Yet another endo-implant algorithm case...
This one was mis-managed by original doctor. This tooth should have been extracted long time ago... however, herodontics was attempted and referral doctor fixed the coronal fragment to the root using a glass-fiber post.
Now, the patient has buccal swelling and sinus-tract.
The tooth was extracted. Due to extent of the lesion i could not think of socket grafting. Obviously, this case needs augmentation in near future.
Healing was uneventful and three months after extraction soft tissue healing was deemed sufficient to start with augmentative procedures.
Today was the day of surgery.
You can see the exact shape and extend of this huge 3D defect. For me, this kind of defect is not amenable to GBR procedure. So, what options do we have now?
- 3D reconstruction a-la Giesenhagen (bone ring and simultaneous implant placement)
- 3D reconstruction a-la Khoury (bone laminates in combination with particulated bone)
- monocortical bone block
I'm trained in all these procedures, however, i'm convinced that Khoury technique is the most appropriate and biologically sound.
A bone block was harvested form left mandible linea obliqua externa using a MicroSaw (by Frios Friadent). Subsequently this thick block was split into two thin laminates that were used to reconstruct missing buccal and palatal walls of the deficient alveolar ridge. Left-over bone was crushed in bone crusher, mixed with spongy bone (harvested from bony crypt at donor site for bone harvesting) and packed tightly into now confined defect on recepient site).
To protect the graft during the healing phase, VIP-CTF (Vascularised InterPositioned Connective Tissue Flap aka palatal pediculated connetive tissue graft) a-la Khoury was prepared and placd over the grafted bone. Care was taken not to compromise vascular supply.
Rehrmann plasty (aka periosteal release) was used to mobilize vestibular flap. Flaps were tightly re-approximated and sutured. Provisional Rochette-type bridge was luted back to neighbouring teeth.
Now, in three months we'll place implant +/- corrective soft tissue surgery
What would you do?
Would you just place Tramonte implant to save the patient from carving holes in the skull???! :-)))))
Images are downloadable from http://gallery.me.com/ken.serota160#100340
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