Non traditional use of a Connective Tissue Graft: Case Study

This is a 64 year old white male who was referred for existing maxillary implant evaluation. This patient had concern regarding fluids “leaking from my nose when I drink”. Patient had 6 maxillary implants placed and bilateral sinus grafts for a bar overdenture 2 years prior to this consultation. Clinical evaluation revealed a fistula of the right posterior maxillary buccal vestibule (Fig. 1). Cone beam CT revealed bilateral sinus grafts with 6 cylinder implants positioned from first bicuspid to first bicuspid and incomplete graft incorporation of the grafted right maxillary sinus (Fig 2). This patient was unhappy with his existing removable prosthesis and was motivated to have a fixed prosthesis. 

Initial treatment focused on correction of the oral antral communication. Full flap reflection of the right posterior maxilla allowed access for debridement and removal of all graft remnants of the sinus (Fig 3-4). The fistula was excised and a connective tissue graft harvested from the right hemi palate was sutured into position on the underside of the flap ( Fig 5,6). The sinus was then regrafted with mineralized allograft (MinerOss), xenograft (BioOss) and PRGF (Fig 7). A PRGF fibrin clot was placed over the window (Fig 08) and a type 1 collagen membrane (Memlok) was secured over the window (Fig 9). Follow up at 1 month (Fig 11) and 4.5 months (Fig 12) revealed stable closure of the OA communication compared to initial presentation (Fig 10). This patient was temporarily lost to follow-up and “resurfaced” almost 2 years later. A post graft CT scan showed excellent bone incorporation of the right sinus graft (Fig. 13) and continued stable closure of the OA communication (Fig 14).

Reentry revealed the expected graft incorporation (Fig. 15). The most posterior implant of that quadrant was removed due to radiographic evidence of significant bone loss (Fig. 16, 17) (BTI implant removal kit was used). A BioHorizon tapered internal Laser Lok implant 4.6 x 15mm length was placed both in the failed implant site and posterior to this site in a non-submerged mode (Fig 18, 19). Three months later healing abutments were removed (Fig 20) and both implants tested for degree of integration with resonance frequency analysis (Osstell) (Fig 21, 22). A fixed hybrid prosthesis was subsequently fabricated (Fig 23, 24).

As you can see there are non traditional applications of connective tissue grafts. For more details we encourage you to be part of our next Soft Tissue Grafting Course. Click Here.

 

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