Failed block graft in the upper left 1+2 region: ideas?

Hyperbaric oxygen. Just kidding this case is tough since the soft tissue blood supply is really compromised and it seems there are muscle attachments which are not helping. I would focus on restoring the keritanized soft tissue first. Looks like there is not much keratinized tissue near the posterior implants on the buccal. I would also be concerned with scar tissue. I would get the patient in a good provisional that is easily removable since this will take a while. Free gingival grafts in the anterior or allodetm ct grafts? Any periodontists out there to weigh in? The good news is that there seems to be good sinus augmented bone. What is the design of the final prosthesis? Could implants be placed in a manner to avoid this compromised area?

Do you have radiographs to show whether you have exposed implant threads? Your photos show that the problem is likely to be the muscle attachments causing movement and not enough tension free closure. I would normally test this by pulling the lip out tight and ensure that this does not cause movement to my flap. Apical mattress sutures are excellent for this.

some question: 1-how old is your patient? 2-prior was he involved periodontitis? 3-is he healthy?has not he diabet or intrensic disease? 4-is he smoker? 5-after GBR procedure whether had he a soft feed rigimen? 6- please more explained about your immediadte temp prothesis?

While primary and tension free closure is essential in these cases, the single biggest cause of bone graft failure in posterior maxilla is the lack of vestibular depth. Look at your photos and it becomes quite clear that even if you get "passive" closure when the adjacent structures are static, as soon as the patient is in function you will get movement of your tissue. Add to that a lack of ketatinized tissue AND two low frenum attachments, you now have a recipe for failure. As CRS stated, soft tissue deficits need to be addressed first. In a case like this, a broad based free gingival graft with an apically positioned flap and frenectomy will give you a tissue envelope that will be more ideal for a secondary bone graft procedure. RJM

That's a through and through defect Buccal to Palatal. What you are attempting is an onlay bone graft which is impossible between teeth. Tension free flap or not it just won't work the way you are doing it. The only way you could possibly do this is Ti mesh with autogenous particulate graft and infuse, as well as a tensionless flap and increased KG.

On the pan the roots of 9 and 10 appear to be present and the soft tissue looks much better, did you extract and graft same day? What was the buccal bone like after the extractions?

In the pano I see sinus augmentation, Therefore you are able to place implants. Place a tissue graft to increase the thickness of the tissue and attachned gingiva, and make a prosthesis that has pink ceramic to simulate the gum tissue. Check the smile line and discuss with the patient. Hope that helps

If you are talking about the anteriors, and if you are able to place implants I would do the same thing that I replied for posteriors

Speaking as a periodontist, based on the initial presentation photo, the proposed treatment will not work. Take a look at the mesial of the maxillary left canine - that defect cannot be grafted (hard or soft tissue)! Any attempts at grafting that, will fail! Knowing that, here is my thought process if you are still considering implants with fixed restorations (using FDI tooth numbering): - Eliminate over contouring on the crown of tooth 27. - Fabricate maxillary immediate partial denture. - Extract teeth 11, 12, 13, 23, insert partial, and allow 2-3 months for soft tissue closure. - Implant placement in sites 13, 11, 23 with hard and soft tissue grafting in the previously failed area to bulk the site up for pontic site development. Remember the previously failed site will have a lot of scar tissue - take this into account when closing the site, you will need a lot of release. - Implant placement as you desire in the posterior. - Temporary restoration in the anterior for emergence site development. - Final restorations. Best of luck, Tom

Looks like a composite defect as it has been identified already. hard tissue and soft tissue deficiency seen , I am not sure what your long term plan for remaining max. anteriors ? Presuming it is just replacement of UL12 I would have done it differently. Implant placement UL12 region making use of existing bone. Tent the Ti reinforced membrane and use particulate graft (Allo/Xeno and HA Combo) Wait three months remove membrane and restore.Note do not use Biogide-useless. In the current situation Could use subperiosteal tunneling technique to gain soft tissue width post augmentation. If you are a general dentist do not attempt this . Seek help of a local oral surgeon who can happily do it for you. If you are lucky you may even gain some soft tissue cover for UL3. As the perio guys say it may be difficult.

I have been referred a number of these Allograft block failure cases and they end up being a lot worse after the failure . You must return the host to its original state , this is regeneration , these blocks never allow that to happen. All the reasons above for the issues are well stated . These cases are difficult and now it is a whole lot more difficult , in fact once here it is going to take a number of costly , time consuming procedures to get some result let alone an ideal solution. Best to avoid form the start. Peter

Reason for failure already discussed. At the end of the day its inability to neo-vascularise the graft leading to necrosis and resorption. I am interested to know what your Plan-B is from keeping patient in mind. Soft tissue graft to improve soft tissue profile and consider bridge? (dont know whats the clinical viability of UL3 as no recent PA's provided) Staged approach when bridge fail consider full arch?

There are many reasons why this graft failed. I have done many of the Rocky Mountain block graft with high success rates. I have histology demonstrating from 70 to 95 % new bone formation after 4 month. In my opinion the best technic is to do a tunnel grafting with an incision distant to the graft. Adding BioOss and BioGlide over the graft pevents the periosteum to provide blood supply to the graft and worst than that, it prevents proper healing by first intention of the soft tissue. I don't understand what was the purpose of adding BioOss over the graft. Another important factor in obtaining good succes with the RMTB blocks or with any other block grafts is to have proper adaptation of the graft to the vital bone and to to proper RAP (decortication) Raul

Raul, You are spot on about the BioOss preventing the blood flow from the periosteum.

Agreed Raul and Richard , as an old Rocky user from the 90s your comments seem to be relevant . Not sure where the ideology of using multiple layers of materials comes from but keep it simple helps the body help itself . Peter

I have read and appreciated all of the previous comments and understand how you are looking for an acceptable restorative solution for your patient. I don't think I can add anything that hasn't already been said that would help with the immediate problem, but wanted to give you some perspective on cases like this. Onlay veneer grafts (block grafts) are a wonderful tool to have at your disposal, but are very technique sensitive. IF the graft becomes exposed you will lose it. Autogenous block grafts have a high success rate and allogenic bone blocks do not (despite what the companies tell you). Ultimately if you do not have a lot of experience doing block grafts you shouldn't start on your patients. There is a steep learning curve. I would have referred your patient to a specialist who had experience in this procedure. Ultimately you are held to the same standard of care that a specialist would be.

Dear Dr. M. I respectfully disagree with your assessment of Autogenous vs Allogeneic block grafts. Once you harvest an autogenous block it loses its vascularity. I have extensive experience with both Autogenous and Allogeneic block grafts, I have histology demonstrating from 70 to 95 % new bone after 4 month. My experience has been with autogenous hip graft, autogenous cranial bone, autogenous fibula as well as tibia grafts. Personally I have obtained as good or better results with the Rocky Mountain Bone grafts. The only other method to obtain a better or different success rate is with vascularized Fibula grafts or with vascularized Scapula grafts. Both of this grafting techniques are beyond the scope of what we are discussing. And yes I have also done many block bone graftings with Ramus and Symphisis autogenous bone. As a matter of fact on Monday I am going to be doing and only a mandibular onlay bone graft on the wife of an Oral & Maxillofacial surgeon friend of mine. He also has vast grafting experience, with autogenous and allogeneic, grafting technics and wouldn’t agree with me doing the graft with allogeneic block if he wasn’t fully confident on the choice of the grafting material.

Another option for this case is the "vital segmented osteotomy" perfected by O Hilt Tatum, DMD. It maintains the blood supply. I'm not saying it's easy to perform but it's doable.

i am surprised that there is no mention of PRF. We have had good success with using autogenous bone and synthograft mixed with PRF...covered with a titanium mesh. We don't not placed the implants until 4-6 months later. The anterior region can be tricky because the thin buccal plate has a compromised blood supply. The PRF seems to increase blood supply and vascularization in this sometimes difficult area. I hope this helps!