9 Responses to “ This is how the ridge begins ”

• Amar Katranji November 21st, 2008

  
  

  In my opinion, this is a case that needs advanced grafting prior to implants. I know she doesn’t want it but you’re talking about the most esthetic region in the mouth. Short cuts here can mean problems down the line. If she doesn’t want autogenous bone grafting then consider allograft block, BMP, or GBR with a proven particulate graft. Another consideration is the incisive canal may need to be grafted since it looks like it’s expanding and can deter your placement.

  Keep us posted on your treatment plan and outcome. Good luck.

• Dr SDJ November 22nd, 2008

  
  

  Dr Amar thanks for your response! It’s for the first time I am hearinng about incisive canal grafting. Could I get more information about the same?

  In my original question I asked about sprinkling particulate grafts like DFDBA, BIOOSS, Beta TCP etc like garnishing on the labial cortical plate, does such an approach work?

  I once attended a lecture where the speaker said that such an approach doesn’t actually work.I heard that good quality bone does not form. Yet I see a lot of pictures here and there on internet and dental magazines where bone is sprinkled on the labial cortical plate & covered with a collagen membrane before suturing flaps. I am confused.

  I am a beginner and I would earnestly solicit your advice

• Dr SDJ November 22nd, 2008

  
  

  How about ridge splits, D expanders?

• Leopoldo Bozzi, MD Italy November 23rd, 2008

  
  

  Dr SDJ,
  it would help if there were some axial reconstructions of the edentulous zone, but as a general rule, you may place two 3,3mm implants in the lateral incisor zone, straight from a slight palatal approach with a little or no expansion of the coronal part of the crestal bone, then grafting with Bio-Oss or any other similarly very slow resorbable biomaterial you prefer the eventually buccal exposed implant shoulder. Don’t omit to overcontour the graft on the vestibular bone to support soft tissues: this cannot prevent buccal bone resorption after the surgery, but may prevent the appearance of a dark shadowed soft tissue over the implant.
  Plan to overcorrect the gingival vertical dimension with a connective tissue graft, and make a 4U bridge, shaping the central incisor site with a ovate pontic.
  Hope this may help.

• james November 23rd, 2008

  
  

  I THINK U CAN VERY WELL PLACE 4.2MM BY DOING OSTEOPLASTY. U CAN SEE THE THICKNESS OF GINGIVA ALSO, VERY GOOD.
  GO AHEAD DONT WORRY

• Dr SDJ November 24th, 2008

  
  

  Thank you Dr Bozzi and Dr James!

• Amar Katranji November 24th, 2008

  
  

  Dr. SDJ,
  Particulate grafting works if you have adequate blood supply to your graft. In my experience, Vertical Augmentation with Particulate may require biologic modifiers like PDGF, PRP, BMP or PRGF and autogenous bone is best. for horizontal grafting, particulate works well as long as you maintain space and have adequate blood supply. Primary closure is necessary to ensure success. Again, autogenous is best.

  The incisive canal enlarges with edentulism over time and can become a problem during implant insertion. grafting it is straightforward (reem and fill) but I suggest working with an experienced surgeon before doing so.

  It may be a good idea to discuss this case with an experienced surgeon anyway because of the esthetic demand in this area and I personally disagree with some of the comments posted. There are many ways to complete this case and focusing on one treatment plan is the way to go.

• JW December 10th, 2008

  
  

  This view show advanced resorption. If you are a beginner, do not try this case. Particulate may work, but the patient is better off with autogenous. Either a onlay graft of particulate and titanium or blocks. The amount of resorption is greater than 2/3rds of the alveolar width. The ridge is too thin to split, you are just going to end up out-fracturing the buccal plate. To get enough bone you are going to have to go to the chin, hip or tibia. This will NOT be a particularly esthetic result either. These cases don’t come along that often, so if you are a beginner, or even a relatively experienced surgeon, you should think twice, if not 3 times.

• Dr SDJ December 11th, 2008

  
  

  By the way there is one more scan at a different level in this case that I have posted did most of you see it?

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