Live Surgery - Regeneration of the Ridge in Vertical and Horizontal Dimensions

One of the more difficult defects to treat with augmentation techniques is the anterior maxillary area with lost teeth and vertical and horizontal bone support. Often the result of trauma, it can also result from prior procedures and subsequent bone loss.  The implant placement depends in large parts on the available bone to support the implants and overlying soft tissue.  Most realize this also impacts the esthetic outcome of the implants and the ultimate fixed restoration. There are multiple papers and book chapters addressing various techniques to obtain the ideal outcome both esthetic and functional.  Many different approaches are advocated to reach the ideal result.

In 2007, the FDA within the USA gave certification for the use of rhBMP-2 in maxillary anterior defects.  This has become one source for predictable bone regeneration of the missing alveolus and supporting tissues.  While the use of a titanium construct is not FDA certified; it has become the main stay for supporting the space maintenance issues needed for bone regeneration.  The questions of wound dehiscence and breakdown are some of the most common post-operative complications and will be addressed.

This live surgery starts with the presentation of the patient, a young female, who has a significant defect in the anterior maxilla due to a car accident. Primary Surgeon Dr. Jay Malmquist explains the starting situation by showing x-rays and images of the clinical pre-operative situation. He begins the surgery with the accessing of the affected area, carefully releasing the soft tissue, and explaining the reason behind his approach. He is assisted by Dr. Michael Malmquist during the surgery. During the opening phase, Dr. Jay Malmquist points out how important the handling of scar tissue is, and what influence it has on the result. Additional to the effect of the car accident, the patient also had several failed implants in the affected area of the maxilla.

In the main phase of the surgery, Dr. Malmquist places the titanium mesh and explains the benefits of using a guiding structure in large bone defect reconstructions. On a study model, he demonstrates the placement of the mesh and what he wants to achieve by using this supporting structure. Together with Dr. Michael Malmquist, he then fills the mesh with bone substitute. During this step of the process, he discusses the composition of the substitute and how it benefits the reconstruction and healing. Both surgeons place the mesh and demonstrate how to secure the position of the mesh to enable a successful creation of the needed height and width of the maxillary aspect.

During the closing phase, Dr. Malmquist points out the importance of passive closure to support a successful healing. He explains his approach to placing the sutures and what kind of sutures he prefers in cases like the presented one. Dr. Malmquist also addresses his approach of providing a temporary restoration to the patient for the short-term and long-term healing phases.

This surgery was broadcasted live from the surgical suite in Portland, Oregon after a brief introduction prior to the actual surgery.  Multiple cameras give the best possible view of the surgery. After the completion of the surgery, Dr. Jay Malmquist covers the audience questions. During the live streaming of the surgery, moderator Dr. James Chow led the audience question and answer, forwarding questions to the surgeons in the operating theatre.

This video is available with captions in different languages - click on the cc button in the lower right corner of the video to select your preferred language.