Dental Tribune U.S. Edition

DENTAL TRIBUNE | September 2011 Clinical 9A After a complete work up, the patient also needed his occlussal plane leveled for ideal function. While it would be relatively predict- able to do an onlay graft to correct the facial defect, the vertical defect utilizing conventional grafting tech- niques was not predictable, as the patient had already experienced. We presented the patient with a treatment option that included orthodontics to correct the func- tional challenges, and offered him a treatment option that would incor- porate a variation of distraction osteogenisis in combination with surgical vertical displacement of the previous onlay graft utilizing the small diameter ERA implants. With their aggressive thread design and subsequent fine tuning with three-dimensional displace- ment of the bone, the ERA implant allows for conservative surgery to maintain blood supply while sepa- rating the cortical bone plates and allowing controlled movement of the bone in the healing surgical site. We divided the treatment into three phases. Treatment phase No. 1 We made a resin bridge from the upper left cuspid to the upper right central incisor, replacing the left lateral and central incisor (Fig. 2). We then placed a 2.2 x 10 mm ERA implant in the area of the upper left central and one in the upper left lateral incisor, making sure that we engaged the previous graft site extending well into the residual bone that was grafted (Figs. 3, 4). The resin bridge was cemented but out of contact with the implants that were placed without an incision with the abutment supragingival (Fig. 5). The orthodontic treatment was initiated during the four months while bone integration took place around the implants. Treatment phase No. 2 The pontics were removed and altered by measuring the clinical crown of the upper right central and lateral incisor (measured from the gingival crest to the incisal edge) then connected to the implants. This then created a step in the incisal edges in this area corresponding to the hard- and soft-tissue defects (Fig. 6). After connecting the new resin crowns that correspond in size to the adjacent central and lateral, a conservative vertical incision was placed mesial to the upper left cen- tral and distal to the left lateral. The soft tissue was raised via tunneling to bone on the facial, but not on the lingual, in an attempt to preserve the blood supply to the bone around the implant, and was also the reason no horizontal incision was placed. The cortical plate was cut such that the implants and the bone between them was freed to allow us to pull the implants via altered resin crowns incisally to have the “in edges” as close to being level with- out blanching the tissue (Fig. 7). The area was grafted with mineralized and demineralized cancellous bone, collagen membrane was placed and the vertical incisions were closed with 4-0 sutures. The surgical site was stabilized using the wire that was secured to the adjacent teeth and orthodontic brackets (Fig. 8). AD After the soft tissue healed and the sutures were removed, the Fig. 3 Fig. 4: A) Residual bone area; B) previously grafted bone area; C) exaggerated arch that will be addressed with orthodontics. C A B g DT photos, page 10A; text, page 12A