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Fixed restoration of the upper anterior jaw

Last Updated: Jan 28, 2020

A 50-year old female patient presented for a fixed restoration of the upper anterior jaw. During the examination it was decided to stage the treatment. First, the failing central incisors would be extracted. The narrow ridge in the area of the lateral would be prepared with decortication and augmentation using Bond Apatite. Since this is the esthetic zone, the preservation of the interdental papillae is important. Due to the presence of bony walls at the extraction sites, the flap was supported by stretching without any releasing incisions. To maintain the soft tissue architecture around the sockets, and to protect the exposed Bond Apatite at the crestal portion of the socket for the next 7-10 days, a collagen plug (see Bioplug) or sponge was placed and secured with stabilizing sutures above the graft. On the other hand, a zone without supporting bony walls (of at least 2 walls), must have maximal closure. An incision line opening of up to 3mm is acceptable but not more than that.

During the healing period, the patient had a provisional fixed partial denture. Ten days post-op, the surgical healing was terrific and the papillae were preserved. Three months post-op, the bone healing and augmentation is evident, in concert with papillae preservation. The soft tissue gap in the lateral area is noted due to patient induced trauma using tooth picks. The patient is to be instructed not to use these rigid implements during the healing phase.

1 Comments on Fixed restoration of the upper anterior jaw

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Peter Hunt

1/28/2020

The challenge in a situation like this is to prevent collapse of the anterior ridge once the teeth are removed. At the outset the remaining incisor teeth had very thin labial bone covering them. This thin bone can resorb very quickly, leaving insufficient bone to house implants. To help the recovery, it is always useful to have a good covering of soft tissues. In this case, vertical incisions were taken on the distal of the canine and between the right central and lateral. It might have been simpler and safer to raise a single flap from premolar to premolar. It could have prevented the loss of soft tissues in the regions where the incisions were made. Augmenting the region with bone grafts when the teeth were removed is obviously the way to go, but where the bone plates are so thin it would be useful to augment outside as well as inside inside the sockets. Calcium sulfate/phosphate graft materials tend to dissolve during the healing period, to be replaced by natural bone growth. There are other materials which are much slower to resorb which would help. It would also be useful to thicken the soft tissues in the region and this could be provided by placing a thicker collagen graft(s) over the bone graft. This may sound more involved and complicated, but by starting with a full thickness flap from premolar to premolar it would be possible to remove the failing teeth, debride the region, perforate the labial bone, augment internally and externally and then place the membranes to protect the bone and thicken the soft tissue complex. Many operators would also consider placing implants at the same time. At this stage you should consider that raising a premolar to premolar flap and expanding the ridge with exterior bone grafts may be useful and required when placing the implants. Good luck with this case. I hope this helps. Best wishes.

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