Suggestions for grafting mandibular?

I have a 52-year old male, good overall health with an otherwise intact dentition. He has periodontal disease localized in the mandibular anterior only. I have treatment planned this patient for extraction of #23-26.  After the site has healed, I am planning on placing 2 implants in the 23 and 26 sites and restoring with a 4-unit bridge.  The mandibular area will require a graft.  In the past, I have treated similar defects with particulate graft, tent screws, and collagen extended membrane. I am looking for opinions on any alternative ways to treat this. Putty? Different type of membrane?  What do you recommend?



12 thoughts on “Suggestions for grafting mandibular?

  1. Dok says:

    Only extract #24. Treat the defect like a walled periodontal defect and graft/regenerate accordingly.
    Bond # 24 ( remove the root of course ) to the adjacent teeth during healing and allow to heal with strong emphasis on preventative maintenance. You may gain back 3-4 mm of bone height prior to extracting the other teeth.

    (1)
  2. Timothy Carter says:

    I doubt if you will need to graft. The vertical is gone at 23-24 so you may as well plasty and be glad it is the anterior mandible where esthetics are of little concern. There will be plenty of bone to place 10-12mm implants and move on.

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  3. WJ Starck DDS says:

    I’m not so sure that implants are the best solution in this situation. Once #26 is extracted you may be horrified at what level the periodontium settles at on the mesial of #27 (speaking from more experience than I care to remember).

    I would:

    1) Consider referring this case to a Periodontist for a second opinion at the very least
    2) Consider extracting #23-26 and treating #22-27 with a conventional fixed prosthesis.

    Sometimes we forget that implants are not the be-all and end-all for every patient and every clinical situation.

    Would love to see some other opinions on this interesting case. Thanks for sharing!

    (0)
  4. WJ Starck DDS says:

    What is the probing depths on #24? It doesn’t look like there is any bone buccally or lingually, so I’m not sure how you can expect to regenerate anything, especially if it is a 2 walled defect as it appears. Now if there is bone on the lingual, then maybe, but I sure wouldn’t bet the family farm on it…

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  5. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    It is hard to be exact with the little information you have provided. Clearly there is periodontal disease involved. However the overall appearance of the mouth does not suggest it is terminal yet (for all teeth). The bone loss on the lower incisor seem predominantly isolated to one tooth. I suspect a combined problem. My recommendation is to start endo treatment on the tooth and to do all the necessary things to treat the perio disease (eg scale, plane, OHI, perhaps splinting). There appears to be some bone matrix still in place and I would usually expect considerable bone regeneration to occur (if the above treatment is carried out) – probably making the tooth viable for a long time. You cannot over look the frenum and hypermobile lower lip being a possible contributing cause.
    Therefore a periodontist consult would be prudent and certainly wise not to commit too soon to implants. As I said, it is hard to be too specific with the little information provided, but to me it does not look like a typical periodontal case and trying to save teeth and restore bone will do no harm, might save some time and money, and could avoid radical treatment.

    (0)
    • Steve Wallace says:

      Tooth looks ready to exfoliate. Maybe you could do the RCT in your hand? May need another degree after your name first.

      (0)
      • Dr. TK says:

        Be civil. You and I would not consider RCT #24; however, someone may specialize in that treatment.

        I do appreciate Dr. Gerke’s consideration of the frenum. I had less than ideal outcome with a similar case resulting from my failure to address a frenum attachment which disrupted the surgical site.

        I am inclined to agree with Dok (the first commenter). Presuming 23 is vital, I would extract 24, graft that one area, splint the crown (and 22-27 if indicated) and then re-evaluate the case in a few months. I have a few patients who had similar presentations and are now perfectly content with the splinted natural tooth.

        Something to consider. The implants do not need to be placed precisely in the sites previously occupied by 23 and 26. Positioning them in the healed interproximal bone 1/2 tooth closer to the mid-line allows a greater bone volume between the implant and canine which may be desirable. The restoration should be routine for the lab.

        My failures in this area:
        1) The previously presented unaddressed frenum
        2) I attempted immediate implant placement following extraction. The facial plate had inadequate thickness resulting in bone loss. I ultimately removed the implant, grafted then placed a new implant. Case turned out well, it just added time.

        (0)
    • comlan missih says:

      100% Agree with Dale! Implant is not answer to all endo-perio lesions. This is most likely a case of perio-endo or endo-perio lesion. We could eventually look at implant option but it’s too early for that. At least get a CBCT to really see 3D view of the bony defect.
      1- root canal therapy
      2- Perio consultation after 2-3 months
      Typically endo-perio lesions could resolve after RCT

      (0)
  6. Andy says:

    #24 is unrestorable. However, I can see thin strip of bone at much higher level on #23, 25 mesials. I recommend extraction #24 only with grafting of the site and, as someone mentioned, provisionally bond the crown #24 to adjacent teeth and observe #23, 25 for 6 months before proceeding with any other treatment. You will need more stiffness than a tenting screw and collagen membrane can afford. I suggest a-PRF membranes over tacked or screwed Ti-dPTFE over cortico-cancellous/I-PRF steaky bone. I predict #23 and 25 will be suitable abutments for Maryland Bridge in this case. If don’t get bone on mesials #23, 25, then have option for 3-tooth implant bridge……#26 shouldn’t be extracted. Also release the midline frenum during the grafting.

    (0)
  7. Wesley Haddix says:

    You and you patient face a challenge. Optimal reults will be obtained with optimal planning , beginning with diagnostics. I don’t know if you are planning on obtaining a CBCT, but in my humble opinion choosing the best grafting method is not possible without a good idea of what the true condition of the cortical-albeolar plates are. I would not rule out a LANAP type laser assisted microsurgical option with rigid splinting and occlusal management depending onwhat the CBCT shows.

    If saving these teeth is truly not possible it is imperative to recognize that the anterior mandible poses enormous challenges due to the proximity of the adjacent teeth. As another comment stated, perhaps only extracting #25 might be necessary; again, back to the CBCT. I’d save the clinical crown(s) of the extracted tooth/teeth for possible use as a bonded temp or on a removable provisional duriin site prep.

    This will be a challenging case; again; I humbly but strongly urge a CBCT and mounted models to start. Hard tissue grafting may require more than one procedure to obtain adequate bone volume in the appropriate area. My choice would be a cortico-cancellous allograft with PRF/metronidazole as a binder. I generally avoid tenting screws to reduce variables in a small area such as this. Good fixation of an occlusive membrane is a must. In any case, prayers and the best of wishes to you and your patient.

    (0)
  8. Anon

    I know every patient and case is different but here is something similar to what you describe. This patient’s lower left central incisor was (very) heavily affected by periodontal disease with very little bone on the medial aspects of the teeth next to it. I removed LL1 and placed a temporary bridge using the crown of the extracted tooth, then completed simple periodontal therapy involving ultrasonic scaling and root surface debridement. On the second xray taken 2 years later you can see the bone remodelling that has taken place adjacent to the other teeth. The situation is now stable and the patient is happy to think of this as a long term solution avoiding any complex implant treatment, at least for there foreseeable future. Perhaps this is something you or your patient may consider if only as a temporary solution until you see how things heal.

    (0)

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