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No Cortical Bone: What’s the Prognosis?

posted in Treatment Planning & Complications, Bone Grafting

« Trouble Getting Primary Stability | Alloderm Graft Failure: What Could Have Been Done? »

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Dr. S. asks:

I laid a full thickness flap to place a dental implant in the maxillary canine area. The buccal and lingual cortical plates were healthy and sound. But at the height of the alveolar crest, the bone was cancellous without a cortical bone outer surface. I filled the defect with Dyna putty graft material.

After 3 months I decided to place the dental implant into the grafted area. When I elevated the flap I saw that the gap was filled with some cancellous bone but still no cortical bone over the crest. While I was drilling with the first dril(2.3 mm) I realized that the newly formed bone was very soft so I tried to reach the mature bone and after second drill i placed 4,1×14 mm implant. The dental implant had primary stability. I decided to take some cortical bone graft from the exposed area and placed around the implant and put a membrane over the graft. I closed the flap without any tension.

What do you think about the prognosis of the dental implant? Do you think grafting and membrane application will improve the osseointegration by helping to form cortical bone around the implant or was that needless?

8 Responses to “ No Cortical Bone: What’s the Prognosis? ”

• Don Callan July 5th, 2007

  
  

  Dyna putty graft material is only 35-38% bone, the rest is filler. You may want to use a material without fillers material that is less than 3% mineral content and that has been process properly.
  Don Callan

• Alan Winter July 5th, 2007

  
  

  If there is primary stability, then the implant should integrate regardles of the graft and membrane. It is difficult to declare that the bone you saw at the crest after 3 months was cancellous without looking at it histologically. It may not have been as mineralized as the adjacent bone, but it was probably adequately healed to insert the implant without a graft at that time. A consideration in the future would be to use partial thickness flaps rather than full thickness. This minimalizes the trauma to the surgical site and reduces the incidence of gingival recession.

• George July 7th, 2007

  
  

  Does Grafton have less filler material?

• Dr. Gerald Rudick July 10th, 2007

  
  

  No cortical bone…what’s the progress?

  In my experience, I would take advantage of the fact there is a lack of cortical bone, but good healthy cancellous bone.

  If the bone appears soft, rather than drilling and removing bone, my suggestion is after you have made a pilot hole to dictate the direction and position of the osteotomy, I would proceed with Osteotomes, and gently pound these instruments to the desired length, progressively using wider instruments.

  What you are doing is condensing and compressing the cancellous bone, making it more dense.The implant will fit very snugly, and require some extra force to screw it to place……screw it in slowly, giving the expanding bone to rest a little.

  Bone reacts to stress, much the same way muscle does when it is worked….so what you think it unsuitable will turn into good implant supporting bone.

  I would also advocate flapless surgery, so as not to interefere with the blood supply.

  Gerald Rudick dds MOntreal, Canada

• Dr. Bill Woods July 12th, 2007

  
  

  Osteotomes are a good thing to remember in this situation. And the comment on the partial thick flap is really significant to me. 80% of the blood supply to the plate comes from the periosteum and a full think flap takes a month to reestablish itself. Rather than using putty, I would use the bone from the osteotomy from a bone trap instead. I think its better than the putty. And I would give that site an extra month or two before uncovering. Its a cuspid and that implant is going to take some load over the years. Why a 4mm implant? If it was due to the B/L width, you could have widened it for a wider diameter. Got to be careful with the buccal plate, though. One of my patients lost a lateral maxillary incisor implant in December - conservative osteotome expansion - everything looked great until uncovery. But it was a full thick flap, thin biotype, 0.5mm plate. The plate just resorbed leaving a real mess. I wasnt happy. Not a fun day but the patient is now happy with a pontic in the area. Regrafting after the initial allograft repair would have required a block and she wasnt up to it. The contralateral incisor implant did fine with The same placement technique there, too. But I am going to have to watch that one. In summary, be conservative, minimize flaps if you can. Stay away from the plate. Select the implant that will function the best in that area. More surface area means more osseointegration in that area, and…dont mind waiting a little longer if you need to to uncover and load. JMO Bill

• DG, DMD September 3rd, 2007

  
  

  I agree with Dr Callan. We use Bio-Oss Collagen. 90% small particle cancellous bone and 10% collagen. No filler and very osteoconductive. Very easy to handle as well.

• Jason Michael September 20th, 2007

  
  

  Hi,
  I went to a dentist who informed me that I’m unable to have an implant procedure due to the area under the gum being completely void of any bone.
  This is my front lower left tooth.
  Is there anything that can be done?
  I absolutely refuse to get any type of bridge-work, subsequently damaging the perfectly healthy surrounding teeth.

  Thank you,
  Jason

• Dr F Tarashi December 1st, 2009

  
  

  Jason Michael
  Do you have any general disease?
  do you have oesteoporosis?
  How you lost your Tooth?
  How many years old you are?
  Are you able to scan your X ray and send it for me?

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