The Atrophic Maxillary Anterior Ridge: Discussion Topic

If you have an implant capable of integrating in a stable clot on a stable implant which is only 1/4 to 1/3 into apical bone and resting in a Palatal "trough" you can handle this situation predictably with Guided Bone Regeneration under a restorable collagen membrane and a mix of synthetic graft granules and harvested local bone. From first bi to first bi maxillary teeth, obtain the x-ray cross section and confirm adequate bone bulk to secure the apical portion of the proposed implant. Design the flap with long enough vertical, parallel lines to allow some apical repositioning if it cannot be release enough to close passively, then flare the mucosal cuts. Instead of starting with a drill point, "notch" the thin ridge edge and then start a slight "trough" approaching the apical target bone, keeping it parallel to the Palatal plate inmost cases (check your x-ray x-section ). Then get out the pilot bur and proceed as usual, submerging the implant about 3-4 mm below the ridge notch. If the implant is finned, it will help to stabilize the graft material. Cut a restorable collagen membrane, place graft, tuck membrane under base of flap and bring it up and over ridge crest where it is folded over and supported by one, looped suture per implant from the attached periosteum at flap base to the Palatal tissue and tie off mattress style on the palate. If too much graft bulk or not enough flap to release and gently meet palate, then cut a half or quarter section of Collaplug and tie that over the membrane stabilizing sutures just at the ridge crest. This delayed crest healing gives you more attached tissue and the graft

Sorry, got cut off short. Forgot to mention that I put many small perforations in the buccal plate to encourage maximal circulation. If you have repositioned the flap, the Collaplug will start breaking up after a few days, but the time it takes to completely slough, prevents graft granule migration. A clinical trough will appear on the ridge crest which fills in over the next few weeks. You need an implant designed to be submerged this deep - at least 3 mm - for this to work without exposing the implant.

Relating to success, of the last six I've done this way, two have required a pink porcelain cuff to bring the gum line even on big smiles. The other four have had enough extra ridge tissue to "flip up and over" to a fairly normal smile line. The patients' labial resorptive tendencies have remained and the labial plates formed ribbed patterns over the implants similar to the adjacent roots. I.e., no matter how thick the graft, the final result has been a thin critical plate arching over the implants.

John M, What you say about the procedure is fine, but what do you do about temporization. From my experience not many people want to go 4 months or more without an upper denture, and wearing a denture after augmentation procedures such as this is near impossible without damaging the augmentation. This is the major problem I have with this type of case. If someone can solve this problem I will be forever grateful. This type of case eats your heart out and is by far the most difficult to do.

Thank you Dr Manuel for sharing his wealth of experience and knowledge. 'no matter how thick the graft, the final result has been a thin critical plate arching over the implants.'- this is so true about GBR. Connective tissue graft may be needed years later to boost the esthetics.

first we need to know if it is a partial of completely edentulous ridge I prefered a staged approach, in which graft with any material( mixed of slow and fast resorbing is fine) , recently I started using Regenaform which gives better matrix to hold, I may use tenting screws, to hold the garft and tent the membrane, I also would recommend, to use a thick Alloderm or pericardium over the bone graft, soaked in growth factors of your choice, Gem21 ot PRP, primary closure is very important, for temporization, if a full edentulous arch, I would use mini implants at the posterior region to hold a denture, that is relieved anteriorly, w/o a flange to avoid impinging at the grafted site, if partially edentulous, then an essix like appliance would be my choice

Dr Berne, I've only done one or two at a time. The Palatal tissue is thick and the Palatal half of the ridge crest is pretty stable within a few weeks. I make bonded bridges for dentulous cases and severely cut back the inside if the labial flange and crest for removable cases, adding soft liner to the Palatal corner of the crest after a few weeks post op. One could always place the provisional implant screws to ensure no prosthetic pressure is carried to the graft site. The ridge trough behaves much like a normal extraction site and is pretty tough. John

I do advise patients that it's best to wear nothing that can touch the graft site initially, and that soft tissue revision down the line leads to the best tissue contours. The two cases with pink porcelain declined connective tissue grafts.

It seems whatever care and precision you invest, there are some patients determined to undermine the procedure. I had one of these GBR cases in for a two week post op evaluation who complained about the many stitches I had placed over the ridge crest (I put tons of 5-0 across the horizontal Collaplug to delay it's loss ). She was upset because she had to buy special tweezers to reach thru those stitches to clean out all those fibers underneath! It was clean as a whistle down to the implant top. Once I got her to stop cleaning the trough out, it granulated over and filled like an extraction site with ni untoward result. So it is a pretty reliable procedure.

In my opinion, this is where nothing but autogenous bone can be used. And yes, it's still intramembranous , so in my hands cranium, chin or the buccal aspect of the ramus, rigidly secured, with cancellous bone/prp and gtr with tension free primary closure. Unfortunately, this is hard to do without the vertical release ,several teeth over, through the middle of the papilla, with a curved release incision, allowing for the broadest base possible. Be prepared to loose at least 30% of your graft, so overgraft. I perforate both the block and recipient site. I come back at 5-6 months . Bv

Excuse me for speed reading the post , but temporization is a necessary sacrifice. I agree, nothing should touch the healing graft/ridge or membrane. So I mandate the Essex temp., only for cosmetics, to be taken out when eating and sleeping. Best bet , is to wear nothing at all. Have used " snap on " teeth, as well. I'm pretty dogmatic about diet as well. There is a lot riding on these grafts! Bv

Dr. Vinci, Thanks for pointing out the high risk and demanding nature of large bone grafting in this situation. I think you and I are in the same camp on this in general, and especially in large, bulk graft situations, but perhaps some clarification of the limited area of my proposed graft procedure would help differentiate the two ends of a spectrum. I am basically just using the GBR technique recommended by the Bicon surgeons on their site's "Webcast Replay" section, modified a bit by having some of the coronal implant Labial surface open to the graft. This is similar to a re-entry procedure in the correction of an implant that had been previously placed with a Labial cortical dehiscence or fenestration. It seems you are describing the placement of a graft bulk wide and deep enough for the subsequent reentry, prep and placement of a cylindrical implant having about 3 mm of bone around the final implant position. I am describing a sort of "stealth" graft, "cocoon" like placement of thin graft over finned, tapered top, Bicon implants, with minimal alteration of the bone contour and only millimeter or two of final labial bone coverage gently rolling back into the ridge site. The larger the graft, the greater difficulty in circulation and incorporation, and the greater the risk for contamination and sloughing. I am using only 1/4 to 1/2 gram of Synthograft mixed with patient blood in most cases. The autogenous bone from the local preparation is placed directly against the implant and the Synthograft/blood mix over that. I compress the Synthograft over the implant side, feathering it into the adjacent vertical cortical plate channels to match the contours of the adjacent teeth, and pull the vertical, 4-0 sutures from the apically attached periosteum, along the trough areas, up and over to the lingual/palatal tissue to maintain this low profile shape. I do not attempt to build a huge mound of bone over the implant. This leaves several millimeters of bone around the membrane, and several millimeters of peripheral periosteum to intimately contact the bone. Of course, the wide flaring base is done to ensure maximum circulation. Perhaps a major difference in the procedure I suggest, is that the graft does not form a huge, wide ridge crest shape, but rather tapers to nothing as it approaches the ridge crest. Since the tapered top Bicon implant is submerged 3 mm below ridge crest bone, and 5-6 mm below the ridge crest tissue, obtaining passive closure is not much of a problem, especially if there was an indentation below the crest, since that allows even more tissue. The final ridge crest tissue is enhanced in steps starting at the uncovering by lifting some palatal crest tissue over and then placing a smaller than final temporary and post. When the final crown is place, the tissue is again split and tipped up for papillae and forward for cervical height. These patients with tiny, thin jaws have genetic systems working to minimize abrupt contours, and placing a "blister" graft, or "stealth" graft matching the plate's contours over existing teeth works well with the existing system and very, very predictably. This procedure certainly does not negate the need, nor success of higher volume graft interventions, but it is a predictable tool to have available. John

Sorry John , I just call this a slightly deficient ridge, but still think that overgrafting the fenestrated implant, is best managed with milled autogenous bone/ prp and a membrane. I don't use realeasing incisions or primary closure, for this case. I do however use alloderm as my membrane, because a soft tissue deficiency is almost inevitable . If less than 20-25% exposure is found, success rates are high, with these cases. Mixing min. or demin. bone with your graft , seems to be helpful. Bv

I've never read this , or heard it anywhere else, but I bur small holes in the alloderm, for obvious reasons. I have gotten the early complaint from the restorative guy, that the buccal contour is too bulky. As we all know, it will not remain too bulky. Bv

BV, thanks for the clarification and the note about venting the alloderm. I am a general practitioner and refer the "heavy lifting" to oral surgeons and/or periodontists. So, I am presenting a procedure workable for a portion of deficient ridge cases, but certainly not all such cases.

I had a 78 year old patient who wanted all his missing teeth replaced. His existing denture was too loose. We replaced all his posterior missing teeth with conventionals. The anterior maxillary ridge was atrophic and narrow. 78 years old !! So we bypassed all the bone grafts etc. and placed in flapless 4 minis/one piece narrow diameters and immediate temporization with acrylic teeth. A month or so later, we cemented on the PFM bridge and that was 4 years ago. A prolonged unpredictable and painful procedure was avoided. Recently, we reviewed him and it was functioning beautifully with quite reasonable aesthetics. The anterior maxillary ridge often has bone height of 10 to 18mm even if the ridge is narrow. Maybe we should do this more often.

Maybe dr. Chow, but the pain issue,that everyone seems to bring up, can't be that big of an issue. One pass with a sharp bur vs. three. The first pass, is the most invasive. I don't hear many complaints about pain and implants, in areas that have been edentulous for greater than a couple of years. Probably because of the theoretical , neuro sensory deinervation, that comes with extractions. I'm gonna keep replacing missing body parts with fixtures, that are at least as big as what was there originally. Bv

Dr Chow, I also agree with Dr. Vinci. Another approach for a well fitted but unstable maxillary denture, is intermucosal inserts. That said, one also needs a stable occlusion.

Ahhh... good old mini vs conventional implant arguments again.. I also use minis and conventional size implants. Although I have some reservation on using minis to stablize upper denture, they are yielding successful results on my patients. ANecdotal, I understand. But minis for fixed application works if occlusion is judiciously adjusted. Do I think they are better than conventionals? No. Limited prosthetic options and relying too much on bone quality ( Since primary stability is what makes these minis stay ).. But once they integrate, size doesn't seem to matter. Minis on chopping blocks for a while and then, now short implants on it as well. They all work depending on situations..

Dear Dr Baker. Pain in dentistry is always a big issue and the bigger the invasiveness, the more the time taken and the bigger the pain and swelling later. One bloody time consuming cut with a sharp bur after lifting a large flap, and compromising the blood supply around the anterior nasal spine versus three short small tiny punches through the gum and bone,........ give me the three tiny bore holes anytime !! Almost no bleeding, no swelling to speak of and healing is rapid.......... isn’t that what surgery should all be about? And with the bonus of almost immediate placement of the permanent prosthesis plus satisfactory aesthetics, sans the lengthy wait if conventionals were used, I take back my word “maybe”. I hereby declare that it should be the treatment of choice unless the patient insists on trying to replicate the lost bone and its appearance as close as possible. The difficult challenge of management of the atrophic maxillary anterior ridge has been overcome many times with minimized dental implants. Last but not least, I take issue with the dogma of replacing body parts with fixtures that are at least as big as what was there originally. We can excuse Professor Branemark LMHL for doing that but we all know by now that a fixture is a totally different creature compared to a living root of a tooth. If we are using the periodontal apparatus to anchor the fixture, then we need it to be as big as the original, but unfortunately we have not been able to duplicate nature yet. Osseointegration or ankylosis require much less surface area to anchor the fixture for the accompanying prosthesis to cope successfully with the forces of mastication. The fixture need not be as big as the original. WADR.

Dr. Chow, it doesn't take a large "bloody flap", to place an appropriate fixture. A large bloody flap, is a bicoronal incision, from ear to ear, utilized by your colleques on a routine basis, to either repair a frontal sinus or an unstable panfacial injury with bony injuries to the orbits or zygomatic arches. The title " flap surgery" used to make me giggle, back in the day. You don't hear our perio doctors using that terminology much anymore, because they are doing more sophisticated procedures, today. So, in one breath you are suggesting raising the flap, devascularizes the bone( which it does) , but in the same one, you are tissue punching and throwing away attached tissue. Which is worse ? Both are pretty negligible, in my opinion. So firstly, it boils down to what is the best option and secondly, what your experience level allows you to offer. By the way, we are reproducing things as they actually were . You have heard of " dolly" the sheep, yes? Also, we are on the cusp of cloning pancreatic islet cells, thus curing juvenile and type one diabetes, but this is an entirely different subject. At least your not drilling straight through mucosa. All of the "real good" studies that I have read suggest a minimum of 6 , 13mm or longer traditional implants, for a fixed prosthesis in the maxilla. With surgery, comes discomfort . We can do a lot to lessen the amount of discomfort and swelling by being precise, knowledgable and effeciciant. Thank goodness for the likes of Morton and other dentist, that had a heavy part in the allowing us to practice the way we do. Thank goodness for the poppy plant, despite all the havuc it creates. I like to think I have a rather fair understanding about what surgery is about. In my opinion, it's about taking care of people, with the best technology available to us, in the most conservative and effeciant way possible. Sorry for the long winded response, but my guest didn't make it today and ducks have stopped flying. Wind at your back's. Bv

Dear Dr Baker, thank you for the interesting digressions and my regrets for getting you into a flap especially when those duckies don’ wanna flap by. Let us get back to the issue at hand. I am against lifting a flap if we can avoid it via a minimally invasive approach and still achieve a similar if not an even better result besides a better healing and recovery phase. I repeat that the treatment of choice in most cases of an atrophic maxillary anterior ridge is to use minimized dental implants with a splinted bridge. We need not lift a flap and place bonegrafts harvested from different parts of the body, which adds to the morbidity and suffering of the patient. We should seriously offer this alternative to our patients before embarking on extensive bone grafting with its accompanying sliding flaps, soft tissue grafts, membranes and unpredictable results. My posted cases speak for themselves in support of my rhetoric. Oh yes, I have heard of Dolly. Have you heard of Snuppy? The first dog ever cloned was at Seoul National University, Korea. It is named after the university, hence SNUppy. I just hope that we never try cloning humans for whatever reason! Back to teeth now, we should avoid obfuscating the issue and give our patients reasonable options so that they can make informed democratic choices for themselves. A key point in treatment planning is to ask the patient his/her expectations and their budget. The issue here, dear Sergio is not a Minis vs Conventionals debate. There should be no debate anymore because both work when used correctly. The issue here is to treatment plan with all the materials and techniques we have available, constantly keeping in mind the patient’s expectations and budget, their medical and oral condition, and our knowledge and expertise. We should use everything we have available in a responsible manner, minis, maxis, midis etc. etc. ‘Nuff said. WADR

Please don't discredit or disrespect the grueling work , directed towards curing the juvenile diabetic. Im certain, this was not your intention. Cloning humans !! Please stop there. I am a " crunchy conservative ", but more importantly the father of a little girl that has this dreadful disease, from nothing other than just, piss poor luck. No more politics, I vow! Stem cell research is huge and even effects you, unless you are not reading . You can suggest that minis are the standard of care, but until I see one last as long as several thousand of my standards , in 19 years of private practice recall, you will not sell me, on that philosophy. Why do you think that not a single omfs or perio doctor in my capital city,places the mini? It's because, they know better. Did I understand you correctly? You are immediately loading these things. Send me a single 5 year success story and I'll continue reading your post. I'm not suggesting you even care if I do. If you practice the full gambit, of Implant/reconstructive surgery and still suggest that minis are preferable, then, what you say has merit . Otherwise, this is just another hammer and nail issue, supported by someone with better than average writing skills. I agree that there is a place in the industry for the mini implant, but it is up to us to choose what is ideal. I could have placed mini fracture plates in my tug boat captains face last night, but by rigidly fixating these fractures with larger reconstruction plates will allow him to open and close today. If we had used the thinner, less rigid plates, he would be wired together for 6 weeks. The analogy, absolutely applies ! When I am done with the temporary mini and go to remove them, the are NEVER integrated. Granted, I am placing them as temps or ortho anchorage and treat them as such. Certainly the newer minis have to be better. Uncle on the subject!! Bv

Dear Dr Vinci. My heartfelt empathy regarding your little girl. I have children of my own and respect your current challenges. I hope and pray with you that JD can be conquered soon via stem cell research and whatever else it takes." Kfc