Vertical 2: The Next Level of Hard and Soft Tissue Augmentation

Istvan Urban

• Publisher: Quintessenz Verlag
• Year: 2021
• ISBN:
  9783868675924
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

In the author's bestselling first book, Vertical and Horizontal Ridge Augmentation: New Perspectives, published by Quintessence in 2017 and translated into 12 languages, the guided bone regeneration (GBR) technique was described in detail. This new publication, Vertical 2: The Next Level of Hard and Soft Tissue Augmentation, is a continuation of that book but at a more advanced level. Now, the author delves into the details where the devil lives, and shares information that has never been revealed before on the topic of vertical ridge augmentation. It is important to read this book armed with the knowledge from the first book as you will need it on this second journey with him.A major part of this book comprises full-color, step-by-step images of patient cases. At times, reading it is like watching a surgical video, where the author 'stops the video' to discuss with you, the reader, what he is thinking and doing at that step, what his next step will be, and the reason for it.Included again are the well-appreciated 'Lessons learned' sections, where the learning objectives are emphasized and further notes given, including ways to further improve the techniques. The section on the mandible is more detailed in this book, with the focus on larger defects and the different surgical steps in native, fibrotic, and scarred tissue types around the mental nerve during flap advancement.In addition, light is shed on the detail in treating the anterior maxilla, which has not been published previously. It includes treatment options such as the fast track, the safe track, and the technical track of soft tissue reconstruction in conjunction with bone grafting as well as papilla reconstructions after bone regeneration. The section on the posterior maxilla hopes to resolve issues such as the management and complications of combined ridge and sinus grafting, including difficulties such as the lack of buccal, crestal or nasal bony walls of the posterior maxilla before bone grafting.In this must-have new publication, the procedures are kept simple, repeatable, and biologically sound. The techniques presented are not overcomplicated; they are simple treatment strategies with lower complication rates and more predictability in the final outcome.

The extreme vertical defect of the posterior mandible

3

Reconstruction of the extreme posterior mandibular defect: surgical principles and anatomical considerations

Fig 3-1 Panoramic radiograph of the defect.

Fig 3-2 Anterior view of the defect.

Introduction

This chapter details a patient case that is a representative example of an extreme vertical defect that required regeneration. The first question we need to answer in cases such as these is whether the defect requires regeneration or whether alternative treatments would be appropriate.

It is necessary to justify this particular treatment for each patient. Alternative treatment options and potential compromised outcomes have to be evaluated and presented to the patient. Regenerating a defect may not be necessary if it is possible to place implants in other adjoining areas by using short implants for well-selected cases or by using pink ceramic restorations if longer clinical crowns have to be made. In this specific example (Figs 3-1 and 3-2), short implants were not a possibility due to the close proximity of the neurovascular bundle.

Another alternative and frequent choice of treatment is extraction of all the anterior teeth and inter-foraminal implant placement. Not only is this treatment simpler, it has less morbidity, is highly successful, and has a significantly faster overall treatment time. However, there may be cases in which healthy teeth are sacrificed in the interests of a faster treatment. A good example can be seen in Figure 3-3a to c. This patient received a bilateral ridge augmentation instead of interforaminal implants. However, another practice recommended extraction of all the teeth, which is considered by this author to be a poor choice for this patient.

Figs 3-3 (a to c) Anterior and labial views of the patient with sound anterior teeth and a bilateral vertical ridge deficiency. (d) Panoramic radiograph demonstrating stable crestal bone after 5 years in function. (e and f) Detail of panoramic radiograph.

In the particular situation shown in Figures 3-4 and 3-5, extraction of all the teeth would have been a viable alternative. The reason for the defect developing was untreated peri-implantitis.

Fig 3-4 Panoramic radiograph demonstrating the vertical defect.

Fig 3-5 Panoramic and cross-sectional CBCT images demonstrating the vertical defect.

Fig 3-6 Note the extreme ridge atrophy.

This patient did not opt for extraction of all her teeth and the placement of intraforaminal implants. She felt that such a treatment would mean losing all her teeth due to previous implants. This author thinks that she was right. In fact, we frequently have this same debate due to implant failures that create such advanced defects. The question is: Why would the regenerated bone serve the new implants better than the native bone that previously existed in the same place? It is our responsibility to provide a treatment alternative that will support function and health over time. This patient, a healthy 67-year-old nonsmoker, was very motivated not to lose all her teeth due to three previous implants.

To resolve this case, the soft tissue quality and quantity was evaluated as well as the defect intraorally (Fig 3-6).

In addition, there was significant attachment loss of the canine to...