Buccal Bone Loss on Immediate Implant: Recommendations?

Dr. Z. asks:

In July 2008, I extracted the maxillary right canine and central incisor and placed 2 immediate dental implants. The lateral incisor was already missing. I engaged the palatal walls of the sockets like I often do and grafted the void between the implants and buccal walls. There was no buccal bone loss at time of extraction. I placed a resorbable collagen membrane over each of the implants and closed the areas. Everything healed fine, no infection, no pain, no suppuration and I took radiographs at 3-months. No bone loss was evident. At the 5-month post-op, I see darkness through the buccal mucosa on the buccal of the canine area. It looks like the implant.

I decided to do stage-2 today uncover on the spot and I laid a flap to discover that the implant in the canine position is completely dehisced on the buccal, but the mesial, distal, palatal aspects are completely covered to the top of the implant with bone. Only the buccal was dehisced all the way down. The implant was completely osseointegrated on the other walls and very stable. I put tetracycline on the buccal surface of the implant, then placed an allograft bone graft (Oragraft) and covered it with a collagen resorbable membrane and closed everything back up. I plan to uncover again in another 5 months. Should I have trephined out the implant and tried to place it so all walls would be in bone? Any recommendations?

28 thoughts on “Buccal Bone Loss on Immediate Implant: Recommendations?

  1. Why to open it again. If you will be lucky there will be not fully maturated bone and it don’ likes to be opened. It’s not easy to create new bone without bone walls. I hope you will successful.

  2. Dr. Z,

    This is a common occurance with immediately placed implants with a thin buccal plate. The canine tends to have a thin buccal plate and immediate placement can result in dehiscence. Autogenous bone is best for these grafts or delayed placement may be the better way to go. At this point, I would consider a ti-reinforced membrane with autogenous bone…and still you may not get complete buccal regeneration. I would not trephine it out since it may create a larger defect.
    You did well to sterilize the implant surface (laser works too)and you may consider thickening the tissue if it’s thin.
    Like always, it’s hard to help without pictures and radiographs but I wish you good luck with the case.

  3. There could be a few reasons to the bone loss ,maybe the thin plate on the canine was fractured during the extraction. Repair is the alternative that appeals most due to the destructive nature of trephining an implant out. You will need bone coverage to allow the soft tissue to attach to to avoid a buccal pocket with associated infection it is said that you need 2 mm of bone but I have seen long term success with a thin layer.The most important part is the preparation of the Implant surface when regrafting and here I use a prophy jet to “blast” the surface clean to attempt to return it to a micro clean situation (not just bacterially clean)
    .You must try to protect the surrounding hard tissue when using high pressure air instruments.
    Personally I then use synthetic graft materials (that set) without a membrane and have had some good results.
    Anyway it has been repaired and good luck the body is our friend it wants to heal.

  4. this highlights a problem with immediate implant placements in the upper canine region in that the buccal plate is thin and more prominent than the surrounding buccal plate of the lateral and premolar . even if you leave a gap of 1.5mm between the implant and buccal wall , the remodelling of the plate can still result in this dehisence . I feel that the safest way to go with maxillary canines is a post immediate placement with simultaneous augmentation at around 2-3 months .

    Dr salama recommends acid etching exposed implant surface for 2 mins before re augmenting. you wont get re osseointegration , just thick fibrous tissue and some bulk to the tissue which will reduce the cosmetic impact of metal show .

    hope your case goes well

  5. Take away lesson. Spend an extra two months. At the time of tooth removal do immediate osseous socket regeneration grafting with small (0.5-1.0) cortical/cancellous PurOss (AlloOss) osseous grafting. Go back in two months and place two single stage implants. Wait 3 months and restore. 98-99+% success. Forget immediate implants in the esthetic zone unless you are willing to spend many more months on a potentially compromised implant restorative result. Much less time in the long run. Much more predictable. All depends on how you present it on the front end. A couple of months is a small price to pay for an excellent result. A surgeons perspective.

  6. If you read the literature carefully, you will see that any study done that looks at bone volume after immediate socket implantation shows loss of bucco-palatal bone volume AND a residual infrabony defect. There is no predictable human histologic evidence of bone reformation, regeneration and osseointegration around placed implants. The promise in that arena is BMP and there’s much study to be done there.
    SO, whether the buccal plate was very thin, micro- or macro-fractured doesn’t really matter. The question is if the current condition is aesthetic, functional and/or maintainable. That will determine whether you keep and graft the implant or drop back 15 and punt after the implant is removed, site grafted (hard and soft tissue) and then a new implant placed and restored.
    Good luck.

  7. Dr.Z
    Raise a buccal flap.Put a cortical autogenous bone graft harvested from the maxillry buttress or mandibular externanl oblique ridge over the buccal aspect of the implant containig socket.Fix it by two cortical screws.Release the flap and cover the socket and its buccal area thoroughly, free of any tension (no membrane is needed).Wait for three months and the load it.

  8. I think you did fine. What kind of bone did you use the first time? The literature definitely supports the protocol that you followed both initially and the stg 2. There must be a fine point that we are missing that caused this problem. Was there an infection? Why were the teeth extracted? Was this a thin tissue case?

  9. First it would have been very helpful to see images of the site and a couple of radiographs.Then at the time of uncovering one should asses the bony defect -there are four classes – and then for this type of defect usualy there’s a mandatory need of autogenous bone used alone with a resorbable membrane or in a sandwich technique . Success of surgery depends on the flap release, stabilisation of the membrane and vascularisation.In these cases Ti -reinforced is not an indication(only if you have had bone loss around the implant so you would have needed vertical gain of the 4 walls-and more than that is not easy to use in short span areas) .Only an alograft with no vascularization is not very predictable but we’ll see after 6 months -hope u have some results.Decontamination of the implant is a very important step indeed.

  10. Dear Dr. Z.,
    Reconstruction of natural bone and osseointegration over the denuded area of the implant is not predictable, even if you put bone graft and membrane over it. However, it will increase the thickness of the overlying tissue and remove te black appearance. Connective tissue graft under the labial flap would increase the soft tissue thickness, as well.
    Immediate implantation is not mandatory in such cases with thin labial bone.
    REMEMBER: Implant placemnet will never prevent crestal bone resorption.
    Thanks if the result could be shown.
    Neda Moslemi

  11. Acid was tried years ago–did not work then except for short term, NOTHING long term. Cut the loss and remove the implant, bone regeneration procedure, wait 3-4 months, reimplant.
    Remember there are no short cuts. Build the foundation first then place the implant.
    Bob Horowitz is correct: If you read the literature carefully, you will see that any study done that looks at bone volume after immediate socket implantation shows loss of bucco-palatal bone volume AND a residual infrabony defect. There is no predictable human histologic evidence of bone reformation, regeneration and osseointegration around placed implants.

  12. you did the best job ,there is not anything alse to do , and as you know regardless the kind of the graft ( outgenous or allo or xeno ..) it is a little bit difficult to expect bone regeneration on the exposed threads in such a situation . anyway it is better going on and go for suprastructure .Cherss

  13. Depending upon the length and diameter of implant, smile line and much more you may be able to prepare the implant body utilizing tremendous amounts of cold steerile irrigation and turn this into a fairly straight forward crown and bridge case from and impression standpoint. The late Charlie English was famous for this approach. There has been a tremendous amount of research from the standpoint of heat generation and it is valid. However, this is a bailout procedure that is very, very successful if you keep things cool. Best of luck to you.

  14. What was the condition of the bone, teeth and areas in general prior to extractions? Bad bone = bad results ie. dead bone no osteointegration and nonunion of the graft.

  15. One of the outcomes of immediate implant installation at the anterior maxillary area is the collapse and/or resorption of the labial wall (plate) of the socket. This does not happen because of implant insertion but it is a common result of tooth extraction. It almost looks like the entity that periodontists use to call a Stillman’s cleft in clincal features, albeit with some subtle differences.For this reason, some expert clinicians have recommended the even minimal gap between the fixture and the buccal plate should always be filled up by some kind of grafting material. Regarding theses clinical facts, you do not need to detoxify anything (e.g. the implant body) because it is not an inflammatory process as is a peri-implantitis. Just cover the so-called cleft of the buccal aspect of the socket by a thick enough cortical slice of bone, in a well-vascularized tension free soft tissue bed “et regardez votre reussite.”

  16. This is a very common situation when you place immediate implants, Today implants are passive devices and they only will be surrounded by bone (osseointegrated) when there is bone present. What happened in your case is a successful integrated implant….soft tissue integrated at the buccal and osseointegrated at the palatal.
    You got what you aimed for. Research about this subject is not new so you are suppose to know that any time you extract a tooth you will end up with a remodeled osseous crest that will be thinner and lower specially at the buccal plate than the original one. This will happens in spite of placing an implant or not.
    Placing the implant palatal and grafting the void is unpredictably, it only works sometimes, I guess it is because you are placing the graft in a resorptive environment (a lot of osteoclastic activity).
    It is very difficult to regenerate bone over any inert nonvascular surface (Implant), and it will be even harder if the bone you want to regenerate is located outside the current bone profile.
    So the best Idea is either to improve the soft tissue thickness at the buccal with a connective tissue graft leave the implant and place the crown.If you appreciate any further problem you have to remove the implant and start again the way you should the first time, first regenerating new bone and later placing the implant in sound bone.

  17. Don Callan is so wrong!Patients dont want thick buccal plates, but they love teeth!So ur patient doesnt really care if there is no buccal plate as long as u can provide him with a nice porcelain crown.Plus the implant will have no long term problems if the maintenance is good and u dont give him a canine guided occlusion scheme.The only problem will be the esthetics, due to the implant being visible under the gingiva.So grafting with an allograft, which is non resorbable is the best way to solve that.It wont become bone but itll stay there and prevent the implant shading through the gingiva.

    The reason u had that problem is that u didnt behave well to the vascularization of the buccal plate.Cause u stopped the blood supply from the periodontal ligament when u extracted the tooth and u also stopped the blood supply from the periosteum when u raised the flap.So no blood, means resorption!So, next time do it the Greek way, do it flapless!So the buccal plate will behave better~Itll resorb, but it’ll do the minimal resorption possible!

  18. You need at least 1 to 1.5mm. of bone on the buccal plate to place an immediate implant without a graft. You also have to consider to status of the extraction site: infection present or not, endo tx tooth with silver retrofill etc.

  19. coxsakie
    Placing implants without a flap is liked having sex with you clothes on. You will have a better result if you will really get withit. A flap is not a pathological defect. Just be kind to the tissue.

  20. I couldn’t agree with Don Callan more. Unless you have a CT scan then tissue reflection is mandatory. This is the only true way to visualize the boney architecture. If you are going to risk it then make sure that you do a poor mans ct with some calipers, pick a patient with thick biotype, nice embrasure form and make sure that you are in a safe place; example Maxillary 1st or 2nd bicuspid.(Watch for undercut on buccal aspect) Nobody is saying that you can’t do a flapless approach. The question is should you? You can jump out of an airplane without a parachute but should you?

  21. Flapless should be the exception ( in the Ideal senario)rather than the normal. Teeth are lost for a reason and these reasons lead to pathology which result in defects.
    As to preparing a implant surface in -situ all that is needed is micro abrasion with a prophy jet ( no acid or anti biotics) . My collegue has made and designed implants for 30 years suggests this and we have some good results

  22. giving a very absolute answer is not propriate in such a case but immediate implant placement in the anterior area is senn in litritures and have high succes rate but, the art about that is when to do so and what are the standardes for that, well for your case I think after the good preparation of the implant surface i think it is very wise to place autogenous bone graft mixed with some synthetic bone graft material and then to evaluate the soft tissues over the area of the defect if it is thin so you will have thikin it. well I think you can wait to see if it worked or not.
    wish you all the luck.

  23. Dr Z,

    I seldom if ever raise a flap when I place implants into fresh extraction sockets. If the buccal bone was intact originally, its loss is probably due to compromised blood supply. Flaps are not pathological, but detaching periosteum from bone will definitely compromise its blood supply.

    Placing an implant into an extraction socket without a flap is not blind surgery. The socket itself is the best surgical guide for the placement of the implant.

    Back to your problem, I think any allograft or xenograft should be able to mask the appearance of the metal through the gingiva. Of course, don’t expect it to integrate. The implant should do well as long as your apical and palatal bone are engaging well.

  24. Been following the exchange and all the comments and have enjoyed it. I work in a perio office as an practice manager and wanted to see how the case came out …Dr. Z can you post a follow up ?

    Thanks everyone for your comments exchange….your varied perspectives have been very interesting

  25. Dr. Z, Did you elevate a flap when you placed the immediate implant? you can expect to get a couple tenths of a mm of bone resorption if you elevated a flap.

    Also, how did the immediate implant turn out on the central?

  26. Hello everyone,

    thank you for your responses and ideas…

    I have been doing implants for a while, and I did elevate a flap to make sure there was no deshience or fenestration on the buccal plate…

    everything looked fine, the central incisor implant is well integrated with bone all around the implant…

    I can’t seem to remember if the buccal plate was thick or not, but it must have been if i decided to place the implant…

    But maybe it wasn’t…that’s the only explanation i have since the rest of the implant has bone all the way to the top…

    So now I saw her 2 days ago for her 3 month postop…i am starting to see darkness through the gum on the buccal…it’s the implant…I think when i uncover it in april i will place a healing abutment and place a CT graft on the buccal coronal half of the implant and let it sit for another 2 months maybe…

    I don’t mind removing the implant, but is it the best thing to do if it’s completely integrated ???

    Comments ??? Ideas ???

  27. if we have to remove implant cos of buccal bone resorption ,then we should have removed a good no. of implants ,which is not the case.the base in medicine is ,diagnosis & then treatment,diagnosis does not only mean buccal bone resorption,it should include,why it happened,how it well progress & what is the effect? this is the wisdom of the doctor to take the decision. every case is different.eithout answering the above Qs.the dicision well be wrong.define the problem then solve it.so after cheking the occlusion ,implant stability,u can decide if it only an esthetic problem or it well be progressive functionl one with progressive pocket formation.the concept in treatment plane is different wether we are facing a functional problem or esthetic one.Good luck

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