Bone Deficiency Case: Correct Orthodontic Protocol?

Really interesting case. I am not sure how to assess without rads, but I think that without augmenting the buccal ridge defect before starting the case may go south. I would bulk up around the standing tooth and into the defect- over filling with a synthetic like fortoss vital. leave it to mature for 4 months so there is mature bone to move into then do a straight coronal ortho extrusion of the premolar. Not sure an ideal case is possible in this situation though,

Dr BF: I have done several cases of orthodontic eruption prior to placing implants, but by no means am I an expert on these cases. I would not recommend that you attempt to distallize the premolar into the bone defect, this will result in premature failure. You may be able to gain some bone and soft tissue around the first premolar that may even improve the attachment levels of the canine if handled properly, but don't expect any gain in the area of the second premolar. Make sure you do an excellent job scaling and rootplaning around the first premolar and canine. Use rectangular wire to keep control of the root to prevent a fenestration through the weak buccal plate. Also be sure to never erupt the tooth into traumatic occlusion by reducing the tooth enough each activation to compensate for the anticipated extrusion. Retain with the final wire for 4-6 months and you can gain several millimeters of bone height and of course the soft tissue follows the bone. Finally, be prepared to graft on the buccal, as the procedure does nothing for bone width. You still will have to deal with the deficient bone in the second premolar area after all this. Good luck!

This is a common problem. The first premolar may be salvageable if the root has adequate length. I would orthodontically extrude to an acceptable ridge height for placement of the second premolar implant. If at that point there is no mobility and adequate attachment on the first premolar you can keep it and restore. Keep in mind a root canal may be required, however, the tooth looks a little beat up so pulp may be receded. If you can't save the tooth, you will need to place 2 implants. When you place the implant, osteotomes are fantastic to expand the ridge both vertically and horizontally.

Also when you place the implant in the second premolar site, leave the polished collar above the bone. This way you will not lose height later and you will may gain a better tissue profile.

Hi! I suggest, the life of first premolar is not good, a controled extrusion crate bone, only at the same level of mesial range; at the same time i suggest a gingival surgery to increase de heigth and wieth of gingival bridge, at the end of extrusion and gingival healing, a bone graft may be possible if you have more than 2.5 mm of bone weith in palatal wall. And of course we need a evaluation of the heith of alveolar bone to the the sinus. And please for more information put a panoramic x ray or perapical x ray plate of the zone. sorry for my vocabulary english is not my natural language.

Orthodontic Tissue Regeneration (OTR) First it would help if you could show us the radiologic examination. I would extrude the premolar slowly, with a very precise and stable fixed appliance design, reduce from occlusal, as late as possible (pain) make a pulpectomy and after few month i would distalize the premolar to create alveolar bone. After this i would extract the premolar. How much egression of the premolar?...depends on the radiographic aspect. You should have enough periodontal ligament on the distal part of the premolar before distalization...otherwise augmentation. No jiggling. Succes.

Please consider the following: If you were to rebuild the ridge, #5 should come out, whether after erupting for bone OR rebuilding the ridge from #3 to #6. The reason for this is that with the bone loss on the distal of #5, there is no way to get a well built height of the missing bone in the #4 area the way it is now. The common use of a titanium mesh means going back in to recover it. However, I just used an Inion membrane for the second time-works great. After soaking it in a chemical, it can be shaped to the bone filled ridge, and when wet holds its shape. NO RE-ENTRY. Wait 5 months and place the implants. The first time I did this I had all the bone I needed in a lower anterior region.

Joe, Inion membrane sounds interesting. Has anyone used this??