Maxillary 1st Premolar Buccal Concavity with Narrow Ridge: Treatment Options?

I have treatment planned a case for installation of an implant in the maxillary first premolar area.  Radiography shows an alveolar ridge bucco-lingual dimension of 4.5mm.  There is 11mm between the maxillary alveolar ridge height and the floor of the maxillary sinus. Can I place a 3.3mm diameter implant and attempt to install just under or just barely against the sinus wall?  Should I engage both cortices for bi-cortical stabilization?  There is about 7-8mm mesiodistal space between the maxillary canine and second premolar. Patient declines sinus lift and bone graft.  What do you recommend?

(click to enlarge)

(click to enlarge)

42 thoughts on “Maxillary 1st Premolar Buccal Concavity with Narrow Ridge: Treatment Options?

  1. I would place the implant short of the sinus floor. No need for internal lift with 11mm bony height.
    The ridge appears wide enough for a 3.5mm diameter implant.
    Drill initial osteotomy with 2mm drill to depth then use bone spreading osteotomes to expand the alveolus.
    Exposure of the alveolus is the key in this situation to avoid perforating through the buccal plate.
    Design the incision with mesial and distal releases at the line angles of the adjacent teeth.

  2. there is two way for this case;
    1.bone split technique
    2.bone spread technique: A.use of osteotom B.use of compression kit
    use of bone compression kit such as MIS kit is easier and no agressive and the reasult is good.try it specially for this case.

    • Ali, splitting the ridge between two healthy teeth, is illadvised, especially for someone that is just getting started, or someone not proficient in skeletal surgery. It sounds good, in conversation, but the reality of the matter is, it’s just not practical. If this patient refuses a simpler procedure (graft/sinus lift), then they sure aren’t gonna go for a ridge split, especially if the surgeon performs a thorough consent process. Ridge splitting has it’s place in implant dentistry, but for single tooth replacement, not so much! Bv

  3. in this case, sinus lift is not necessary. you perfectly can install a 3.3 or even a 4.1, i suggest allograft in the buccal face of alveolar bone for improve the biotype, even if the threads are not exposed…. a better prognosis you will have. it looks a simple case…. but always must be careful
    good luck
    camilo

    • Dear dr ulloa bone augmentation bucaly is a nice suggestion but if the drilling and implant insertion will not cause buccal perforation, have we perforate it before application of the bone substitute or what.

  4. as long as there’s a tooth distal to it, should be ok. May want to set the patient up for a GBR with buccal membrane. Flap, implant osteotomy, save the bone shavings from the drill, if no dehiscence, just install. If there is a dehescence, put the bone shavings first, then some mineross or biooss on top with membrane and close. Stitch it closed. The stitching being the most important. It’s gotta be completely closed. Put tetracycline powder on the stitch, and put perio bandage on top. Rx antibiotic 10 days. As long as you are super anal about not getting infection, this should be a slam dunk. Good Luck!

      • bone subbstitute in the implant field is like a gata-percha in the endodontic treatment. shall we educate our patients about that or let the the Patient to decide what we may face in the future with failing implant.

    • Dean, the most important thing is “the stitching”? Come on now. The whole premise of the membrane, is to avoid the need for primary closure, in my hands. You are “robbing Peter to pay Paul “, if you are raising your mucosal flaps so much, that you can get passive approximation of the wound margins. Certainly, there is a place for ” this “, but not when you are replacing a single tooth. It is a proven fact, that most of the nutrient supply, comes from the intact, periosteum. I’m going to suggest raising the flaps just enough to get your resorbable membrane secured. Bv

  5. Implants 101:
    Place when you have 2mm of bone circumferentially. Anything LESS is a compromise – PERIOD! Do compromises always fail? NOPE THANK GOD!
    But you know what really sucks? to loose an implant in an area that was compromised to begin with! Now you’ve got twice the grafting to do! HOORAH!!!

    Consider INFORMING the patient what will decrease or increase the chances of survival of the implant and move forward. Yes, some type of augmentation, or ridge split procedure should improve your boney mass. Yes, you can “fit” an implant in the given bone without doing anything and hopefully it’ll all turn out nicely! Pick your battles wisely!

    BTW – Tanaka forgot a very important ingredient of any augmentation procedure – you’ll need to perforate the buccal plate in several areas to allow blood to flow (hence angiogenesis). Your membrane is going to prevent influx from the tissue, and just by stripping the periosteum alone does not guarantee blood vessels will form thru the graft. Without angiogenesis, you’ll loose your graft or have a very high rate of resorption. Please review the book “Tissue Engineering” by Lynch, Genco, and Marx page 92. Have fun!

    • Kevin, I just watched mike block show 20 plus cases of bovine augmentation, done in the last 3 years, with exceptional results and he never perforates the buccal plate, primarily because he uses a tunneling technique, with absolutely no vertical release incisions and can’t access it enough to score or perforate the plate . I agree with you, but this presentation was very compelling. He did not place the implant into “that material”, with the exception of the minor buccal dehiscence. The ” grafted ” material looked good, both radiographically and clinically . He used sonic weld, as the membrane and did not cover the ridge, with the membrane. I’m sure a published document, is forthcoming. Bv

  6. Since patient refused graft, I would place a 3.3 and do it by compression/condensation (hartzell makes a wonderful kit), and i would place an 11.5 so to intrude lightly in the sinus for better initial stability and that will give you a good result. Is the patient aware of the probable lack of cosmetic result?

    • (2 mm of bone buccaly)very nice advice, that is very important to give a support for buccal mucosa and mai

      ntain the aesthetic implant in the future.
      nice comment Richard

  7. bone spreading using osteotomes should be ok for this case. Insert implant utilizing the full height avaliable.

  8. This case seems good for bone expansion. Tatum surgical makes kits to expand the bone. One can fairly predictably place a 4×14 Tatum S implant in this site. This is not so easy unless you know what to do and how to do it. You can learn these types of techniques at Dr. Jose Pedroza’s hands on course in San Juan Puerto Rico. Dr. Tatum attends and instructs in most of the sessions. There is probably no better qualified person to learn this technique than from the master that has perfected this modality.

  9. Dear Dr, your planning is the very good for the kind of patient you have, You can use 3.3 x 1o straight, or 3.6,3.7 tapered implant, drill a little parallel aiming to go bisecting the buccal concavity and the palatal wall keeping in mind an angled abutment for the prosthesis,

  10. I would use a 3.0mm x 8.0 mm Bicon implant…hand instrument the last reamer…no need to graft or split ridge…but inform patient that if any type of perforation on buccal or lingual some synthetic bone graft will be needed with GTR membrane. Up to patient at that point.

  11. Looks like you have minmum of 4mm bucco – lingual dimension there,
    in this case you can expand the ridge easily in maxilla with osteotome to place a 3.3 or 4 mm diameter implant comfortably. The ridge may also be split quite easily also. Wouldn’t worry about the sinus too much. you can tent it for 2mm no problem without graft. Just take your time expanding
    the ridge and tenting the sinus floor.

  12. You can do the case with bone expansion/ ridge expansion utilizing osteotomes or ridge expansion kits like one from MIS or Meissinger . Plan the expansion beforehand such that there is sufficient bone ( 2mm ) around the implant after expansion osteotomy and placement You will need a good flap release to achieve primary closure over the implant site . In case you notice any dehiscence any where over the implant body after insertion , you may need to graft the site with a suitable bone graft and place a membrane over the defect .

  13. Not a big fan of bicon. Biohorizon 3.0 laserlok would work. This is a rare case that I may even say (shudder at the thought) a mini, 2.5 or so.

  14. Mike, are you treating the ct scan or the patient, when you make that suggestion? A thickened sinus membrane or an opacified sinus, even, does not an infection make. This mentality, is exactly why we are getting super- resistant bacterial strains. Unless the patient is experiencing rubor, tumor and calor, then there is no need to give empirical antibiotics. Bv

  15. Bv is correct as usual. Why over medicate.

    I would use a 2.0 pilot drill than install megagen anyridge 3.5 x 11.5. No compression needed. You can use this specially designed implant to compress. Just remember after installing at crest reverse torque 1-2 thread the reinsert no more than 45ncm.

  16. I would use bicon 3.5*8mm implant, first use pilot reamer (2mm) after this 2.5mm and then start to expand gently,you shoud have minimum thickness 1mm of eache wall of your osteotomy,no need of full thickness flap elevation on the buccal side(because it will compromise blood supply to walls) if you dont perforate the wall.And of course no need to elevate the sinus.In case if you have dehiscence you can use “sandwich technique”-
    place autobone(its available if you use Bicon technique),subsequently put SynthoGraft and cover with resorbable membrane( for realization this raise full thickness flap with implication of minimum nearest 2 teeth
    Good luck from Ukraine

  17. Well said BV , I would be exicited to have this much bone compared to most cases that get referred in , just raise a full flap so you can see what you are doing ( Scans may not be the full picture ) and x-ray your pilot to check angulations .
    Simple
    Peter

    • Dr Peter is it paramount to raise the flap in this case,I suggest its enough to check the walls from osteotomy with curette each time we change expander
      Thanks

  18. HI You Need Atleast 53 Space Buccopallatally.You Must Do Surgery For Expansion With GBR and Membrane At Buccal Side and replace fixture at the region same time and after 4 months you can load imp….

  19. Dr. Kazemi, the patient refuses the graft. The case will be a bit comprimised, but it can be done without splitting or expansion. I would engage the sinus, ever so slightly.

  20. From prosthetic point of view the space 7-8mm (mesiodistal) is too wide for the future first premolar restoration, and my concern is a possible patient’s cosmetic complaint.

    • Dear Richard a wonder like Dr. Zavyalov and i know anatomically the mesio-distal dimention of premolar is about 7-8 mm, but my wondering is from biomechanical view (how the implant with narrow diameter will carry that larg crown,shall think about the posibility of insetion of wider implant with some type of grafting or expantion to make the prosthodontist satisfy.

  21. Hi Rusian , I did my flapless thing a few years ago , it is always better to know visiually especially in this type of case that you have not perforated . I still never trust myself and angles even after over 20 years of placing.
    Peter

  22. A pretty straightforward case.
    No grafting needed…pilot drill then 2mm drill….expand for a 3-3.5mm any approved system will do .I would certainly flap this …otherwise an easy case can get messed up.

  23. Place the implant after using tapered osteotomes in the osteotomy. Place an onlay graft. It the patient won ‘t have the graft then don’t do the procedure as it is in their best interest for the long term success of the implant.

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