Gentle implantation in complex clinical cases – case analysis Part 2

In the previous part, we examined several cases where it was possible to perform a complete restoration of the dentition without bone augmentation surgery. We also discussed a case where we successfully managed serious complications that arose after an unsuccessful bone grafting procedure. In this article, we will analyze a few more cases, presented as a medical confession. After all, true medical wisdom lies not in skillfully extricating oneself from difficult situations, but in avoiding the very possibility of complications. 

Patient No. 1: Bone Grafting Using a Teflon Membrane: A Cautionary Tale

The initial situation involved relatively recently placed implants in the region of teeth 23, 24, and 25, with 3/4 of the implants exhibiting exposure.  

Pictures of the problem area with exposed and mobile implants from different angles YouTube / Dr. Kamil Khabiev / Dental Guru Academy 

The structure was mobile, and the prosthesis could not function normally. The situation was deemed hopeless, so the decision was made to remove everything, augment the bone, and replace the implants. 

Exposed parts of implants – prosthesis and implants must be removed YouTube / Dr. Kamil Khabiev / Dental Guru Academy

It was decided to perform guided bone regeneration (GBR) using a non-resorbable polytetrafluoroethylene (PTFE) membrane.

The surgery followed a strict protocol. First, the old implants were removed. Then, osteoplastic material was introduced into the defect area, and everything was covered with a PTFE barrier membrane reinforced with a thin titanium plate.  

Surgery process for increasing alveolar ridge height using non-resorbable PTFE barrier membrane YouTube / Dr. Kamil Khabiev / Dental Guru Academy 

The membrane was intended to form a new contour of the alveolar ridge, bent and fixed in an arc shape, as shown in the photo below. 

Formation of the alveolar ridge from PTFE membrane YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The perimeter of the non-resorbable membrane was additionally covered by a resorbable collagen membrane. The gum was then sutured with a cascading, layered suture in three tiers.

The procedure was executed perfectly; the photographic documentation could easily be included in textbooks. However, reality had other plans.

Some time later, the patient’s prosthodontist called, reporting a slight opening in the gums and suggesting a re-evaluation.

Upon the patient’s return, the doctor observed a disastrous situation. Unfortunately, the photographic record of the exploration of the failed surgery site was not preserved. However, several pictures of membrane fragments remain. 

Remains of PTFE membrane after failed guided bone regeneration surgery YouTube / Dr. Kamil Khabiev / Dental Guru Academy

As a result, the augmentation within the maxillary sinus was preserved, but the material deposited in the alveolar ridge area was lost due to severe inflammation.

It is important to note that we are not suggesting that titanium meshes or PTFE membranes are inherently ineffective or a poor solution. Here is a real-world counterexample. The pictures depict a successful case that is over 8 years old as of Autumn 2024. Regrettably, a photo of the original condition was not preserved, but there was a very thin cortical layer, and the body of the implants was practically visible through it.

The decision was made to perform guided bone regeneration, utilizing a titanium mesh as a barrier and to shape the new contour. In addition to bone augmentation, soft tissue grafting was also performed.

After 6 months, the titanium mesh was removed, yielding the result shown. In the right picture, the gum has already healed, and the significant thickness and robustness of this part of the jaw are clearly visible. An increase of more than 10 mm was achieved.

Successful surgery to increase bone tissue volume with the placement of 4 implants YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Moreover, the conditions for the surgery were challenging; the picture below illustrates that the neighboring teeth were affected by periodontitis.

Successful surgery to increase the thickness of the alveolar ridge against the background of pronounced periodontitis YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Patient No. 2: Titanium Mesh and Complete Failure of GBR

The patient received 4 implants in the lower jaw, after which it was decided to perform GBR surgery on the upper jaw. 

Clinical picture after successful placement of implants and before GBR surgery on the upper jaw YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The surgery was performed according to a standard protocol, using osteoplastic material and a titanium mesh. However, the patient was lost to follow-up for 6 months and returned with this picture.

Exposed titanium mesh 6 months after GBR surgery YouTube / Dr. Kamil Khabiev / Dental Guru Academy

There was complete exposure of the mesh, with granulation tissue and significant contamination underneath. It was necessary to completely remove the mesh and the implants and redo the entire procedure from start to finish.

Summary for both clinical cases: We are in no way suggesting that titanium mesh or PTFE membranes are inherently bad. There are many successful cases, including the example above, but such failures are not only very unpleasant, but also prompt a consideration of techniques that allow us to avoid bone grafting altogether. However, if the clinical picture dictates that GBR with a barrier membrane is unavoidable, then strategies to manage potential failures must be considered. 

Patient No. 3: Successful Implantation in a Patient with a History of Periodontitis

The patient himself is an anesthesiologist. The initial situation presented with severe periodontal disease, pronounced periodontal pockets, and generalized tissue atrophy along the entire perimeter. 

Initial situation of severe periodontal disease YouTube / Dr. Kamil Khabiev / Dental Guru Academy

In the facial projection, we see pathological abrasion and a significant reduction in vertical dimension of occlusion (VDO).

Low bite and pathological wear of teeth in patient No. 3 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The prosthodontist suggested the following treatment plan: placement of 8 implants in the upper jaw and 4 implants in the lower jaw.

Treatment plan suggested by an orthopedist YouTube / Dr. Kamil Khabiev / Dental Guru Academy

However, an alternative view of the CT scans clearly indicated that the treatment needed to be divided into several stages.

The image reveals a slight curvature of the nasal septum and bullous deformation of the middle turbinates. Most importantly, we see total opacification in both maxillary sinuses. They are completely filled with homogenous content. The osteomeatal complex is blocked, preventing sinus drainage. Therefore, any sinus lifting procedure was contraindicated. 

CT scan shows bilateral opacities in the maxillary sinuses plus lack of sinus drainage – sinus lift is contraindicated YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Furthermore, in the third quadrant, a mental nerve loop is visible, along with a sublingual frenulum attachment. This was precisely where the prosthodontist had planned to place an implant.

A mental nerve loop in the third quadrant where the implant is planned to be placed YouTube / Dr. Kamil Khabiev / Dental Guru Academy

While a short implant, 8 mm in length with a small diameter, could be placed, this option was not suitable for a large man with powerful jaws. Bone augmentation in a clinical picture complicated by periodontal disease was also not advisable. Therefore, it was decided to slightly reposition the implant.

Considering the condition of the patient’s sinuses and the situation in the lower jaw, the first stage of treatment was:

1. Extraction of all teeth in the upper jaw and placement of implants in the anterior segment, avoiding the lateral areas where a sinus lift was needed. Extracting the lateral teeth of the upper jaw eliminates the endogenous cause of the patient’s sinusitis and prepares the site for the ENT specialist.
2. Extraction of the lateral teeth of the lower jaw and placement of implants, taking into account the anatomical variations.
3. After 1.5 months, a second CT scan will be performed, and the patient will be referred to an otolaryngologist for management of the maxillary sinuses, with the goal of enabling a sinus lift and placement of the remaining implants in the lateral regions.

The plan for the first stage of treatment is the extraction of the upper jaw teeth with the placement of 4 implants in the anterior section, the extraction of the lateral teeth of the lower jaw with the placement of implants in the lateral sections YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Let’s examine the stages of treatment in more detail. The first stage was the extraction of the teeth of the upper jaw.

Upper jaw teeth after soaking in hydrogen peroxide YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Next, primary surgical treatment of the wounds was performed, excising necrotic and inflamed areas of the mucosa, trimming all non-viable fragments, and performing thorough debridement.

Primary surgical treatment of the wound with removal of all necrotic areas of the gums and deep cleaning of the sockets YouTube / Dr. Kamil Khabiev / Dental Guru Academy

To facilitate the procedure, it was decided to first place implants in the debrided anterior region and then proceed to remove the lateral teeth.

Preparing a clean wound (surgical field) for implant placement YouTube / Dr. Kamil Khabiev / Dental Guru Academy

First, the implant was placed at position 21, and then, guided by a parallel pin, at position 11.

placing an implant in the 21st tooth position YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Two pins were used to guide the placement of implants at the positions of cuspids 23 and 13. 

Parallel pins placed in implants at positions 21 and 11 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

All frontal implants are placed at positions 13, 11, 21, 23 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Before suturing, a radiograph was taken to confirm proper implant positioning, adequate depth, and lack of sinus involvement.

Control image immediately after placement of implants YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This completed the anterior segment. Debridement of the second quadrant commenced. A perforating oroantral fistula was present. The surgeon’s task was to remove the granulation tissue while keeping the fistula opening as small and suitable for suturing as possible.

Oroantral fistula after cleaning YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This was generally successful; the photo shows the former cystic cavity, cleaned and ready for further procedures.

All voids and defects were filled with Platelet-Rich Fibrin (PRF) clots, including the sockets of extracted teeth in the anterior and lateral segments. The soft tissues were then sutured.

Preparation of the frontal and lateral sections for suturing YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Suturing began in the anterior segment, followed by the lateral segment.

Suturing of soft tissues after placement of healing caps in the anterior region and after and after tooth extraction and sanitation of the lateral region YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Finally, the hopeless lateral teeth in the first quadrant were extracted. Debridement and cleaning were performed, maintaining the integrity of the septum and preserving as much of the outer cortical plate of the sockets as possible.

Extraction of hopeless lateral teeth in the first quadrant YouTube / Dr. Kamil Khabiev / Dental Guru Academy

PRF clots were then placed, and the wound was sutured.

Final suturing of the wound in the first quadrant YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Results of the first day:

1. All teeth in the upper jaw were extracted.
2. Four implants were placed in the anterior region.
3. A site was prepared for the ENT specialist.

Final snapshot of the first day of treatment YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Early on the second day, work began on the lower jaw. Bone deficiency was present in the fourth quadrant. Placing short implants in the distal mandible is generally discouraged. Therefore, the surgeon deviated from the prosthodontist’s recommendations and placed three implants (positions 45, 46, and 47) instead of two (positions 45 and 47) in order to distribute the load more evenly.

The picture below shows the position of the mandibular nerve, indicating that the planned placement of the implants did not allow for a reliable design.

The actual location of the mandibular nerve and the planned location of the implants – it was decided to place not two, but three implants in the third quadrant YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Implants placed at positions 45, 46 and 47 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Even short implants, when used in multiples, can adequately withstand the masticatory forces.

Snapshot after placing the implants in the fourth quadrant, the implants are in optimal positions, the immersion depth is adequate YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Moving on to the third quadrant, the situation was more predictable, although nuances were present. The mental nerve loop mentioned earlier was directly in the projection of tooth 35. However, bone augmentation was again avoided due to the elevated risk of complications.

Mental nerve loop and insufficient height of the alveolar ridge in the projection of the 35th tooth YouTube / Dr. Kamil Khabiev / Dental Guru AcademyMental nerve loop and insufficient height of the alveolar ridge in the projection of the 35th tooth YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Therefore, the surgeon decided to shift the implant placement point from tooth 35 to tooth 37. This was accomplished by removing teeth 36, 37, and 38, performing thorough debridement, and placing two implants at positions 36 and 37.

Removal of teeth 36, 37, 38 plus cleaning of sockets for subsequent placement of implants YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Parallel pins were used to verify the positioning. The narrow portion of the alveolar ridge and the mental nerve loop were effectively bypassed.

Successfully placed implants at position 36 and 37, the position relative to each other and the antagonist teeth is optimal YouTube / Dr. Kamil Khabiev / Dental Guru Academy

A control radiograph was taken to document the two days of work. The first stage of treatment in the upper jaw was completed:

• All teeth extracted.
• The cyst was opened and cleaned, and the oroantral fistula, which was the source of inflammation in the maxillary sinuses, was eliminated.
• Four implants were successfully placed in the anterior zone.

The first stage of treatment for the lower jaw was completed:

• Lateral teeth extracted.
• In the fourth quadrant, three implants were placed instead of two. One implant was of standard length, and two were short due to insufficient alveolar ridge height. The original plan called for two long implants, but the second long implant could not be placed without bone grafting. Therefore, two short implants were used instead of one long implant to distribute the load more evenly.
• In the third quadrant, two implants of normal length were placed, but the position of one of them was changed. According to the plan, implants were to be placed at positions 35 and 36, but in fact, the implants were placed at positions 36 and 37, thereby simply avoiding the problem in position 35. Bone grafting was avoided entirely.

Control radiograph after the first stage of treatment YouTube / Dr. Kamil Khabiev / Dental Guru Academy

As of the time of writing, 6 months have passed since the first stage of treatment. The patient was treated by an ENT doctor, the maxillary sinuses were cleaned, and drainage was restored. A sinus lift will be performed in the near future, along with the placement of implants in the lateral sections. Work will also continue on the lower jaw, where 4 more implants will be placed. Ultimately, both dentitions will be restored.

Plan for the next stage of treatment for patient No. 3 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This work is fully consistent with the topic of our article, namely, gentle implantation in difficult conditions. Is this a risky approach? No, the likelihood of complications is minimal, and the result is predictable.

Will the changes in implant position cause problems for the prosthodontist? No, on the contrary, he will be grateful, because creating a well-fitting prosthesis will be easier than with the original plan.

And once again about the durability of implant-supported restorations

The restoration we will analyze is already 11 years old. Pay attention to the first quadrant. Two implants and two porcelain-fused-to-metal (PFM) crowns are present.

Successful restoration of 2 upper teeth 11 years after placement YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Bone peaks are preserved between the implants and between the implants and natural teeth. The crest of the bone is at the level of the platform switch. There is no evidence of marginal bone loss. One might conclude that this restoration was made recently. However, this restoration is already 11 years old. And we anticipate a favorable prognosis for another 11 years of service.

Examine the surgical images of the same patient. As you can see, over the past years, nothing has changed in either the first or fourth quadrant.  

Surgical images of a patient whose restoration lasted 11 years and completely preserved the volume of bone tissue YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Patient No. 4 

Another illustrative case of how complex reconstructive measures can be avoided. To reiterate, all methods of bone grafting and other complex surgeries are valid and appropriate, but they always carry an increased risk of complications.

We want to showcase a technique with minimal iatrogenicity and risk of complications.

The patient is 50 years old, with no significant medical history. She was referred by a prosthodontist for implant placement in an unusual distribution. The plan proposed by the prosthodontist is shown in the pictures below. 

Initial situation and plan for implant placement proposed by prosthodontist YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This case combined two implant systems, utilized a PRF clot, and assessed the primary stability of the implants with an Implant Stability Quotient (ISQ) device. Teeth that could not be saved were prepared for the retention of a temporary prosthesis.

Pictures of the fascial and proximal projection of the upcoming field of work YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Plan for the first day of work: 

• Remove teeth 17, 12, and 28.
• Place implants at positions 17, 14, 12, 21, 24, 27 and perform bilateral sinus lifts with simultaneous implant placement.  

An interesting and unusual distribution of one tooth/one implant was planned.

After removing the planned teeth, significant unevenness in the height of the alveolar ridge was observed. Depressions were apparent where teeth had been lost long ago, while peaks were present where teeth had been preserved. The entire jaw resembled a roller coaster. This is an important consideration when planning to place implants.  

Clinical picture after extracting teeth 17, 12 and 28 according to plan YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Let’s begin placing the implants. The first implant was placed at the 21st tooth position. Note that the implant was placed slightly palatally, with a deviation from the outer edge, to preserve as much of the outer cortical wall as possible. The remaining implants were placed using the same principle.

Successfully placed implant at the 21st tooth position YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The same principle of palatal displacement is also noticeable in the example of the implant at the 24th tooth position.

Successfully placed implant at position of the tooth 24 with palatal displacement YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The average value of primary stability, as measured by the ISQ device, fluctuated around 70 units.

Checking primary stability with the ISQ device YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The preparation of the osteoplastic mixture deserves further discussion. We all know that autogenous bone is excellent because it is osteoinductive. We also know that xenograft material is beneficial because it is osteoconductive. While mixtures of autogenous and xenograft materials are generally accepted, the optimal proportions remain a subject of debate.

Preparation of an osteoplastic mixture from autogenous bone chips and xenogeneic bone graft YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Not long ago, a 50/50 ratio was considered the “gold standard.” Later, Istvan Urban began to promote a 70/30 ratio in his publications. Then, publications emerged suggesting that pure xenograft material works best for sinus lifts, exhibiting the least resorption and promoting bone formation due to the large contact area and the closed space of the maxillary sinus. Some clinicians even advocate using only PRF clots in the sinus, although the results are questionable.

Of course, each specialist decides which osteoplastic mixture to use, and personal preferences develop with experience.

However, most of the specialists with whom we work still prefer the “gold standard” 50/50 mixture. We believe this mixture is the most physiological. Autogenous bone is a potent stimulator of regeneration and a source of growth factors, while the xenograft material provides stability and a long-term scaffold for new bone growth.    

Ready-to-use bone material in a 50/50 autogenous/xenogeneic ratio YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Small fragments of auto-bone plus a large fraction of xeno-bone are the ideal ratio for bone tissue growth YouTube / Dr. Kamil Khabiev / Dental Guru Academy

We first fill the right sinus with the mixture shown in the photo above and simultaneously place the implants. 

Sinus lift with simultaneous implant placement YouTube / Dr. Kamil Khabiev / Dental Guru Academy

However, in the area of tooth 17, a problem existed: the buccal wall was missing, but an implant needed to be placed there. 

There is no buccal wall in the area of the 17th tooth YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The palatal wall was intact, but the bone density was D4. Therefore, it was decided to place an implant with wide threads and an aggressive thread profile in this position.

Placement of a wide-helix implant in a problem area at position 17 YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This implant “bites” into the loose bone and remains stable, as confirmed by a value of 60 on the ISQ device.

The control orthopantomogram shows that all implants are correctly positioned, with no issues of parallelism.  

Control orthopantomogram after implant placement YouTube/Dr. Kamil Khabiev / Dental Guru Academy

After the control image, the surgical wounds were sutured. The surgeon attempted to make the incisions and flap elevation in a manner that would allow for accurate repositioning and simple suturing.

The soft tissues are sutured and the patient’s jaw is ready for placement of a temporary prosthesis supported by ground teeth YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The situation before and after placement of a temporary prosthesis supported by ground teeth YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The first stage of treatment was completed. Let’s discuss future plans. A deficiency in bone width was evident at almost all implant placement sites. However, the risks of performing such a complex bone augmentation procedure were deemed too high.

At all points of implant placement, there is a noticeable bone deficiency along the width of the alveolar ridge YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Therefore, the doctor opted for soft tissue plastic surgery. After 8 months, during the second-stage surgery (healing cap placement), small fragments of connective tissue will be grafted opposite each implant to correct the vestibular contour of the gingiva. 

Areas for connective tissue transplantation YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This will increase the volume of the vascular bed, which is beneficial for preserving bone tissue, and will also improve the gingival contour and the quality of the gingival cuff around the abutments. This will be addressed in the next stage. For now, the jaw appears as shown, with the undulating contour of the soft tissues after suture removal.

Appearance of the jaw after suture removal YouTube / Dr. Kamil Khabiev / Dental Guru Academy 

After complete healing, soft tissue transplantation was initiated. The incision was made strictly along the crest of the ridge, as shown in the picture below, creating a pocket for the graft. 

Beginning of soft tissue transplantation surgery YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Since 8 teeth were extracted in advance, adequate space was available on the tuberosity for graft harvesting. The excised tissue was processed to prepare a connective tissue graft. 

Deepithelialized connective tissue graft YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Preparation of the graft: the epithelium is cut with a scalpel YouTube / Dr. Kamil Khabiev / Dental Guru Academy

First, graft strips were positioned to ensure proper size and volume.

Checking how the graft fits into place over the soft tissue YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Next, the graft was placed under the gingiva and secured with two mattress sutures in the coronal-apical plane. 

Securing the graft with mattress sutures in the coronal-apical plane YouTube / Dr. Kamil Khabiev / Dental Guru Academy

The immediate effect of increased volume and a smoothed gingival contour due to the graft was evident.

The effect of leveling the gingival contour due to the graft YouTube / Dr. Kamil Khabiev / Dental Guru Academy

A similar procedure was performed on the opposite side.

Preparing a pocket for a connective tissue graft YouTube / Dr. Kamil Khabiev / Dental Guru Academy

Here is the final picture after the connective tissue transplantation. 

The final stage of connective tissue transplantation YouTube / Dr. Kamil Khabiev / Dental Guru Academy

This concludes our case. In conclusion, let’s briefly discuss sinus lift. Although both parts of this article focused on methods to achieve restoration without bone grafting, sinus lift remains an exception due to the extremely low risk of complications. This is a closed space with excellent blood supply and a large contact area between the osteoplastic material and living bone.

We hope this material is helpful. Stay tuned for our next publication.