Ortho case gone wrong: available options?

Would recommend to obtain a CBCT of the maxilla to have a good idea of the horizontal and vertical bone volume deficiency as a stating point. Obviously #7 is lost and would like to know the distal interproximal bone height on #8 as your augmented vertical height is dependent on that level. I would follow Dr. Istvan Urban's protocol for bony horizontal and vertical augmentation. Patient will require a 50/50 combination bone graft of autogenous and xenograft covered with a titanium reinforced d-PTFE membrane. You are going to lose your vestibular depth and will have loose unattached mucosa advanced palatally. Nine months later, if no complications, return to place your implants and add a second graft on top of your implants at that time( depending on soft tissue crestal thickness may need a CT graft at the same time). A few months before uncovering reposition the loose unattached tissue apically and secure in the new depth of the buccal vestibule. You will also need to place a horizontal free gingival strip graft slightly more inferiorly to prevent migration of the loose unattached tissue. The exposed supraperiosteal tissue needs to be covered with a mucograft at the same time. With regards to implants have your surgeon place implants more apically rather than at the crestal level and would pick an implant that has platform switching and a smooth collar . As you can see not a quick fix. You will also need a great lab. I would not place implants if not having a vertical augmentation in combination with your lateral augmentation. There is always a FPD with pink porcelain skirt is possible or RPD with a pink porcelain skirt. I strongly recommend you read many of Dr. Urban's scientific articles and as well as his book on bony augmentation before recommending treatment to your patient.

Everything that needs to be said, has been said by Texas OMFS

I have done few cases like this with vertical alveolar distraction and the results are very good. I used to do onlay grafting but many times soft tissue is an issue. VAD gives me both bone and soft tissue. Is I want a wider ridge I distract it more and during implant placement I can do an alveoloplasty. Would be glad to share pics via email. Thank you

I would suggest a different approach. Horizontal transport of a segmental osteotomy can address this type of defect. I have experience with vertical alveolar distraction and its effective use here is limited. I would also not discount the value of keeping the "hopeless" lateral incisor. I have attached a link to a short video that I created to illustrate this technique. https://youtu.be/wbieDtxtAHA

VAD is a great way to go in this case. Since VAD does not adds height but not width a particulate graft may be needed after the distraction. Another method is a J graft harvested from the chin or ramus which will provide both height and width. Finally a soft tissue graft to obtain an adequate zone of attached gingiva will most likely be required after hard tissue augmentation. A CBCT is a must to evaluate which method will be best.

As a concerned GP, I have the option of explaining the three methods, the Istvan Urbans Protcol that would deliver Ht and width, or the Verticle Aleolar Distraction (VAD), and finally the J graft harvested from the chin or Ramus. Although, I have explored these different option, I have not come to a position to give guidance. I am going to have an meeting w/ the OMFS that I have referred this patient to and will go from there. I will listen to him and look for his guidance too. Thank you all very much for your input-DrH