[Surgery]  Preparing future implant site w/ titanium mesh?

Hello all,


I would like an opinion on whether to place another bone graft and titanium mesh for bone heigh in place of a previously extracted 2.4


Patient is motivated to have an implant instead of bridge and is informed that for an aesthetic result he might need further site preparation.


The photos are of the healing site 1 month post extraction, PRF and bone graft.


My concern is regarding the healing site and bone loss. Due to previous periodontal disease he has had some interproximal bone loss which will impact my crown to root ratio as well as buccal bone loss.


What should i do to restore buccal morphology? I was thinking of another bone graft and a titanium mesh. Please advise as to the need for the mesh or would a simple graft with membrane be sufficient?


Thank you,


by Ilia Oukhalov at Tue, Apr 28, 2015 6:36 PM

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Ho-Young Chung Replied at Wed, Apr 29, 2015 3:36 AM

Hi Ilia, I would also wait for healing, take CBCT. You might be able to get away without doing a CTG here if you make your initial incision slightly palatal and push keratinized tissue buccally. based on your photos, I"m going to make an assumption but I'll bet your patient has a low lip line. And that moustache helps hide a potentially longer tooth. having said all that, allow initial graft to heal 4-6 months. then CBCT

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Jim Yeganegi Replied at Tue, Apr 28, 2015 8:37 PM

Dear Ilia, This is a challenging case indeed. Does the patient have a high smile line (Julia Roberts like) where you see the buccal corridor? If not then you have less challenges with respect to getting the ideal result. If the smile line is high then you need to educate your patient on the challenges that you as the surgeon have ahead of you. Looking at these initial one month post op pictures my concern is that you have little keratinized tissue on the buccal of #24. There is also bone loss proximally which means you have no papillae and unless vertical bone is grown you 're not likely to get papillae. Growing vertical bone is a dream (and one which we should all continue to aspire to do); however the challenge comes in that even with a mesh and PRF you will have to have mesh stability, and some interproximal bone to grow up against. You also have limited blood supply from the crestal aspect which makes vertical growth somewhat challenging. The roots of the proximal teeth will have to be treated meticulously and treated with EDTA or Citric Acid to give some hope of bone growth. So the challenges are there. We don't have a CBCT with slices to see how much horizontal (Buccal-palatal) bone you have or Vertical height before you hit the sinus floor. If there is sufficient room you may consider implant placement getting a longer implant in and doing some tissue grafting procedure on top of it to regain attached tissue and tissue bulk. That will help in the esthetic result. I think you should consider Soft Tissue procedure with PRF and autograft (palate) or alloderm to get some thickness. If you don't have enough bone then consider doing GBR concurrent with tissue procedure and then go back and place your implant. Some CBCT slices would be very helpful for diagnosis and tx planning. Best of luck Jim

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Mark Kwon Replied at Tue, Apr 28, 2015 8:33 PM

I would get a CBCT taken. #24 had medial bone level deficiency even prior to the extraction. That defect seem to extend to distal of #23. Even with additional bone grafting it will be very hard to regain bone height on the mesial. Buccal deficiency can be corrected with GBR at the same time of implant placement #24 (depending on the severity of defect). You can wait for initial graft to heal first, then send out for CBCT to assess the remaining bone volume. - mark