Grafting Options for a Palatal bony defect of Maxillary Molar site?

Interesting case. Do you have more iformation related to the loss of the tooth, such as when it was removed and if there was infection at the time, an X-ray of the tooth before removal would be helpful if available. One of the interesting anatomical challanges is the shallow palatal vault, which by definition restricts the hieght of the palatal wall.This relates to the predictability of the graft you are contemplating.If the tooth is very recently removed I would wait for some tissue to develop so you can get primary closure on what will essetially be a ridge maitentance graft. Primary flap closure will increase the predicability of what is actually a very challanging graft. You connot expect your graft to go any higher that a line joining the palate to the buccal plate and this may not be enough to place an implant without sinus grafting.I suspect you may still require a sinus graft given that the root af the tooth removed appears to have been within the sinus space. Measurements of your CT would be helpful in this regard. Titanium mesh is very technique sensitive for new operators. I would certainly not make this my first titanium mesh case if you have minimal experienc in this regard, forgive me if you do have a lot of experience with Ti mesh. The grafting must be executed flawlessly and the patient compliant as the buccal plate although lookg good now could face devastation if the case has complications. I am sure you will get many comments and excellent opiniions on this case Rob W

Look into sonic weld by KLS Martin, perfect for this case

Bone from exactech, try bioxclude membrane 2 layered. Collatape helping hand for primary closure ? And u need to know how to get a primary closure ;-)

How about a bridge? I know it's a side issue but I'm always intrigued by the 3D reconstructions that go with these CBCT scans. What does this particular reconstruction tell you?

Looks to me tooth was recently extracted and socket has not had long enough to ossify. I would wait a few more months, then reassess the bone structure available when it has cortified and clearer where the bone levels are. Either way, looks most likely an open sinus lift is required here. My 2 cents

There appears to be an oral antral communication, ie no maxillary sinus floor. This is tough to get height as soon as you raise the flap the soft tissue which is holding this together will open up to an oral antral communication. If you don't know how to manage that refer it to an OMS. I suspect when this was extracted quite a bit of trauma was caused damaging the palatial bone and creating a floor defect which was not noticed or repaired at surgery. This is what it looks like when the soft tissue granulated in. It closed with soft tissue since there was no palatal bone. May want to consider a bridge. It will be very difficult to get primary closure on the palate to use sonic weld. If it were me I would repair the sinus floor first and graft over it if I had good soft tissue to start. I would not advise a sinus lift without closing the floor, tough case to fix. With a decent base the implant can be placed to the buccal.

Quick question how long before this Scan was the extraction ? The palatal periosteum has great osteogenic value although I did hear a well known speaker say that Periosteum is not good ? Hence pig membrane needed .... Probably best to socket graft ..but no membranes the host healing will deal with it ... Also scan at the time may not show this true healing picture fully yet so timescale of events important Peter

For this case you need a printed 3d model. The most important thing to recognize is that their are other options. if there is no inflammation, no deep pocketing on the mesial of the molar, perhaps a three unit bridge is the best option. In any event, to restore this bony foundation is going to take time, money and expertise. If you think you can do it, go ahead. Just remember, treatment comes after the diagnosis and the treatment plan. Do not be in a hurry to make a mistake

The 3d Image shows osseous defects on the palatal as well as the MB area of the residual ridge. Without knowing the history I would suspect the tooth was removed due to periodontal infection. It is possible that the site was not thoroughly degranulated when the extraction was done. I would make a mid crestal incision and expose the site with minimal flap reflection. I would remove the existing granulation tissue with a #8 round burr down to bleeding bone. Place a graft an cover with a non resorbable Cytoplast PFTE membrane. Remove the sutures in 10 days and remove the membrane in 4 weeks. Wait 4 months and place the implant. My personal choice for a graft material is a misture of FDMB and Fusion bone binder. Ed

Interesting case. Need to know when tooth extracted relative to what we see today in the CT scan. Extraction sites need at least 4 months to adequately show mineralization from bony repair of socket. CT scan too dark so cannot tell if oral-antral communication. However, if small, normally periosteum on floor to sinus will grow over defect leaving at least a soft tissue floor. My approach would be to take a CT scan 4 months after the extraction. Based on the scan, if an oral antral communication, I would use collatape as my base for the bone graft for this defect. I am not that worried about building additional height. The key here is the initial incision before flapping. That incision should be mesio-distally closer to the buccal, but preserving 2 mm of buccal marginal attached gingiva for later closure. This is very important. Since you have 3 walls to the defect the 4th wall (palatal) can be created by using the collotape, double thickness, and placing it vertically on palatal side of socket and curving it onto the mesial and distal socket walls. The piece of collotape should be long enough to also drape over the occlusal of the graft. I prefer using FDDM, cortico-cancellous, and using saline and the patient's blood to create a packable mixture. I then tamp with a non -woven 2x2 gauze to allow greater bone density to the graft. Once I have overbuilt the bone on the weak palatal side, I would add a collotape membrane on the buccal side draping it over the occlusal of the graft so the whole graft is collotape covered. I would then do a buccal split thickness flap dissecting the connective tissue just over the periosteal side to release the connective tissue and muscle attachments, allowing for the relaxed flap to really close over the total collotape covered graft. It is important to release both distally and mesially at least one and 1/2 to two teeth so as to really have a loose buccal flap to draw over the buccal collotape membrane and the graft, which should also have the collotape socket membrane over it. You should now be able to do routine interrupted uturing with chromic gut sutures, or vicryl sutures, The patient must be on Peridex or non-alcohol Listerine (equally bactericidal) twice/day for 3 weeks, B.I.D. Remove sutures in 3 weeks if not dissolved (chromic will dissolve in 2-3 weeks). Vicryl must be removed. Now wait 4 months and do a new catscan to determine how much additional bone was obtained, and decide on width and length of implant. You should have enough for at least an 8-10 mm length implant. If 8 mm, use short wide type implant. If 10 mm, many implant systems will work. Hope the above helps. Dr. Howard Marshall

I like Ed's ( June 3rd ) solution, Slight change would be to use the Cytoplast membrane with a Ti support. Place it and leave it until you are ready to place the implant. Significant advantage is that is designed to be placed without primary closure so that if your suture line should open you will be safe. This is far less technique sensitive than other materials. You should get great width of bone. You may also find that you increase your height of bone. I would use a bioactive modifier in this case, PRGF- Endoret is used in our office. For an out of the box material look at Gem-21. Mix with FDDM, cortico-cancellous bone. As for sutures, I prefer the Cytoplast sutures, they have a little stretch to them and are less likely to tear the tissue if you have swelling during the initial healing phase. They are very clean and you won't have a wicking problem. Use a horizontal mattress suture as your first closure then suture the incision line with interrupted sutures. Warm salt water rinse for the first week then Peridex on a cotton swab to clean the site for the next week Take out the sutures at the week two appt.