[Surgery]  anterior implant needed due to accident.

Hello Bite instructors.
Happy New Year! I hope you all had some rest.
I have more information about this case.
Patient had an accident in September and lost 11 and 12( knocked out). In VGH 21 which was dislocated was repositioned and splinted for 10 days. No treatment done after that.
The patient has open bite. Not a very high smile line. He is not very worried about the look. He wants some teeth there.
I wanted your last suggestions to start the treatment.
I had two things in mind.
1- On the day of surgery, remove 21 ( upon examination it had mobility) and 13 and try to access the root of 13 from palatal area. Assess the buccal bone.If there is enough buccal left and I did not loose any , place two implants in 13 and 21 area. Also assess and see if I can place a third one in 12 or 11 area. Sure I will use bone graft and PRF.
2- In case I lost bone in buccals, bone graft and PRF. Take impression and make a flipper with no buccal flange for 4 to 5 months to go back and do implants.
Please let me know your thoughts. :)

by Admin BITES at Thu, Jan 8, 2015 4:15 PM

1365 Views | 4 Replies

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Mark Kwon Replied at Mon, Jan 19, 2015 10:56 PM

Hello everyone, Not an easy immediate case. Apical bone of those potential sites are quite narrow it seems. (next time if you can give us jpegs with some measurements would really help. Thanks!) stick to narrow plat form fixtures (ie. 3.5mm diameters). Soft-tissue management will be a challenge since you will anticipate some loss of papillae. Let's hope that his expectation does not rise after the treatment. - mark

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Roushanak Shafaghi Replied at Sat, Jan 17, 2015 1:04 AM

Hello , Attached are more views of the case.I hope they have better quality. When I did my studies, I believe I can not do any immediate implant placements, There is no where More than 3.8 bone Buccal-lingually. Please share your thoughts. Thanks,

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Ho-Young Chung Replied at Fri, Jan 9, 2015 2:54 PM

I second that what Jim said about what patients do once they go out the door. I recently had a patient whose implant failed. Afterwards he told me that he had been playing with his healing abutment all this time. Everyday and night! Jim has given sound advice on all other aspects of this case. Please keep us updated. I like what he said that sound logic should also be used. We could use the best implants in the world, the best bone, PRF and whatever we can think of but common sense should prevail. Ho-Young

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Jim Yeganegi Replied at Thu, Jan 8, 2015 8:38 PM

Dear R, Thank you for forwarding the digital clinical images and some more patient history. If I recall you were going to send us some better more clear slices off of your CBCT but nonetheless here are my two cents: 1-It appears from your pictures that the patient doesn't exhibit a "high smile line" however you can see some tissue and papillae most certainly. From a restorative esthetic standpoint you should be fine as a) patient's expectations are not high b) the prosthesis (bridge) will allow for pink porcelain and papillae etc. 2-It's not likely that you will have much buccal plate around #21 or any of the anterior segment if there has been trauma and the tooth was "repositioned". surely there would have been some inflammation and potential buccal plate bone loss/remodelling. 3- With respect to #13: Most cuspids , due to their position and root prominence, have either buccal bone defect or dehiscence . If you attempt to access the root from the palatal and exo it then you may exert a lot of force on the buccal plate and may risk fracture of whatever buccal plate you may have. Use a #11 blade, or periotomes and approach the root tip from the side and work the blade down the side to sever the PDL.. You may also use a piezo , laser (if you have one) to come in from the proximal and sever the PDL to loose up the roots. If not then a long tapered fissure bur (169l) will work also. Trough from the mesial and distal very gently and this should allow you to loosen up the root and elevate it out Keep a finger on the buccal plate and apply pressure against the root as you're elevating to help stabilize the buccal plate. If all is well and you determine you have enough bone to place your implants then you should be golden. (as perivously mentioned I would personally try to use 3 implants vs. 2) to replace 4missing teeth in the anterior segment due to likelihood of type D2 bone. In this case though, given the history, I would probably prepare to graft the region though.and be equipped to do so. PRF and Allograft are magic and Dr.Jin's PRF protocol has done wonders for me. With respect to going back and placing implants in 4months? I would probably wait 6 in this patient. The reason being the history of trauma , and the skeletal relationship. He's Class III with severely proclined lower incisors. If you place and load early every time he bites into something it will apply outward forces on your prosthesis, implants (which are in grafted bone) and may have long-term consequences. So perhaps it may be better to wait an additional 2 months for your graft to bevsolid and then place your implants. (PRF is magic but sound logic should also be used). Finally: if you do buccal grafting you will want to have no mobility of your graft as such 1)post op instruct your patient not to smile too big or pull his lips up to see what you have done (you'd be surprised at what people do once they leave your chair) 2)make sure there are no frenum pulls on the soft tissue that would mobilize it or your graft 3)NO flange on your RPD or go with an ESSEX retainer with teeth in it. Sorry to have rambled on. Best of luck and keep us posted. Thanks Happy New Year to everyone. Jim