Anterior replacement with no buccal bone: recommendations?

I can tell you to place and Implant and do GBR and achieve primary closure and every thing will be OK. But it is meaningless if you don't have the skills to do it. I recommend you to follow the ITI ASC classification and determine, what kind of case you are dealing with. And if it is advanced you need to determine if you want to do it yourself or refer. For that reason, if you would like to get more accurate advice, you also need to provide accurate information e.g. clinical images of smile line, and medical history of the patient etc. All these matter and when i see the information is not adequate, one may interpret that they were not even looked into, otherwise they would have been mentioned here. I hope i could help and guide you in the right direction how to approach this case.

BY THE WAY, If you don't have the ASC book by ITI, you can use the online assessment tool at: https://www.iti.org/SAC-Assessment-Tool for free.

This is a very interesting case. At first look, it appears very complex and difficult. Any time the labial plate of anterior tooth is missing is a cause for real concern. Here though you have some good factors going for you. First, it looks as though there is bone on the sides of the defect, i.e. still on the adjacent teeth. Second, you have palatal bone in place as well, so this is essentially a three-wall defect. This is a type of defect that can be very amenable to therapy. So here is how to approach the defect. Some would try to do this with a closed “Tunnelling” approach, but with this you would not see the topography, only feel it. Probably it would be better to raise a large flap from distal of canine to distal of canine, taking special care over this particular defect to keep thickness in the flap. Then it is a matter of debriding the socket completely, which can be a challenge. At this point you would want to make sure that the bone is bleeding, maybe establishing a few bleeding points with a #2 round bur are required. The next challenge is to gain stability for an implant, which would most likely be in the apical region. One should not “fill out” the defect completely with the implant, all you would need to do would be to make sure the implant is stable. You want new bone to surround the implant. We would place the implant platform relatively deep to allow for later “Emergence Profile Development”, then place a bottleneck gingivaformer instead of a cover screw. Then it’s a matter of placing the bone graft over the implant and down between the bone on the adjacent teeth and the implant. Build the graft material out and over the adjacent teeth. It will tend to shrink back in healing. Cover the region with a good membrane, and maybe a connective tissue graft or equivalent bulk of Fibro-Gide. Advance the flap to make it tension free and then suture the flap back carefully to get good closure. Tricky, but interesting, and certainly worth a try. It’s actually more conservative than you would imagine.

It may be best to raise a full thickness flap, split the ridge with a scalpel and D osteotome, expand the ridge and place a 3.2 mm implant then cover the site with allograft and a barrier membrane and primarily close.

Always interesting to see the difference between the simple UK approach (Peter Hunt) versus the complex US (Dennis Flanagan) approach. Being a Brit I naturally tend to side with Peter! This is a 3-wall defect and essentially you need to slightly overfill the defect with the graft material of your choice, cover it with the membrane of your choice and wait for guided bone regeneration. If you're unhappy to place an implant at the same time wait until the graft has consolidated and place the implant at a second stage. Attempting to split and expand the ridge will be fraught with difficulty and you stand a good chance of fragmenting the remaining palatal cortical plate.

A single tooth split is difficult to consistently accomplish. I would graft and wait as I would rather deal with one problem at a time.

I would follow a True Bone regeneration protocol rather than GBR ,allowing the host to optimise healing the way it has done for thousands of years in millions of cases before Dentists tried to improve biology in the late 80's by using a membrane . So minimal flap place and graft with a stable , osteo-inductive synthetic and place at the same time even if low primary , suture closed with no membrane . Then load a 10 weeks , a daily predictable solution . What we do for last 17 years seems OK , the less we do the better host healing is . Regards

Oh Dear! I've just realised I've insulted Peter Hunt by calling him a Brit! Sorry Peter, I was confusing you with Peter Fairbairn (who is actually South African but works in London). I'd better shut up before putting my foot in it any deeper.

Both Peters have done an excellent job explaining what to do. As a matter of further clarification (particularly if you have not done this type of procedure before) I feel it would help you to preplan where you will place your implant and have a surgical guide constructed. The only decision then will be whether to implant and graft or simply graft. This will depend on how much primary stability you can get and you might not finally know until you have debrided the area and have direct vision (CT scans do not always tell you everything). However, preplanning will give you a pretty good indication what is likely. So you can proceed with the objective of implanting and grafting, but be prepared not to implant if you feel you do not have enough bone to get good implant stability – and if so - simply graft and go back in 3 months to place the implant. If at that time there is still some buccal plate deficiency, you can add some more grafting material at that time.

What will be most Predictable for Success? Lay out options: 1. place implant, graft, minimal flap 2. place implant, graft, maximum flap & release 3. Block bone graft, delayed implant placed 6 months 4. Particulate graft, maximum flap, delayed implant placement 6 months 5. Fixed bridge 3 unit Success depends on primary closure and vascularity of graft in healing in my opinion. Intermediate issues: type of membrane (or not), tacks, PRF,PRP, health of patient, smoker, clotting factor issue, nature and time of initial infection ie years with bacteria permeating in the bone. My opinion only from experience, some literature, no I am not an expert, GP but I do know patients don't want to get worse with treatment and will take extra healing time for predictable success. As listed above by number: 1. I feel with an infected defect, (was it RCT) , anerobes activated in surgery, that this is the most unpredictable, placing, likely infection, lack of vascularity with implant present, hard for primary closure; if surgery goes downhill, the adjacent teeth could be lost. 2. Flap full thickness cuspid to cuspid, periosteal release will allow most bulk of graft over the implant surface. Membrane options: PTFE, Pericardium, collogen, tacks to contain graft. primary closure; I feel has average success but long term no buccal plate will form and probably dehisce in few years. 3. Block bone: I have not had good success. need PRF, cortical perforations, RAP, immobility with screws, primary closure essential. 4. Full flap cuspid to cuspid, decorticate, PRF, particulate graft of choice, membrane: PTFE, Amnion, Pericardium etc, tack for containment of graft in first 2 weeks. No temp for 6 weeks, periosteal release and primary closure. 6 months for consolidation, mineralization and lamellar bone formation, may form buccal plate. 5. This may be an option that patient wants. This may be the option if all others fail. I choose #4 due to my experience with predictable high percentage success and BTW, does anyone remember the USC Perio-implant symposium of 2008 where 8 noted world experts presented their noted failures of implants and grafting? Everyone went to particulate bone graft-GBR to bail the case out, delayed implant placement! Again, these are my experiences and the literature will show pros and cons to all. Leonard

Actually John T. , I am British from Torquay, a 4th generation dentist. But after having done 3 years of post-graduate trading In PerioPros at Penn could not find a teaching Job in Britain.. America welcomed me back, but all this was before implants anyway. These days you can turn to the internet to get all sorts of good education, so where you come from is less and less important, it’s how you think, act and keep learning that counts!

Just did a case like this on Friday. I am not a fan of immediate placement in that big of a defect. Placed a block graft in the area covered with corticocancellous bone and resorbable membrane. Stabilized with tacks. Now I wait for the integration.

Thank you all, for the help

Obviously there are many ways to skin a cat as can be seen from the various approaches mentioned. During my perio training 2004-2007 I experimented with every approach possible. Over the last 12 years I have discovered that these cases can easily and predictably be treated in a simple single stage approach. I would place the implant (Zimmer 3.5mm platform is my preference but any quality product works) and graft with a particulate allograft. Feel free to use any barrier membrane of your choice though it is probably not necessary. I don’t get too concerned about primary stability. I would achieve primary closure and for me I use 4-0 chromic gut. I would caution against trying to complicate this particular case by using advanced “look what I can do” techniques!!

1) New bone develops from the trabecular/marrow blood supply of existing bone. Any implanted surgical device that obscures this supply to a graft compromises the outcome. And increases the risk for avascular infection. 2).My recommended approach not involving the collars of the existing teeth, Thoroughly debride the graft bed and generously create bleeding points with an irrigated round bur. 3) Use a just-prepped L-PRF graft consisting of condensed, morselized L-PRF to which IV metronidazole was added prior to centrifugation. Mix 50/50 with corticocancellous bone particles. Fill to a level verified with a guide made from a pre-op wax-up. cover with a cross linked collagen membrane rehydrated with PRP/PPP liquid/IV metrinidazole). PRP liqud from white top tubes can be used to creat firmness in the graft. Tack the edges dow with bone tacks. 4) Score/spread periosteum to achieve tension free closure with 4.0 Vicryl; loop the crestal sutures around the necks of the maxillary anteriors. 5)Maintain patient on Amoxicillin/Metronidazole 10 days ( Started 24 h prior to surgery), CHX rinse, ibuprofen/acetominophin tid (again started 24 h prior to surgery) for 3 d, supplemented by appropriate narcotic if needed. 6). Sutures out at 10 d (CHX scrub of suture line prior) 7). Guided placement of implants at 3 month if CBCT confirms proper volume of healing. Not fast, not fancy, but predictable; further, a failure in this area creates other issues for doctor and patient relating to aesthetics and perio that then must be overcome. Prayers and best outcome to both you and your patient.

Dr Carver in this day of animal rights and peta I was not offended by your cat skinning analogy. Just my attempt at a little humor. Thanks to all for some well thought out treatment approaches.

A company called "Reimser" used to make thin bone squares that you can hydrate in sterile water. I had a case just like this for tooth #5. Extract; debridel; irrigate w/CHX; place implant; pack with bone graft; close with inserting of the hydrated bone square on the buccal and suture closed. A membrane may be neseccary depending on the type of bone graft material used. Wait six moths; uncover and restore.

Bonering technique. google ‘bone ring’. It works great but there is a learning curve

Google ‘bonering’. It works great but there is a learning curve.