Managing cases

Hendrik Terheyden

Prof Terheyden presented two cases involving extreme atrophy in totally edentulous patients. The first case was treated with a mandibular sandwich osteotomy filling the interpositional space with biomaterials. In the maxilla, a Le Fort I osteotomy was performed, the pre-maxilla was advanced and bone ‘piano pieces’ from the iliac crest were interpositionally grafted. Standard implants were then placed and two overdentures were secured.

The second case was treated with a Le Fort I osteotomy rebuilding the maxilla using interpositional and onlay grafts. A fixed prosthesis on eight implants was finally placed.

David Nisand

In the anterior region, Dr Nisand recommended bone augmentation to achieve successful long-term aesthetic outcomes. In the posterior region, when the available bone allows for a graftless solution, the use of short and narrow-diameter implants should be considered to simplify treatment. The decision should be based on a thorough case evaluation taking the patient’s specifications and wishes into account. In cases involving extreme atrophy (such as less than 5mm of mandibular bone above the nerve or 3mm residual bone below the sinus) guided bone regeneration should always be implemented to allow for the placement of standard implants.

“In cases involving extreme atrophy guided bone regeneration should always be implemented”

The first case was relatively straightforward: the patient was taking bisphosphonates and the decision was made (according to patient’s condition and their preferences) to place a combination of short and narrow-diameter implants instead of a staged or simultaneous bone augmentation.

The second case involved a female smoker with ongoing periodontitis and peri-implantitis. Aetiological treatment allowed for periodontal treatment along with removal of implants in the posterior zone causing advanced vertical bone defect.

Again, in the context of an all-encompassing treatment plan, the patient’s condition and preferences contributed to the decision to place short implants in the posterior mandible. This was aimed to provide a simpler solution for her and to help the retention of a partial removable denture. Short and narrow implants are indicated in elderly and medically compromised patients.

“Short and narrow implants are indicated in elderly and medically compromised patients.”

For normal patients, they can also provide a faster and cheaper alternative. But three objectives must be fulfilled:

• patient evaluation, to guide them to an evidence-based decision
• correct 3D position for implants
• perio-friendly restoration design