Treatment plan for the case where there is limited mesiodistal space and considerable bone loss?

Whatever you decide graft the site to protect the adjacent natural roots and repair the defect. I would use a Teflon membrane and prgf, staging it since there appears to be no baccal or lingual plate. I 'm cautious about trying to place an implant at the same time since you have no cortical plates. That a way if you get any bone at all then place the implant and add a bit more bone. How did this defect occur and why wasn't it grafted at extraction? No shame with a resin bonded or fixed bridge either, this is a tough situation .

This is a tough case. A Maryland Bridge with cervical pink porcelain may be the best option. Perhaps grafting as CRS mentioned and later placing a narrow body implant may work. I have grafted and implanted these in the past. Impladent Ltd. make a root form that does do well in these situations. Just do not use the abutment. Simply prep one site of the post which the abutment attaches and you are good to go. The gingival or papilla issues are the most critical. This is all after successful gone grafting!

thanks for all of your suggestions..

I wonder about the clinical situation of those two adjacent teeth is there any mobility and to what grade. are they stable with good prolong prognosis or what, if thy are not may be the extraction and changing the all treatment plan will give a prolong good prognosis, because i am worry about the success of very high augmentation also i am worry about the stability of Maryland Bridge even if it used for a transient period.

One can always help the prognosis with well executed grafting I like to graft extraction sites even when a bridge is planned, no divot under the Pontic better hygiene and good bone for the abutment teeth. Mandibular incisors are tricky not much room for error and this case is a grafting challenge. I perform it at extraction for best results and will select grafting materials based on morphology and clinical parameters. I re- evaluate and modify the treatment plan based on the grafting results. I see it as a defect which needs to be addressed and stress this to the patient no matter what type of restorative treatment will be utilized. Sometimes you get lucky with a case like this and one caveat check and adjust the occlusion,why was this tooth lost next to healthy, non perio involved teeth ?

How "recent" was the extraction? A week or so? The bone levels on the adjacent teeth look good and there is some trabeculation. I would hold back from doing anything for 10 - 12 weeks then take a new PA to see how much bony infill has occurred then you may find that a more straight forward grafting procedure may be required. I don't think it will be a bad as you think

I agree with CRS that these sites in an esthetic area should always be grafted no matter what the final prosthetic treatment plan will be. Some times we need to wait until all has healed and then decide on the best course of action. Remember, what ensures successful healing of any site and good bone fill is the blood supply. The blood supply comes from adjacent bone. If an implant were to be placed at the same time as grafting the blood supply to the buccal and lingual plates would be minimal. There would be high risk of dehiscence here.

Excellent thought to place implant and crown. While the periapical xray seems to show a paucity of bone at the edentulous site, it would benefit the patient for you to get a CBCT image to appropriately evaluate the buccolingual dimension and true alveolar height. I am most successful at that site grafting autogenous corticocancellous bone. Not a good area in which to place implant at same time as graft.

This is a simple small diameter implant case. A 2.0mm, or if buccal lingual bone allows up to a 3.0mm mini type implant up to 18mm in length could work very well here. Clean the adjacent root surfaces for grafting and place a particuate graft at the time of implant placement. Allow up 4 - 12 weeks of healing before loading. If placement torque is over 40 the implant could perhaps be loaded sooner or even at the time of placement, but it is best to wait. If too much placement torque is used when attempting to place the narrow implant it could separate and could be difficult to remove. Follow the manufactures recomendations. If you send the study casts and x-rays to Tod Shakin at F.I.R.S.T. LAB they will do a free consult and help plan the case. I have been using this type of implant for replacing maxillary lateral incisors and lower central and lateral incisors for well over 10 years. It works very well.

If you were planning a bridge, would you use something like anorganic bovine bone covered by a membrane which would persist? If you were planning an implant, would you need an autogenous graft here?

I see no reason for augmentation at all in this case. BCS 3, 5 10 mm and immediate loading with provisory crown. Immediate benefit for patient and dentist.

I have a similar case of missing lower anterior incisor and did bone grafting for it. At the beginning it appeared very good and it was followed for several months for healng. The V shape bony defect regenerated but eventually it resorbed again. Patient could not maintain very good oral hygiene. I am wondering what is the success rate for grafting a deep V shape bony defect with buccal and lingual wall missing and adjacent bone slightly lower than this posted case.

At this point ( post extraction ), do CBCTto evaluate the bone. If a graft is indicated, do an onlay graft using a particulate bone or DFDBM ( collagen membrane with both ). Flap design is critical -- don't split the papillae or start center ridge. Your horizontal incision should be to the lingual, extend to the buccal leaving the papilla intact and extend releasing onto the facial. As you reflect the flap you willbe able to visualize the buccal bone -- remove all soft tissue, get " bleeding " bone, place your graft, then membrane and finally, suture. TIP: If you can carefully undermine the lingual tissue, you can suture your membrane in place and then fold and " tuck " it under the reflected flap. Sounds complicated -- It would have been easier to extract the tooth atraumatically, place a 2.1mm 3M MDI immediately, place bone around the implant, place GelFoam over the grafted area ( alongside the implant ) and place the healing cap, make a temp, etc. TIP: You will need at least a 15mm implant, and will probably need a drill extender.

Thankyou for your reply Dr Ingel. The patient already had the lower incisor tooth extracted before by someone. The patient has deep V bony defect. Although suggested bridge initially, patient insisted that he did not want teeth cut. Anyway, Mineross and then BioOss were used and then collagen membrane in the bone grafting. Done in similar fashion as you mentioned. The lingual wall was regenerated but for some reasons, the buccal wall resorbed. CBCT indicated that the apical bone is quite narrow and 15mm might pose problem since originally 3.0 diameterx12 was planned. Don't want to perforate lingually in the apical area. I will check with 2.1mm MDI. what is the success rate for bone grafting in deep V bone defect with buccal and lingual missing? Patient does have interproximal bone like in the posted case but missing V shaped buccal and lingual walls. Thanks.