No buccal sulcus after closure of OAC: advice?

A friend's dad. A few upper teeth were extracted last year due to failing bridges, but both sides ended up with significant oro-antral perforation and chronic fistulous tract. Since then, he has been treated by GDP and an oral surgeon. Big buccal advancement flaps were raised on both sides to close the mouth-sinus holes. Both sides are healing well now and the pt came to me for a restorative solution. Upon examination, significant bone loss was noted. No buccal sulcus at all. the mucogingival junction, as you can see on the study model, is too palatal to the crest ridge due to big buccal flaps. Any advice on how to restore this case?

Brian G comments:

If you are talking surgical then I pass, way over my head. Precision attachment RPD? Having the distal abutments helps. Been a while since I made one but they were excellent and might be ideal for a removable in this case

Andy K comments:

Agree. Implant is not for everyone/ every case. This case with distal abutments R/L is perfect case for RPD. Placing implants after OAC - you’re asking too much IMHO.

Rok Zupancic comments:

Even if implants are planned, a RPD is probably necessary, because you can not leave the patient with no teeth for a year. I would suggest making a good precision attachment RPD, which can either be a final solution or a long term provisional.

Dr AG comments:

Need 3D advanced bone graft (sinus graft and horizontal bone plate) if placing implants. If not, removable with crown in the front and back to make precision attachments like it was mentioned. You can reposition the mucco gingival line with soft tissue graft from palate, but some limitation from the horizontal bone lost. So what is your plan and how much surgery you want to do ? Could ref to surgeon also.

Dr K G comments:

Need MaxFax intervention. Hip bone block transplant inside the sinuses. Then implants.

Alejandro Berg comments:

This is just the case for the Heuckmann minimally invasive lateral tunneling technique , it is THE indication in maxillae. Easygraft is the material that the technique was designed with and you can get nice tissue, eventually implants, if that is your goal. cheers

guest comments:

Free gingival graft taking graft from the palate, split thickness recreating the vestibule on buccal

Dennis Flanagan DDS MSc comments:

Bilateral SFE using almost any graft material except autogenous. Wait a year then consider endosseous implants

CONAN TENG DDS comments:

Considering pt age, pmh, med list, and sx. prosthesis can either be removable or fixed. if pt insist to retain as much maxillary natural dentition as possible. 1) ext #1, 16, 5 and fabricate PUD. should last the pt for a while if pt has good OH. or just fabricate PUD and add teeth #1,16, 5 to PUD as you lose them. 2) FPD, possible but not recommended but seen numerous done in mexico is a round house bridge from #1-16 (if #1, 16 not mobile) which most likely will fail in a couple years or less (specially pt lost b/l upper FPD already)

Implant retained/supported prosthesis. all remaining max teeth will need to be extracted. pending CBCT eval of bone apical of #6-12 parasinus area

  1. max overdenture w/ 4 implants in the parasinus region can be done
  2. all on X. 4-6 implants placed in the parasinus area. pt will need to use a FUD while implant healing.
    These are treatment plans thinking inside the box.
    The easiest tx pl is probably the PUD.
    It is very hard to evaluate implant placement for such a difficult case on a PANO. really have to evaluate with CBCT.
    i think avoiding the sinus is key here due to h/o large OAF. unfortunately, pt’s posterior ridge is nonexistent. even with good sinus lift trying to recreate missing buccal/palatal dimensions with block graft is just too difficult.

Scott Bobbitt DMD MAGD DI comments:

That's extensive damage. I'd pass on the implants and surgery needed to predictably restore the upper posterior. Why not stick to conventional dentistry and address the lower right side before it blows out? You can hem and haw and debate the process or (in the case I have attached here, a Bredent precision RPD) whether I should have had multiple premolars vs single molar replacements, but the case has been in function for 13 years. Not every case needs to be treated with implants.

Tony comments:

I have a similar case like this... severely resorbed maxillae. But, the patient does not have any distal abutment teeth. What would you recommend? If he continues to wear his existing partial, which is very loose, what will be the eventual result? Will he lose even more bone? Then, what is the treatment. Thanks!

Scott Bobbitt DMD MAGD DI comments:

Fabricate an RPD with an open ring major connector and extend the flanges to achieve the most coverage of the tuberosities. The Bredent attachments with good guide planes on the milled crowns should provide excellent retention. Good luck!

BroMike BroMike comments:

I am not considering implants at this stage. The issue is actually the soft tissue. The buccal flap/muscle was pulled much too palatally. (the photos are not very clear). The movable soft tissue is very stiff and actually more coronally positioned than the alveolar crest ridge. I am very concerned about the retention of upper denture even with precision attachements

Greg Kammeyer DDS MS DABO comments:

Sacrificing teeth for an all on x, doesn't leave enough posterior teeth without an excessive cantilever. Yes a partial is easier and it will beat up the bone. Yes, you could do ptyerigoid implants yet the AP distance would be great and again you'd sacrifice teeth for the all on X.

I agree with Dr AG. The floor of the sinus needs augmentation with a horizontal bone plate (autogenous via the Kouray technique or an allograft), along with the rest of the sinus: SA4. You can still do the lateral window yet disecting the synedrian membrane from your OAF closure is challenging. After the bone graft is consolidated ( I ALWAYS ADD PDGF to speed bone healing for large sinus grafts). This one I would let the graft sit 7-9 months and have a CT to confirm the graft consolidation around the prior OAF. Then you can do a vestibuloplasty and a free gingival graft. Check out Istvan Urban’s technique to use less palatal tissue. As long as the patient has a patent OMC and isn’t prone to sinus infections, this should work nicely.

Richard comments:

OK Max RPD with room in framework to add a locator attachment to the RPD. Do bilateral sinus lifts distal from the sinus tract area. Place one implant each side each. Do gingival grafting where necessary and use locator attachment to shorten the span and lessen long span flexion. Be sure to have immediate bilateral cuspid lift to less pressure on the posterior spans. You will need a CBCT and stent to guide the implants accurately to the planned sites.