Graft and Implant in One Step or Graft and Wait?

You could do envelope technique with flapless: 1- could use membrane and particulate graft (DFDBA) 2- Or just envelope with use of DBM sponge strip from Surgical esthetics- I don't have share with them. I just like the product for some difficult cases. This could also be use for thin buccal plate at the implant placement surgery. Good luck

Check the Ethoss website. It should give you a few ideas. The advantage is that you do not need to place a membrane. In this case I would consider a tunnel graft initially (which is minimally traumatic) to gain bone width (and can be done while bridge is still in place). Then position about a 3.2 to 3.5 wide implant leaving enough palatal bone and if the 3D radiograph (2-3 months after initial grafting) shows more buccal bone is required, then overlay the implant with more Ethoss on the buccal aspect at the time of placement. I am sure there will be many other suggestions. I would recommend that whatever you do, become familiar with whatever technique you want to use (which would be whatever you are most comfortable doing).

The ridge is wide enough to ridge split it to allow placement at that same surgery. Will need flat blade osteotomes to start (perhaps a piezo to start) then once wide enough you go to round osteotomes. I like the VGO oteotomes for this from Zepf sold through H&H (see article in the Jan issue of Dentistry Today https://dentistrytoday.com/articles/10641) I would then place the implant put a cover screw in and let it heal for 4-6 months before exposing to restore.

A viable option would be to find out why the bridge debonds and find a remedy for it, as the anchor teeth are already prepared.

A couple of options. 1. Single component mini implant. 2. I like the option mentioned before of a ridge split. This can be really a traumatic with a magnetic mallet. Start with a blade then switch to the round osteotimes. There is no heat and the patients report no discomfort during or after surgery.

This is getting to be an interesting set of opinions. This situation is complex, let’s start with what is evident. The tooth was lost, the bone and the soft tissues in the region have collapsed down during the healing process. The aim now has to be to re-build the region and to have an implant to support a restoration. That means the bone and soft tissues in the region have to be augmented. Just parking an implant there will not be sufficient. As a precursor to the re-building process the region needs to be de-granulated and rid of any residual infection. Usually that is most easily accomplished by an open flap approach. Then comes the degranulation, then bone penetration with a small round bur to facilitate angiogenesis to the bone surface and to facilitate the flow of stem cells into the bone graft that will be placed there. At this time, an implant can be placed. Much of it on the labial and approximal surfaces will be exposed. We can cover that with a bone graft. We use a slow resorbing xenograft material with 10% collagen. This provides a gel mix which promotes angiogenesis while resisting infiltration and contamination during the early healing phase. We over-build the graft because it always wants to shrink down during the healing process. In very complex situations we use a liquid containing PDGF in the bone mix. On the top of the graft we place a loose collagen “Mat” which contains the bone graft and the implant and is then terminated under the palatal gingival margin. This helps thicken the gingival complex and enhances angiogenesis. Finally we need to cover the region with the gingival flap. That will not be possible if the flap is not first “freed-up” and allowed to advance. The slow resorbing bone graft establishes the matrix for bone regeneration in the region and allows it time to re-establish a durable, solid bone complex. We have not found this to be the case with many of the socket regeneration materials that are advocated. These may help an intact socket to regenerate, but the situation here is one where the labial aspects of the socket have long gone. With this amount of loss of complex, a more structured approach is needed to recover the situation.

This is not an easy situation to treat, it requires a very experienced team to get a good result.....refer this case to people who work with these situations on a regular basis, and attend the surgical procedures, so you will be equipped to handle these cases in the future.

Curious why a fix fix bridge is debonding so regularly. However if gap replacement of implants is necessary - One miracle at a time - Option for me would be tunnel graft, allow healing and then go in (papilla preserving flap and placement with further graft. Preference would be Peters Ethoss (or any BTCP and CS synthetic) as within bony cavity and will allow regeneration. If your looking to bulk out, use NovaBone so that it doesn't remodel works well but trickier to predict. Also if your not sure get a mentor or refer, last thing you want is to do surgery and patient loose confidence and make later surgery harder.