Vertical Bone Augmentation in Aesthetic Zone: Treatment Plan?

I am planning the treatment for this case as follows:

  • Step 1 – Frenectomy to help achieve tension free closure of flap
  • Step 2 – 8 weeks after Vertical bone augmentation with autogenous and bovine particulate bone 20/80 ratio, titanium screw and resorbable collagen membrane
  • Step 3 – Implant placement 6 months after augmentation
  • Step 4- Roll flap and implant supported temporary cantilever bridge to create papilla/ soft tissue contour
    CT graft if needed?
  • Step 5 – Final 2 teeth cantilever bridge

What are your thoughts on my plan? Anything you think I can do to improve the outcome?

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6 thoughts on “Vertical Bone Augmentation in Aesthetic Zone: Treatment Plan?

  1. I would do a CT graft at step one when you release the frenum so that when you go back to osseous graft you have more tissue to manipulate to get closure. am not a fan of bovine bone as the particles remain. I would consider getting some Ti mesh shape to the area fill with Novabone mixed with the autogenous then fixate the ti mesh with screws and close over it. without rigid tenting your not going to gain much height. Other option is use block grafts to widen ridge and also tent up then fill between it and the ridge with graft material block is held with screws

  2. 1. Improve soft tissues first with alloderm or connective tissue with frenectomy. You will never cover a bone graft with the tissue that you have to work with.
    2. Get a 3D model of the upper jaw (350$ from nsequence or other company) so that you can really appreciate defect. I like to do these cases with mesh. I pre-bend and cut the mesh on the model so the surgery goes very smoothy.
    You have a significant composite defect here- and one screw (if that’s the way you are going) is not enough.
    3. Rescan after 5-6 months to confirm bone growth.
    4. Place implant – another chance to augment soft tissues.
    5. Uncover implants – yet another chance to augment soft tissues.

    Be very honest with your patient. If you get papilla here that would be one heck of an outcome.
    You will
    Likely be looking at long teeth and pink porcelain.
    Just make sure your patient knows that this is a distinct possibility.
    Vertical augmentation is the most difficult kind of grafting.
    Regarding choice of materials – That’s up to you and your experience.

    I’m assuming you have a scan for this. Standard of care.

  3. Agree sboms , this is a very complex case and host healing will be compromised as well …… experience has taught me to be very wary o f this case .
    What is the metallic object sticking out of the buccal mucosa ? , is it a screw . As this looks like a previously failed case ………..dangerous land here
    Regards
    Peter

  4. 1} Enhance better soft tissue by a CT graft simultaneously with frenectomy
    2} Kazanjian designe flap …3D bone augmentation using mixture of autogenous and allograft meterial with mesh ( not collagen membrane) …. or using merely autogenous bone graft if you are familiar with Khoury technique .
    3} Four months later place the implant and [ if needed] enhance more tissue quality may be using pedicled palatal CT flap.
    4} proceed with prosthetic phase ( you can still do some soft tissue modification to achieve more pink esthetics)
    5) Do not promise the moon …. This is supposed to be the first step.

    Good luck

  5. Agree generally with the surgical steps others have proposed.

    I see no difference between the use of Ti-mesh or Ti-reenforced membrane so long as they hold the intended shape; use whatever is easiest to use in your hand…that said, I personally find mesh to be less forgiving and more technique sensitive (prob b/c don’t order a 3d model to play around with).

    Depending on your patients smile line, this could to be a very challenging case esthetically…pink porcelain, 0% of the time look good when you have real gingiva to compare with on the contralateral side.

    You will probably have to prepare the patient mentally for Veneers or Crowns on #6-11 to try to ‘blend’ in the implant restorative work after your bonegrafting efforts.

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