First lower molar extracted one year ago, severe atrophy: suggestions?

CRS, thank you for the input. The tooth was lost due to profound caries. I did bone sounding it revealed 3 mm wide ridge 5 mm down vertically .I didn't get it , why should I graft the ridge for the bridge? It will resort without the implant anyway. Any suggestions on the future implant specs ?

Here is the reason, the bone on the adjacent teeth and the bone under the Pontic will be replaced, easier for the patient to maintain. What I do is if I get enough for an implant then I place the implant. If Bio-OSS is used it will hang around and the ridge is preserved making it a cleansable under a Pontic.

A bridge is NOT a good option. This kid is 28 years old. He could live 70 more years. You want to destroy two perfectly healthy teeth?! Look at 18 and 20 and give me a good reason why you want to remove ALL of the enamel from them. Graft and implant or make a partial but please don't ruin good teeth.

Lighten up it is a very predictable procedure if you know how to restore the buccal plate, it's called an onlay graft. I like to restore what was lost, the best time to do this is at the original extraction. If you are more comfortable just doing a bridge then do so, my point is that if there is very little base bone you need to see how much bone develops. A second graft can be done after expanding the plate at implant placement. It is about knowing what you can accomplish with grafting. If you place a bridge over this without grafting, the Pontic needs to be modified, it works well but is difficult to explain in a blog.

Unfortunately this tooth was removed without conservation of the buccal plate. If it had the situation would be less severe even given the time frame. At this point bone will need to be created where it was removed. I would perform an onlay graft with FDMB and a mixture of Fusion bone binder. I would use a Cytoplast PFTE membrane that would not require release and advancement of the buccal mucosa. Be sure to perforate the buccal cortex with a #2 round burr in many places to establish bleeding points before placing the graft material and placing the Cytoplast membrane.

It depends on what you are comfortable with. Onlay grafts with harvested block bone are one way to go. I use particulate with space maintenance either reinforced Teflon, sonic weld or osteowrap. What will help is the fact that there are healthy adjacent teeth to scaffold off of. Every case is different, a good flap with primary closure and space maintenance is key. Grafting materials are personal choices I use growth factors and allogenic bone. Don't get me wrong I am confident with my onlay technique I am just realistic in how much the patient will heal which as an experienced surgeon I am thinking about vs boasting about. Unfortunately there seems to be a lot of boasters out there vs giving honest advice.

Thanks you are too kind, I'm an OMS and I am pursuing my ABOI to better serve my referring colleagues.

Majid, Thank you for the comment. What type, size of the proposed implant do you recommend on this case?

Classical Titanium Implant would be the best of choice. The type depends on where you live, as i am here in France so we must be having different companies. Regarding to the size, bone volume strongly determines diameter and size of the implant. As you are going for guided bone generation with membrane in the same seance then you do not to be worried a lot. 4.2 to 5.0 would be the size of choice which may resist the opposite occlusal forces. The implant will succeed 94 to 99% at the condition of good oral hygiene and non smoker patient.

This will work if you can get primary stability possibly by expanding the alveolus, the type of implant does not fix it, restoring the bone does. I would still stage it. The original extraction was probably not grafted, the comment on localized perio is interesting. If this patient did not heal well initially why would a riskier procedure work? If you place the implant at the same time and it fails you'll be replacing it probably for free. That's what I would do see what you get then place the implant.

When flapped this will not have any buccal wall to get primary retention to place the implant at time of grafting and will fail. this unfortunately needs to be staged to get success

Hi, I will try to show you a case with with guided bone regeneration with implant insertion in the same seance. Give me some time to learn a little how to post photos on this website. You have also a new technology which is called Basal Implantation. Basal implantation is a revolutionary technique developed in Switzerland jointly with the European Community of Implantologists. It allows restoring the teeth (from 3 teeth) without the bone augmentation. This method uses the special design of implants, custom-fitted to the patient. The implants are installed in a single procedure with the abutment (it is a part of structural design of basal implant upon which the denture is installed). Depending on the condition and the bone size, the implants are selected that have a special attachment and structure for better fixation in the tissue. In addition, in areas of strong atrophy the additional implants can be placed at an angle where the bone allows ensuring the maximum stability of a dental structure that can withstand high loads and not get loose. On the third day after the implantation, the metal- plastic denture is installed. This is the final part of the dental structure, which allows the patient to chew using the new teeth in a week. The essence of the basal implantation method is to provide for the patients the ability to chew, so that in the process of chewing will stimulate the natural regeneration of bone tissue. Due to this technology, there has been achieved an aesthetic effect right after the implantation, and also it reduced the time of implantation in the dozens of times. Basal implantation advantages: It does not require the bone augmentation in most cases, the basal implants can be installed at a certain angle, so they can be securely locked in any size of bone tissue. It provides an individual approach, to restore the teeth the dentist-implantologist selects different dental structure in length, shape and design, so the implantologist can evenly divide the load between the implants and reduce the time of their engraftment. It favors the fast teeth recovery, the basal implants allow to fix the denture within 3-7 days after the implantation, and therefore, the entire treatment process takes about a week. It favors the bone tissue restoration, so due to immediate chewing load the implants allow restoring the blood circulation in the bone and improving the regeneration process. It causes the minimum number of contraindications, and there are only a small number of the patients who are refused to install the basal implants for the medical reasons. In addition, in many cases, the basal implantation is available, even if there were discovered some contraindications for the classical method. It provides the resistance to infections, the implants are installed in bicortical layers of the bone that are deep, so the probability of penetration of bacteria and germs in it is minimal, and thus it reduces the risk of rejection of the implant. It gives guaranteed result, the fast recovery of bone tissue provides survival of the implants within a short period of time, as well as an excellent aesthetic and functional results, and a full recovery of the teeth in a couple of months after the surgery. In order to prevent the atrophy of bone tissue, the patient must immediately be concerned with the issue of dental prosthetics after the tooth removal. However, the patient should give the dental implantation preference, as it is the most natural way to restore the missing teeth.

In USA basal implants do not have FDA approval so cant be sold here. Even with basal implants one needs bone to place it into. placing a basal implant at this site would have the entire buccal half of the implant sitting outside the current bone and making the cuts into the remaining bone would weaken the current lingual plate which is the only bone present. This case as I said before needs to be managed ina staged approach with 1st phase being grafting then months later phase 2 implant placement

Please provide literature (peer reviewed) that supports the statements you are making about basal implants. The little literature available I have seen is all from the company who makes the implant or the dentist who owns the company and speaks for them

Can we post photos here?

Yes, simply click on the "Post a Case" link located either at the menu at top of the page, or at the left side of the title of every post.

"The tooth was lost due to profound caries." 

Gregori says- "the other option if the patient doesnt want to wait that long, or undergo the grafting or the financial aspect is too high is a traditional bridge on the adjacent teeth." This guy lost a tooth to caries at 27 years old. He's not going to be able to keep a bridge clean and then he'll have 3 teeth missing. Fixed bridgework is as archaic as bleeding people to reduce bad blood. Implant or leave it as it is. Doesn't anyone remember, "First do no harm!" ? Don't cut healthy teeth.

Gregori, Let's imagine that your mesh technique worked fine and you will get the bone volume you satisfied with. What size of the implant would you then place to replace this lower first molar for the best long term prognosis? I do not know details about extraction, this patient came as is, I have not done that extraction. There is no any sign of inflammation or chronic infection around the entire quadrant .

I think based on what seems to be available mesial distally your probably looking at a 4mm diam implant, placing a wider one may be a big challenge creating a wide enough ridge to house it.

Why would you place two 3mm implants at a molar site, a site that gets high occlusal loads? 3mm implants have thinner walls and are more prone to crestal fracture when over loaded. Why subject apatient who is 28 and has hopefully 60 years ahead of them to placing implants that are too narrow to last their lifetime?

Hello Greg, why over load the implants? Think about the area (square mm) that will have contact with the bone. An implant of 6x11= 66 sq mm Two implants of 3x11=33 x 2 = 66 sq mm of contact area Titanium-Bone. Two implants joined by one crown, good oclusal distribution. A good designed crown easy to clean, no periimplantitis. Titanium grade 5, stronger than 4 or 3, because of thin walls. The number of osteoblasts and osteocytes present in an onlay graft in posterior mandible mmm... But as I wrote, first the CT Scan, maybe a 3, 3.2, 3.7 depending on the Company.

We have to look at the individual implants and a 3mm wide implant will have much thinner walls at the connector then an implant that is 4mm 5mm or greater and as we know under occlusal loading the molars take greater loads then premolars or anteriors so higher chance of implant fracture in a 3mm implant

What is the Russian AAA technique?

Dr. Martinez, Please wait until tomorrow I will demonstrate the results of Russian AAA surgical technique to everyone .

CRS, Thank you for the compliment. The reason I posted this case was to confirm that by this date, there is no other reliable surgical approach to treat this cases with one surgical procedure. I posted only "before" images to stimulate the discussion. In my previous comments to other Drs posts I tried to bring attention to alternative treatment option such as Russian AAA technique and I posted links to my web site but osseonews removed those, including links to this case . I also want to bring to your attention that I do not say on my web site that my implants "never fail " . It is said "never fracture". I am happy to hear your desire to be "lighten up" with Russian AAA technique. I have plans to set up hands on course for that .

Bravo Dr. Manuel! So far only you were able to see the advantage where others saw the opposite! "The hole you see is actually a benefit in that it becomes a three walled defect.." But your choice of Bicon can spoil the whole project for the following reasons. 1. Since its not threaded implant system, Bicon has lack of initial stability sooo needed for this case. 2.That's why you have no choice but to use 4 mm diameter to replace the MOLAR! For those who is unaware , it had been realized that 6+mm diameter implants is the best choice to replace posterior teeth like this first molar. 3. Bicon has disadvantage of creating black triangles since it is hard to parallel the implant axis with the contacts of adjacent teeth. 4. Also Bicon has loosening problems in grinders . This case was treated with 7mm diameter implant 5.7 mm platform. Opss, I completely forgot to mention, Russian AAA technique does not require preoperative CT scan in 90% of the cases. Russian AAA is a versatile technique which could be used in situations where is no "benefits of three-wall defect" - on severely atrophic ridges to replace multiple missing teeth with dental implants in ONE surgery!

Manuel, First of all, I never said "impossible" replying to your comment. Secondly, you are right, I never used Bicon. It is a good system but it has its limits. it ,simply, does not fly with Russian AAA and and it has a number of serious flaws for reasons I've already posted. It happened, that Bicon's headquarter is in Boston where I am. I took several courses there, but decided not to go with it. I can continue the list of Bicon system disadvantages, but for the sake of this case, I've said enough. Thirdly, and finally, please do not take it offensive,because " Discussio mater veritas est!" . We are in the free country and I hope, in free world. I do not see why should I restrict my opinions? I am open minded clinician and I never stuck to a single technique or an implant system. Just the last year alone, I'd purchased two implant systems and this year, so far, one. The world is changing , so Dental Implantology is changing too, dear colleague. Those, who are stuck in the past , will eventually loose it.....

This is starting to sound like an infomercial you already have treated this case and are promoting your technique. No one like to be mislead. Myself included.

I have an even better technique it is the Triple Salchow Technique. It works every time unless there is a Russian judge! ;)

Thanks, you are very kind. Are you splitting the ridge and placing the graft in between?

A couple of questions what is RAP and do you have more information on the tunnel technique . With a lingual/crestal incision and tunnel to the apex do you go past the attached mucosa to get primary closure? How do you stabilize the graft? I see your integrity in your posts and appreciate the information. I use a combination of expansion, prgf, particulate and a fixed membrane to maintain space. I am always looking for simpler techniques. By the way I'm in Chicago.

Dear Raul with a tunnel technique do you go past the attached mucosa for release and primary closure? How do you stabilize the graft without bone screws and what does RAP stand for? As you see I'm intrigued . Any article or photos of technique? Always like to learn new things Thanks.

Well Russia does have issues with drinking too much vodka so.............