Grafting into a large bone defect: recommendations?

These images do not give a clear idea on the extent/volume of bone/tissue loss. If these are CBCT reformats, it would be more helpful to share true tangential cross sections through the defect sites, and possibly a clinical picture.

Need more info, the images you've attached are not informative. You've highlighted some important facts to help guide your decision on whether to do this case: Young female Esthetic zone Large boney defect- Can you refer to someone with a lot of experience and shadow the surgeries to learn? There will likely be a soft tissue deficit as well, and a potentially though and through defect of the alveolus. More then one grafting surgery may be required along with implant placement. I

Note: Some new photos have been uploaded for this case.

This is a young patient with an avulsion injury refer it to an oral surgeon who knows how to repair this prior to placing implants in a compromised fashion. Patients do not dictate treatment regarding how a defect is repaired . This is heading down the wrong path. The best treatment for this case us referral to an experienced oral surgeon, sorry.

Sorry to be always banging on about this, but what has the CBCT told you that you could not have gleaned from a history, clinical examination and plain x-rays? Pretty clearly this young woman has sustained a dentoalveolar injury with loss of 2 upper left incisors and the associated buccal cortical plate. Taking a CBCT to confirm this defect is akin to taking 3D reconstructive x-rays of the hand to prove someone has amputated a finger. Equally clearly it will not be possible to place implants without preliminary reconstruction of the bony defect with a corticocancellous autogenous graft.

John T- I couldn't disagree with you more. I simply don't have the time nor space here to explain why scanning a patient like this is crucial. I'm sure that anyone placing and restoring implants would agree with me. With this case not only would I scan, But I would also have a 3D medical model made so I could better explain this to patient and to make my grafting surgery easier. Total cost about 300$, And worth every penny.

Actually I think you are both right. Clinical exam first, CBCT or CT scan with a scan appliance with the tooth positions in place specond.Or the three dimensional model is a great way to go and scan again after grafting for tooth position. The discussion of how the reconstruction is planned may be beyond the scope of this blog. At least this poster is asking instead of attempting this. What is key is management of the soft tissue flaps a clinical photo would be great.

John T: please explain how you are going to get primary stability in this site and place an implant without prior site preparation. Thanks. Also if you re-read the original post you will see that the pt does not want any autogenous graft.

Have you asked your patient if she wants a bridge ? Not everything is implants , just a thought , thanks for sharing

"Pt does not want autogenous bone grafts". I don't want to pay taxes either. Patient driven treatment plans rarely work. If things are as bad as they look she may be in an impossible situation. She could spend lots of money undergo lots of surgeries and still not be able to have an implant. My suggestion, and I am ready to be flamed, is to suggest she recieve a bridge. If its onlay retained or full coverage it doesn't matter. Or removable. Do whatever it is that you feel is in this patients best inteest long term.

In your ragiographic evaluation, if there is severe height loss or little to no medullary bone in the area, I recommend referring this to someone who has done countless numbers of these or to someone you do not like.

I had two different opinion to treat this case. From a perio side. He wants to do it with reinforced membrane and tenting screw and allograft. From the oral surgery side . The other doc wants to do mix of allo auto bone screws and resorbable membrane. The client can not go for a auto block from other site. But if that was the only way . I have to let go. For me I thought about obtaining 2 surgeries on different intervels . To obtain bulkness and hight. She didn't mind that as long it's for the same area. Thank you all

This defect would be nicely treated with a ringbone allograft, with immediate placement.

If you are looking at xenografts then why not consider the patient-specific milled blocks that are now available with pre-drilled holes for your implants? Osstem do them so do a few others (Swallow dental in the UK are rolling out a product)

This is a young patient with a recent injury which needs to be reconstructed in experienced hands then the dentist should get involved not the other way around. The patient does not make the decisions but the surgeon guides her. When referring I would advise someone who is trained to handle any significant complications and knows the higher level of care. Many of the techniques which are suggested are not appropriate in my opinion. The biology and bone base need to be restored from the trauma this is a different etiology,the blood supply, soft tissue and bone need to be reconstructed by someone who has this background and training. Get this to the appropriate specialist for the clinical situation. I give you permission to let go, refer and do the appropriate thing vs having posters tell you what you want to hear based on what they don't know. Go with the trauma trained oral surgeon, then you will be able to do a beautiful dental restoration on a healthy reconstructed regenerated base on a young patient who deserves a great result. I hope the dentists understand this and put any feelings aside it is not about that.

I have successfully treated trams alveolar defects in non esthetic zones. I would take the advice of the oral surgeons. Refer to a well experienced OMS that you trust. Implant site development is very important. The patient may desire certain things, however they have to be realistic.

This is a routine case with synthetic particulates and placement at the same time... Load at 10 weeks .. Peter

Sorry Peter (Fairbairn), for once I disagree with you. The sagittal x-ray shows complete loss of both the labial cortical plate and the interdental bone in the UL1,2 region. Only the palatal cortical plate is left. This is maintaining ridge height but not ridge width. This would, of course, be visible on simple clinical examination without the need for tomographic x-rays. As I said above (May 11) taking a CBCT to prove the point is akin to x-raying someone's hand in order to count their fingers! There simply isn't enough bone to place a 3.5 - 4.5 mm diameter implant with any prospect of stability. The ridge needs preliminary augmentation. I know you're a fan of synthetic materials but in my opinion this divot is so large that an autogenous graft has a much greater chance of success. Once the graft has consolidated the implants can be placed at a second stage, at the same time as removal of the bone screws. Incidentally, the time to take a CBCT is after graft placement, as part of the implant placement planning - although simple study models and a trial wax-up would be more useful. My main concern in these high velocity avulsion cases is that the patient may have also lost her labial attached gingiva as well as bone and teeth. This will have healed by secondary intention and the soft tissues on the labial surface of the ridge tend to be very scarred and adherent. This makes it difficult to raise a decent flap and advance it over the graft at the first stage, and makes it difficult to create a keratinised gingival cuff at the second stage.

Hi John , I agree it sounds like a rash statement I made but as the palatal plate is intact and which good host bone on the adjacent teeth with no severe perio issues it is very repairable as long as soft tissue is viable . I have many cases like this and yes a failure or two ( both where the palatal late was compromised as well ) . There is enough bone apically for primary stability although it is not necessary with the newer materials ( have published a case (of many ) with no primary stability showing 78 ISQ at 10 weeks ).Had another case with video Posted on the Osstell site with video at grafting and raising a full flap ( only way to truly assess the bone ) to see the regenerated bone . Here primary stability was low , 28 ISQ and at 10 weeks was 76 .. Yes possibly an autogenous block would be best but is too risky now here in the UK as long term remodelling and loss of the graft block over time may lead to an unhappy patient and then the legal issues of the donor site may further complicate matters . Just writing up a really nice 20 rabbit study on these and more traditional materials , with MIcro CT and histology which backs up all the logical biology . As Long as we have regenerated the site with true host bone the gingiva will correct itself with time .... At 4 months it may have been better to graft earlier and yes thinner Implants 3.5 - 4.0 best Obviously all just conjecture without seeing the site . Hope you are well Kind Regards Peter

I have seen more research recently stating to use narrower and shorter implants (around 7mm) and bypass grafting and that success rates euing these implants is similar to loner and wider implants plus bypass grafting. Does anyone have referrences on implant length/ diameter on sucess rates and also if you have information on whether membarne/ particulate grafting at time of implant placement is as sucessful as cases where grafting was not used? Thanks

Consider a horizontal Khoury block (the shell technique).