Vertical Bone Regeneration for Implant Placement
Dan Holtzclaw, DDS, MS
Diplomate - American Board of Periodontology
Diplomate - International Congress of Oral Implantologists
One of the Tooth 8 presented with 9mm probing depths and grade 3 mobility. The tooth had been endodontically treated for approximately 6 years.
Extraction of tooth 8 revealed a severe osseous defect of the facial plate. The lack of facial bony wall extended to the apex of the adjacent teeth.
A tenting screw was placed to obtain space maintenance and grafted with freeze dried bone allograft. A resorbable collagen membrane was placed for epithelial exlusion, graft containment, and wound stability.
Vertical bone regeneration of approximately 10mm was achieved. Note the pattern of the resorbable collagen membran on the regenerated bone. Following removal of the tenting screw, a 4x13mm implant fixture was placed.
Radiographic series demonstrating vertical regeneration of bone at the site of the central incisor. Note that the original extent of vertical bone loss approaches the the apices of the adjacent teeth.
Surgical site 3 months after implant placement.
Second stage surgery.
Final restoration. Note complete regeneration of bone at the central incisor location and excellent papillary fill.
Radiographic series of vertical bone regeneration at the central incisor location. Note that bone loss orginally approximated the apices of the adjacent teeth.
Before and after photos of vertical bone regeneration at the central incisor location.
Before and after photos of completed case.
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Comments
Alena: Tenting screw answer
Alena
The screw that was used was KLS Martin. I would recommend either, KLS, Synthes, or Salvin screws.
You will notice in the pictures that the bone graft goes up to the head of the screw in this case so it is easy to remove without damaging the bone graft.
I have had some cases where the bone has grown over the screw, in that case you can carefully uncover the screw and remove, usually it does not hurt the graft.
Hope that helps.
Tenting screw
What brand of the tenting screw did you use? How does it affects bone graft at the removal of the screw?
Screw type does not matter in my opinion
KLS screw was used in this case. However, I think any screw can be used. A screw is a screw. It's purpose is to help maintain space.
Personally, I use a screw kit from Salvin. Very easy to use. The screwdriver securely holds the screw...a key thing to consider when purchasing a screw kit. There is nothing more frustrating than having your screw fall off of the screwdriver as you attempt to place the screw. This does not happen with the Salvin kit.
Great work
A few questions:
Do you use different types of resorbable barriers depending on the "memory" you need?
Are you adding a graft enhancer to the material?
Do you prefer frozen or room-temperature in these cases?
Very nice case! Outstanding aesthetic result.
next time, save me a core when you place the implant!
Great Work
Well its been really great to see that there are dentist which still believe in vertical bone grafting.
Answers to Bone Graft Questions
On this particular case I used regenefill and layered FDBA on top. Kind of like Hom-Lay Wang's Sandwich Technique. I used a double membrane to test out a suggestion offered by Dr. Lemler. I used a tenting screw for support and tacked the membrane. I originally placed 3 tacks, but as you can see on the xray, 1 tack was lost before closure.
The bone was allowed to heal for 4 months prior to implant placement.
The bone had a type 3 feel upon implant placement, so allowed the implant to integrate for a bit longer than normal.
I did not add growth factor to this case.
Answers to questions: RAHDDS
I believe this case was done with regenafil and Lifenet FDBA.
I usually prefer to use roomtemp regenaform. I occasionaly add gem 21 or a blood product.
My Membrane of choice is ossix. It has no memory and it will be there when you go back to place the implant.
Was it vertical bone growth?
We know from literature that the amount of bone growth is unpredictable. In your case, the preoperative showed the bone level adjacent to the adjacent teeth was not much affected. Choquet et al. 2001 and Kan et al. 2003 demonstrated that this is an important factor affecting the final outcome. In your case the bone gain may not necessary be "vertical bone augmentation" and I expect similar result could be obtained with routine GBR procedures with bone fillers and collagen membrane. What is the opinion of others?
Looking at the radiographs, looks like vertical growth achieved.
Probably cannot call this completely vertical growth of bone. While there is definitely no facial bone and little interproximal bone, there is some palatal bone. With that being said, however, there was a significant amount of bone regenerated vertically at the facial and interproximal aspects.
I disagree that just adding bone and a resorbable membrane would have achieved the same results. I would be willing to bet that less vertical facial height would have been achieved if that was done. He could have used a titanium reinforced membrane in this case and gotten similar results IMHO.
In any event, the case looks like it definitely achieved its objectives. The radiographic maturation of the regenerated bone is very nice.
1.how did You prepair bone
1.how did You prepair bone block for this vertical augmentation case, do You know any tools which standartitized and help to adjust recipient place to donor bone(like digital scan of the teeth for prosthetic work)
2how did you managed soft tissue(did You score periosteum or use different technic.
tenting screw.
you used a tenting screw for the vertical height and I also saw two other screws. what are they for and did you use the biogide resorable membrane?
where did you buy the screw ?
thanks
Journal CE is a nice addition and easy to use.
Hats off to that. Very easy to use.
Excelent case, my question is
Excelent case, my question is the time between graft and implant placement and wich implant do you use??
Dr. Chinchilla the time between graft and implant placement.....
Dear Dr. Chinchilla,
The time between graft and implant placement will vary based on what you are trying to achieve and how much you are trying to graft, materials used, etc. In this case, I believe Dr. Holtzclaw went back at 6 months, due to the fact he was trying to achieve vertical augmentation which is not very predictable in comparison to horizontal augmentation. I believe he placed a 3i NT implant or a NB replace select tapered.
Regards.