Prosthodontics, and Dental Implants by a collection of the best in the world and over 60 year of experience and documentation. I have been doing Implants since 1982. Don't tell me I am blind. I just write on this site for fun and to help. Go and do what you want. Ignore what we say. No problem. It is always fun to see someone dig themselves a hole so deep when they do not even know it. Cool. Thanks for the entertainment, John! ;o)

First, 'chronic adult periodontitis'? As a perio, is this really your diagnosis? Do yourself a favor and go read Amitage's classification of periodontal disease and conditions. Second, I did not post this case, but merely offering my 2 cents. Third, did I say periodontal issues need to be worked out after ortho or prosthetics? I dont remember saying that. Anyhow, you can't make a periodontal diagnosis or treatment just of a PAN, no less, dear Penn grad. Fourth, there you go again with 'posterior bite collapse' as your diagnosis. How the heck are you coming to this diagnosis?!? I dont get it. Where in the intraoral pic does it tell you this person has posterior bite collapse? Hopefully, you're smart enough not to tell me th PAN. Lastly, dont get so bent over my comments - its so you can learn.

Kong, we have to agree to disagree!

DrtheMusician: I agree w you 100%.

To Dr. theMusician First, there is no posterior bite collapse in this case. Second, I did not find any helpful practical recommendations based on your background. Third, too many emotions, which are not related to the subject

obviously esthetics is not a mayor concern for some one that looks like this ! i would take cbct and study case .. i agree with most of you, most approaches are viable .

I can't help it, John.. I just have to comment further. There is a saying: when you are in a hole, quite digging. Every statement you made above is a nail in the coffin of ignorance. Simply astounding. Arguing words and phrases in periodontal diagnostic phrases is astoundingly ignorant. Call it what you want but it still is Chronic Adult Periodontitis, Chronic Inflammatory Periodontitis, Inflammatory Periodontal Disease, whatever. Class I, II, III, IV, etc is really stupid. This is fun, and thanks again for even more entertainment. Yes, I do see that you did not post this case. But you did post comments and have stuck to your guns even though they are not loaded. Kind of funny, that. How can anyone make a diagnosis from a pan? A blanket statement, really. It depends on what you are diagnosing. I can, for example, given the photos and pano diagnose significant bone loss, less than 1:1 root/ crown ratio, missing and tipped and rotated teeth, hyper-eruption of the upper right posterior quadrant, lesions of trauma, caries, possible cyst or remnant of cyst distal to #32, hopeless teeth, splaying of anterior teeth, periodontal disease (or would you prefer pyorrhea?), loss of vertical dimension, and more. If you do not call this a classic case of Posterior Bite Collapse, Grade 1-3 (impossible to tell specific grade without more information) then you have much to learn and with your statements made I would suspect that is unlikely. You should have been able to see ahead of time that your comment regarding diagnostic ability from the pan (and photos, by the way) was a minefield. With your accumulated statements on this thread, it is clear that you have no business ever treating a case like this without more training and understanding for you are missing the fundamentals and when you do not understand the fundamentals (they are so very obvious), the basics, all of the wandering around specifics are a waste of time and a detriment to the patient. While this has been interesting and entertaining, it is also sad. Unfortunately, dentistry is full of those that really are banging their white canes together. I the field of knowledge and experience, you sure fell deep. Thanks again for the fun, John. Lol.

Please keep the comments on topic and refrain from personal insults. It is perfectly possible to argue different viewpoints about a case, without the need to attack people personally. Thank you for your understanding.

Well noted, Moderator. Thanks for the reminder. After all of this I noted that Dr. Alex Zavyalov noted that there was no posterior bite collapse in this case that was posted. For the information of anyone reading this, Posterior Bite Collapse (PBC) happens whether teeth are missing or not, whether or not there is loss of vertical dimension or not. Graded, PBC Grade I-II is without loss of VDO (there are a number of ways to note vertical dimension, depending on where you are educated, such as OVD, VDO, etc., but they all mean the same. For sake and this discussion, I will call it VDO) . Grade II-IV are with loss of VDO. For example: Over the years dentists may provide many restorations in a patient's mouth. Often, these restorations are made so that there is limited or no occlusion, example: a filling is done and for the sake of ease, the filling is not in occlusion, there fore the patient is happy and it is easy because the occlusion of the filling is not an issue at all. (do I really need to explain this further?) When this type of dentistry is done over time, over many restorations, the occlusion changes and the result is an adjustment of the opposing teeth to eventually arrive at contact again. This is also PBC. The result of which can be occlusal trauma (that is adapted) of other teeth that deepens the cusp/fossa relationship and in the end causes trauma to teeth with varying results. This would be Grade I and there is no loss of VDO, and the result is increasing trauma to one or both teeth. Grade II PBC is where teeth are missing but there still is no loss of VDO. Grade III is where there are not missing teeth but there is loss of VDO. This type of case happens when there is severe wear through the various mechanisms of traumatic occlusion, example of which would be someone that bruxes such that all teeth are worn and loss of VDO occurs. Grade IV is the one most dentists think of: the obvious where varying numbers and positions of posterior teeth are missing and the result is that there is significant trauma on incline planes and the remaining teeth change position. The case above indeed has PBC and to ignore this is to take the position that the common type of PBC is the only one, and that is in error. If you do not agree with the above explanation of PBC, that is your choice, but I think you are missing some very important issues in occlusal diagnosis. This has the potential of being unfortunate because the understanding of occlusion is paramount in Implant Dentistry (and, really, all good dentistry). In the above case, there are all of the signs of Posterior Bite Collapse. It is a very easy diagnosis once your eyes are open. Indeed, it is the most important diagnosis, over all, in a case such as this because it drives all other aspects including how you approach treating this patient's periodontal condition. As for periodontics, the bone loss apparent in the presented panorex is obvious. It is beyond comprehension that anyone seeing the bone loss in the anterior teeth and the calculus and bone loss between #18 and 19, and the distal of #14 can come to the conclusion that there are not inflammatory lesions present. I would urge all reading this to consider these issues for they are only a part of this case. The most important concerns of this case, regardless of teeth that are hopeless, are the periodontal issues and the occlusion issues. To ignore these is simply a disservice to this patient. I would sincerely hope that NO ONE would approach this case without presenting these facts to this patient. To deny PBC in this case is to do so without a clear understanding of what PBC is and what it means to the over-all case. I have limited time to argue the obvious to those that do have a full understanding of these issues. I applaud those that do. While this has been interesting and entertaining, I am truly saddened for the public at the hands of those that choose not to learn. The odd thing is that this is really common sense.

Pardon the error, Sentence 6 should read Grade III-IV, etc. Typo.

Yeah, well I obviously wrote that without re-reading it. The last paragraph, first sentence, should read "I have limited time to argue the obvious to those that DON'T have a full understanding of these issues." Now I really am done with this discussion...

This is your classic Class II, Division II malocclusion with secondary occlusal trauma to the maxiallry anteriors. This is NOT a posterior bite collapse nor is it generalized periodontitis. There is super eruption of the mandibular anteriors which creates a dilemna with regard to implant placement in the premaxilla. Conservatively, orthodontic intrusion of the mandibular anteriors is necessary before any definitive treatment of the maxilla. More expediently, extraction of the mandibular anteriors will dramatically shorten treatment time. Regardless of the route taken, failure to address the trajectory of occlusal contact will probably doom any implant therapy in the opposing arch. RJM

Interesting case. For some reason, the lower second bicuspids and the upper first bicuspids were removed in an attempt to correct a possible bimaxillary protrisive malposition of anterior teeth with limited orthodontic therapy early in this patient's life. We can see the atypical distally tipped position of the lower first bicuspids and the atypical upright position of the lower cuspids, and the rather close proximity of the lower incisor roots ... an attempt at orthodontically retruding this segment of the lower anterior dentition ... this may have led to elongated position of the lower incisors. A similar attempt was made on the maxillary anterior segment. All this treatment resulted in a posterior bite collapse due to molar tipping and a detrimental and pathological occlusal scheme including an excessive anterior overbite with little overjet ... a very tight envelope of function anteriorly leading to dysfunction and primary occlusal trauma initially, then tooth mobility and secondary occlusal trauma and drifting of teeth anteriory as the neuromusculature tried to reposition or self-correct the orthodontically created tooth position to a more acceptable state for more comfortable function ... and, perhaps it is no surprise to see endodontically treated incisors with no carious lesions. MM

We all have come up with possable treatment plans. What we have to consider is the patient's wishes. and resources. That is what will determine the treatment!

This case has a major vertical problem which caused the perio(trauma from occlusion caused perio). This problem needs to be addressed by approaching Ortho(skeleta anchorage is required to intrude the teeth). #9&10 need to be extruded for bone stimulation for future implants placement. Ofcourse, we need more info/pics/PAs to diagnose the case in a comprehensive way. But, without addressing the deepbite if someone decides to do the bone grafting and place the implants, it will be a road to a failure!!!