Initial Situation

 

A 40 year old lady was referred into our clinic for replacement of a failing UL2 root canal treated tooth. The tooth had a previous history of repeated apicectomies over the last 14 years which had left extensive scarring. The tooth had repeated periapical infections of late and a colleague within the practice removed it and made an immediate Rochette Bridge.

Following review of the healed site 5 months after extraction my colleague decided it was beyond his competent skill set and referred the case to myself.

Her remaining dentition were well restored and stable. The periodontal condition was also stable. The occlusal scheme was stable and we would look to replicate this and the corresponding guidance.

The patient wanted a fixed tooth solution after many years of feeling self-conscious and worried the problem tooth would come out at any minute. She did not want a denture, a bridge or to keep the Rochette Bridge long term.

She was also aware this would be a lengthy process due to the presence of scar tissue and history of repeated but failed apicectomies.

Treatment Planning

It was clear from the shape of the neck of the Rochette Bridge that there was a large bony discrepancy and clearly extensive hard and soft tissue volume loss.

We discussed the lack of available bone and the use of the rochette bridge as a diagnostic tool to show the restorative challenges that lay ahead.

We took a CBCT scan to evaluate and plan possible implant placement. This showed a large horizontal defect and implant placement without some form of bone regeneration technique would be required.

The 3D imaging showed a very large horizontal offset and massively reduced bone volume from the neck of the restoration to where the implant would need to be placed to provide a screw retained restoration.

We removed the rochette bridge and evaluated the soft tissue of the site for health and to ensure it had healed appropriately.

Due to the very high aesthetic demand of the patient – a high smile line in a young female patient – we agreed that a rebuild of the lost bony volume with a staged augmentation approach was required.

Whilst discussing the various options available for block bone grafting – with the patients extraoral skeletal class 2 profile – we presented the opportunity to use an allograft biomaterial as an alternative to an autogenous block in order to remove the comorbidity risks of the grafting procedure in a Class 2 patient.

Following a successful period of healing we would then place a single bone level tapered implant and restore it with a conventional screw retained approach.

Surgical procedure

6 months post extraction the allograft block augmentation procedure was carried out. A large flap was raised from the mesial of the Upper left 1 to distal Upper left 3 with a remote palatal approach and periosteal relieving incision to allow passive flap closure.

This exposed a well healed but very narrow alveolar ridge. The max graft allogenic block fig8 was trimmed and adapted chairside and then fixated using the Straumann bone fixation kit to provide excellent primary stability of the block graft.

Botiss cerabone was used to augment around the edges of the block graft and then a Jason membrane used to cover the graft to prevent soft tissue inclusion.

We used a Platelet Rich Growth Factor technique over the top of the Jason membrane to help improve soft tissue healing especially important due to the history of scar tissue from repeated apicectomy surgery.

The surgical site was closed and a periosteal relieving incision was used to ensure it closed passively. The rochette bridge was recemented and it was clear immediately that the emergence profile of the pontic was in a far more ideal position. The post op pa shows good block fixation and volume. The review appointment at 2 weeks revealed excellent signs of surgical healing of both the hard and soft tissues.

The site was left to integrate for 4 months before we reevaluated the bony dimensions with a CBCT scan.

We decided the graft had fully integrated and was ready for implant placement.The neck of the rochette bridge and emergence was looking aesthetically much improved. We removed the rochette bridge to reveal a well healed fully closed surgical site. A single sided flap was reflected to expose the healed block graft and the fixation screw was removed.

The osteotomy was prepared as per Straumann drill protocols for a bone level tapered roxolid 3.3mm x 10mm fixture.

Emdogain was applied over the grafted surface and to encourage soft tissue healing and a 2mm healing abutment was used to try and tent the soft tissues to gain thickness of the connective tissue. The post op radiograph showed good placement. The site was closed uneventfully with vicryl rapide sutures and allowed to heal for 8 weeks prior to exposure.

Prosthetic procedure

At 8 weeks post placement the prosthodontic workflow was kept very simple. The rochette was removed and a remote small h-shaped incision was used to expose the implant fixture and place a monoscanbody to enable us to take a digital itero scan.

A screw retained crown was fabricated with a customised cad cam abutment.

It was tried in and torqued to 35ncm as per the Straumann protocol. The post operative radiograph shows excellent seating of the restoration and good bone levels.

Final Result

 6 weeks post fit of the final restoration a review appointment demonstrated very good hard and soft tissue healing and integration.ross cutts bone augmentation case

A look at the shape of the ridge from an oblique angle shows excellent ridge form reconstruction from the allogenic block.

The mesial and distal papillae have reformed as can be seen in the photographs due to excellent vertical interproximal bone heights. ross cutts bone augmentation case

Conclusion

In this case the use of an allogenic block graft is an excellent alternative to the need to harvest a graft from an intraoral donor site. this enables us to avoid the morbidities associated with a second surgical site and is a much nicer experience for the patient.

Management of the soft tissues is key – to ensure passive flap closure which allows uneventful healing. This significantly reduces the risk of graft dehiscence and the potential complications associated.

The patient is extremely happy and confident with her new front tooth and an excellent clinical outcome has been achieved.

Dr Ross Cutts BDS (Lond) Dip Imp Dent RCS (Eng)

Dr Ross Cutts BDS (Lond) Dip Imp Dent RCS (Eng) Practice Principal, Cirencester Dental Practice

 

Practice Principal, Cirencester Dental Practice

Ross graduated from Guy’s Hospital, London in 2000. He is a dentist with Special Interests in Implant Dentistry and Advanced Restorative Procedures. He has placed over 2,000 implants in the last 10 years.

He is a Fellow of the International Team for Implantology (ITI) – and is a Study Club Director and clinical mentor for this Worldwide Organisation. He regularly holds implant courses and lectures nationwide on a variety of topics at different levels, however he has a particular interest in Aesthetic Implant Dentistry, Digital Dentistry and complex Bone Grafting procedures.


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