Best approach for anterior case?
Last Updated: Jul 17, 2019
This patient came to me nine years ago before I began placing implants. Teeth #8 and #9 [maxillary right and left central incisors; 11, 21] were already bonded together and super- erupted and showing the gingival and underlying boney defect. We have cleaned up everything else in the mouth and she is ready to proceed with replacing #8, 9 with implants. She is also hoping I can do it for her rather than referring her to a specialist. At this point I am very comfortable placing implants, but I try to keep it straight forward in my office and let the specialist have the difficult patients.
If I were to extract and place immediate implants at the level the bone is at now, without grafting, we would have really long teeth. But that could still be a good option since she really can’t smile high enough even to show her ideal gumline, let alone the central defect.
Those of you who would do ridge augmentation grafting, are we needing a block graft and connective tissue graft, or could you get away with particulate – perhaps tenting with a titanium mesh? And speaking of tenting, would you place the implants in their ideal position where you want the new bone to be, and use those implants to hold the titanium mesh in place? Would this then hold in place the particulate graft that you have packed around the exposed threads of the implants?
PA #8 & 9
photo #8 & 9
36 Comments on Best approach for anterior case?
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CRS
07/17/2013
I agree with Peter, there is both a hard and soft tissue defect. Without much palatal bone to work with. Depending on how much tissue is regenerated a fixed bridge would be a good option but the defect needs to be fixed whatever you do. Your stated treatment plan is risky and a lot can go wrong. The patient won't care who does the surgery as long as a good result is obtained. Good luck.
ahmed
07/18/2013
we can extract the upper centrals and use a synthetic bone graft whith collagen membrane foe dentoalveolar ridige augmentation
Dennis Flanagan DDS, DABG
07/18/2013
Perform a ringbone graft after extracting 8 and 9.
Pablo Acosta, Odontólogo
07/25/2013
Would you explain this procedure?
Thanks in advance.
Richard Hughes, DDS, FAAI
07/18/2013
Dennis, that is an interesting approach.
K. F. Chow BDS., FDSRCS
07/19/2013
This is an extremely difficult case to graft because there is only a very narrow ridge of bone to contact intimately with the graft, plus great difficulty to fix a scaffold for the graft, plus having to stretch the soft tissue in such a way to achieve primary closure passively over the graft, plus a notoriously low blood supply in this area. If the patient is willing to take the chances, then proceed with eyes wide open for all concerned and take the knocks as they come. An alternative is to place long narrow diameters, long enough to reach the floor of the nasal sinus for bicortical stability and restore with pink porcelain gumwork to camouflage the lost bone and gums. Offer the patient the alternative from the trauma of unpredictable bone grafts, the time and cost that may be wasted. Check this out:
pickle
07/20/2013
You should probably perform a frenectomy before attempting any regenerative technique in this case.
Peter Hunt
07/23/2013
The case seems to be under good periodontal care at the present time. It would be worth considering supra-erupting these teeth. Not just a little bit but as much as you possibly can. The tooth is a handle to move the bone, so that if done carefully you might be able to achieve a surprising improvement in the bone line. The soft tissues can be re-aligned at the time the teeth are finally removed to place implants.
sharon
07/23/2013
Hi Peter! I was thinking about ortho extrusion too! How much bone would you expect to extrude? Can you pnly get to the most coronal level of the interproximal peak of bone between #8 #9? Thank you!!
Andrei s
07/23/2013
Orto extraction+ graft? Any way you habe to stabilize the defect for long term
Gregori Kurtzman, DDS, MA
07/23/2013
Problem here is it needs a connective tissue graft as there is insufficient tissue to be able to stretch over a graft placed and get primary closure.
I would extract the teeth, clean the site fill the defect with a graft and then place a connective tissue graft to thicken the tissue. Your aim is not to increase the height a this point but to thicken the tissue.
After 2 months, do a split thickness flap place the implants place more osseous graft and titanium mesh more alloderm or purous dermis and get primary closure and allow to heal 4-5 months.
after the healing flap remove the titanium mesh, place temp heads in the implants with a screw retained temp. suture soft tissue around these and let heal 4 weeks then you can convert to final prosthetics.
Would recommend an Essix temp during the healing phases before the screw retained temps this will keep all pressure off the area and graft during healing
sharon goodwin
07/23/2013
Hi Gregory;that is a very interesting treatment approach. How long does the patient have to wear the essix for? 4-5 months or less? If less time is needed then can they wear ain interim RPD? If you do not have ideal bone at the time of implant placement how can you plan to place the implants in the correct esthetic position? Is there a reason why you might not consider ortho extrusion prior to extraction and grafting to facilitate the case? Thank you!
timothy Hacker DDS D-ABOI
07/23/2013
This case can be done with vertical vascularized grafting.
Bruce G.Knecht
07/23/2013
I feel that the problems must be disected. First, the frenum must be addressed. I would do the frenectomy and wait two months for healing. Second, I would remove the teeth and graft the sockets. Take connective tissue from the palate(yes this will hurt) and tuck the tissue under teh buccal lingual tissue socket areas and cover with PRF in thesurgical site and the donor site. after gaining stability spray the area with PPP from one of the remaing tubes that you wre using to make PRF. Make a clear retainer with 8 and 9 as obate pontics so that the tissue can form. Wait two more months and place the implants and place Lab temps with PEEK abutments to again further develop the tissue. Hey, we all can backseat drive but, it is surely not a good idea if you have not done a few implants.
alessandro aversa
07/23/2013
if i wos you i'd proceed with an ortho extrusion, with any doubt; even if you don't extrude all the bone you need ideally, it will be enough to reduce surgery and graft at the minimum and with the max rate of success.
CRS
07/23/2013
The teeth are already "orthodontically extruded" since they are supra erupted. Ortho extrusion works to bring down bone when the periodontium is healthy, you'll end up just extracting the teeth! There is no bone to build off of here. I agree with the frenectomy with a VIP or pediculed graft to fill in the space with soft tissue. If the patient really wants implants place them in the lateral incisor areas and do an implant supported bridge with the central incisors as pontics with some pink porcelain. Somebody waited too long and the bone is gone. Vertical augmentation without a palatal base to build off of in the anterior maxilla is very unpredictable. Socket grafting or block grafting as no base to support the graft. Nothing wrong with a six unit bridge with good soft tissue for future hygiene. Perhaps a CT may show a base of bone that I can't see clinically. Basic understanding of biology , blood supply and how grafting works. Nothing wrong with good prosthetics, pick the cases appropriately.
Jerome BHUNJUN
07/23/2013
Hi,
I would advise the Bernhard Giesenhagen bone ring graft!!
Google the guy and you'll have a huge amount of live videos.
Regards
Jerome (MAURITIUS)
CRS
07/24/2013
Dear Jerome, thanks for the article seems like a viable technique, but when I looked closely at the clinical photos there was palatal plate to work with and the osseous defect was a different shape more severe horizontal bone loss with a palatal wall to pack the ring against. I like th fact that the graft is smaller and more precise fore initial stabilization. Bone grafting works if the graft is able to be stabilized and has a blood supply. The morphology of this defect simply does not support that. If these teeth are periodontally sound with healthy attachments orthodontic eruption will gain some height but since the teeth are splinted together and over erupting themselves out of the alveolar housing I feel the prognosis is limited. I would ask the poster to show the final treatment I would be very interested to see how these hopeless teeth turn out. This is way beyond my capabilities and experience, I think the ship has sailed on these two teeth and the supporting bone. I don't think there is enough bone for distraction or a pediculed flap and this is an esthetic area a lot of risk here. And by the way I have a regenerative practice and do a lot of grafting so I am always looking to add to my arsenal. Thanks for th resource and thanks for reading.
Eduardo Favilla
07/24/2013
I would try ortho extrusion too, after frenectomy.
Peter Hunt
07/24/2013
There is a difference between eruption and extrusion in dentistry. Eruption brings the bone with it and extrusion does not. Whatever the cause of the "blow-out" periodontal destruction between the central incisors, it seems to have resolved. Although there is an aesthetic defect the current periodontal condition in the region looks good. The pocketing is probably minimal, as is inflammation. So the concept would be to erupt the teeth, bringing the bone with the attachment. It's simple, quick, relatively non-intrusive and very effective.
I would keep things simple by maintaining the soft tissue complex as it is at present, changing it only by the tooth movement. It would look far more normal at the end of the eruption process. It would be easy enough to manage the frenum problem when the implants are placed.
CRSt
07/24/2013
The frenum may exert a force on the soft tissue once you start the ortho, since it is thick, a z-plasty will be helpful prior to initiating treatment. The point being the soft tissue needs to be preserved, this is often done in orthodontics. That's the usual sequencing and it will give the soft tissue more time to mature , and redevelop blood supply.
Peter Hunt
07/24/2013
I should have added that the first step in orthodontic extrusion would be to separate the two incisors, to shorten the two teeth down greatly and to remove the one remaining nerve. Actually, it would probably be easiest and best to place temporary crowns and these can have orthodontic brackets attached very easily.
sharon
07/24/2013
peter since there is so little bone left would ortho extrusion just erupt them out of the sockets? Thank you!
John T
07/24/2013
I agree with sharon. In my opinion there's no way any orthodontic extrusion/eruption forces applied to the upper central incisors will achieve a significant increase in interdental bone height.
Peter, can you show us any similar cases which have been successfully treated in the way you are advocating?
07/24/2013
1. Please, it's eruption which is needed not extrusion.
2. I am as keen on surgery as anyone, but one of the prime reasons I get good results is that I do as much as possible to improve the site / region before I operate.
3. The Periodontal Prosthesis Mode of Transition to an Implant supported dentition, Hunt P, Norkin F and Serrano J, Compendium 27,1,12-22,2006.
Jaime ( Portugal )
07/24/2013
When erupting , invert the brackets thereby creating more buccal plate and also mesializing the roots thereby preparing a good interdental bony septum and papillae . I would suggest brackets be place 3-3 for better control .
Light force . 022 slots
Peter Hunt
07/24/2013
Well at last someone is getting serious about eruption, thanks. I would just place a bonded lingual splint 3-3. This therapy can only improve the situation prior to surgical replacement of these teeth with implants..
CRS
07/25/2013
The proof is in the pudding, go for it! Would love to see result after the ortho please post!
K. F. Chow BDS., FDSRCS
07/25/2013
Another option is to just do splint crowns on the centrals with two Maryland wings bonded to the palatal of the laterals. This is usually extremely successful and economical and makes full use of whatever gum is left and avoids all the pitfalls of building bridges.... I mean bone and gums too far!! Yeah .... another option is to use endodontic stabilizers and restore the teeth with splint post crowns. We can give the patient all the options with the lowdown on the highs and the lows of each roadmap.... and then lo and behold ... let the patient decide..... with or sans implants. Cheers.
mike ainsworth
07/25/2013
this may be a case a la Coachman, ie dont try to build vertically, cut back and buccal graft giving enough room to make a properly contoured prosthetic with pink papilla, then blend the junctions with direct composite. you have to think the patient would be motivated enough to keep it clean but may be the most pragmatic approach in this case.
Tuss
07/25/2013
From a pros point of view I think you have too great a vertical loss to retain papilla position. You may put your patient through multiple surical procedures that look great for a short period and then start to relapse. From contact point to crest looks like its well over 10 - 15mm. What is the patients lipline like when smiling? Hard and soft tissue grafting to allow you to place a decent length of implants (not necessarily to close the black triangle) combined with pink aesthetics may be a more stable longterm fix for this patient.
Peter Fairbairn
07/26/2013
Hi Mike good to see you back on here . I used pink a few months ago ( about the 5th time since 91 ) and whilst Coachman has great cases I always have a heavy heart when fitting and feel like I have failed to an extent even though the patient is happy .
I feel this could be done relatively easily using my standard technique which you know but again the poster may be best to refer as many areas to fail in.
Peter
mike ainsworth
07/26/2013
Hey Pete, hope you are well.
Yes I agree that you should try to do the case as a regenerative one if possible, but all the ducks have to be in a row! I think its a case of trying to get marginal gains everywhere. If you are fully familiar with grafting techniques then it is possible to do this case. It just depends on the severity of the bone loss.
Looking at the case I would deal with the occlusal interferences using endo and crowns into a non contacting occlusion, with a splint and a bit of patience you may be able to partially resolve those conical defects non surgically. Personally I think ortho is a non starter in this case.
I think the main issue with grafting would be frenal pull so as previously posted a deep periostial frenectomy to make sure any muscle attachments have been taken off would be key. I think flap design is going to be key also.
mike
Dr. Alex Zavyalov
07/29/2013
The cause of the problem is that the lower antagonists are more powerful then the upper centrals. I predispose that it’s going to be with inserted implants after any type of bone grafting. Probably, it’s not a good case for implant treatment
Frank Avason DMD,MS
07/30/2013
Traditional tooth borne bridge w/ gingival ceramics. Esthetic Disaster awaits with implant therapy here..
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Peter Fairbairn
07/17/2013