Deeper implant or buccal graft?

Dear colleagues, I have been seeing many cases like this where there is adequate alveolar ridge height but deficient buccolingual alveolar bone width, about 4.8 – 5mm. What is your protocol to treat cases like this? If I place the implants like in this sketch, a few threads of the implant would be exposed on the buccal side. Is the best option is to put some allograft/xenograft over the threads? What would you do?

28 thoughts on “Deeper implant or buccal graft?

  1. ST says:

    Ridge split or ridge expansion with osteotomes, apologies to Dr Buck but 3.2 mm diameter just too narrow for posterior region.

  2. Dr. Drew Moore, DDS, MS says:

    Lean it a bit to the lingual. Use a thinner implant and go a bit deeper. I try to follow the parameters as much as possible. If you have less than 2 mm on B or L, you will lose bone. Unless you have really good walls of bone to the M and D of the showing threads, a graft is not guaranteed. It will also save money for the patient and materials, worry and headache and additional surgeries, if you sink it properly.

    I don’t take chances anymore.

    This is from a board certified 3-year residency trained periodontist. No herodontics.

    • George Yzaguirre says:

      You are exactly right doc. These parameters will be best for long term success of the implant. Bravo

  3. Marcus says:

    What kind of case is this? I don’t see any teeth around. If it’s a hybrid case or other edentulous case, I would just do selective alveolectomy (i.e. plow down the ridge) to the appropriate width as long as you leave enough bone superior to the IAN. Ridge split in the mandible is tricky, prone to fracture and not easy. GBR will give you 2-3 mm (maybe), solid block graft either allo or autogenous has been shown consistently to give the most predictable and reliable results. I would be very very cautious with placing the implant with exposed threads unless you put titanium or tenting screws to keep the periosteum pushed out otherwise I’ll guarantee the bone you place to cover the threads won’t take (don’t forget that that titanium implant will block mesenchymal outgrowth into the grafting material).

    As far as what others have said, I agree that if there are teeth around the implant site, knocking back the ridge to gain width wouldn’t be appropriate as it will likely introduce a perio disaster.

  4. João says:

    I posted this case. This patient has the following missing tooth: 45;46;35;36. I’m brazilian. We actually do not have too much access to this “densah burs” far as I know. I have a simple implant kit, Neodent. I guess I’ll probably go with GBR prior to implant placement.

    • GB OS says:

      Interesting thread to follow .

      Some thoughts –
      Posterior mandible as shown in this case has little cancellous bone and also diminished width .
      No matter what the finished restoration is , if the plan is to place an implant , we must help our colleague to place appropriately a suitable implant .

      Since this looks like a healed extraction site with very little cancellous bone two stage procedure would be detrimental as we would have initiated RAP and triggered resorptive process . Particulate graft material may help a little only if used with tenting procedure but tell you what in 3-4 months if you found increased bone width with any additional bone that could be used you will be lucky!

      I personally prefer one stage procedure .
      1st option since you have adequate height overall why not consider nerve reposition get the correct height and diameter you want and then restore as per plan .

      If that isn’t what you want then still one stage procedure with few threads exposed won’t do any harm . But as few have said here use buccal augmentation with a tension free primary closure . Use proper sub perio steal dissection and a layered closure . Wait 3 months and then restore .
      You could use narrow implants – 3mm but if you can use two of them one for mesial and other for distal – that could do the job .

      Open for critique .

      We all learn and keep learning .

      • Marcus says:

        You don’t need subperiosteal dissection. You know what nobody’s mentioned here? Referring this case to a specialist who doesn’t have to reinvent the wheel. Primary closure? Uhm isn’t that an absolute no-brainer? Sad actually that this sort of discussion is even coming up. So many specialists. Too bad generalists and specialists seem to be making a hobby out of distancing themselves from one another rather than working on people’s strengths and serving the patients with the best care.

        • John Beckwith DABOI/ID says:

          I can appreciate that comment but we as a discipline need consistent guidelines. I personally was trained at Misch as were many specialists. Its not the fact that someone is perio or O.S. or general. Its implant training. Unfortunately there is no consistent implant training unless an individual seeks reputable training. Let s all get on same page.. short narrow implants??no
          There are only a couple of ways to do this case.
          This is a typical board case. Ask the ABOI guys and stop the guesswork

  5. VD says:

    To keep it simple (avoid ridge splitting/grafting), I have placed a number of these implants up to 3mm subcrestally in order to avoid or minimize thread exposure. When restoring, I choose abutment height of only 4mm, so that the force at the abutment neck is kept to a minimum. Crestal bone on mesial and distal side of implant will resorb over time.

  6. Manny says:

    You are asking the wrong question. The apicocoronal level of placement is dictated by the location in the arch, the midbuccal CEJs of the adjacent teeth, and the mesiodistal space available for a proper emergence profile of the restoration. Too many clinicians look at implant placement as the endpoint instead of the final restoration being the endpoint. When you see the final restoration as the goal, you will be more attentive in approriate treatment planning to ensure your implant placement will support that versus making a crown fit your implant placement, often with unesthetic restorations that are not easily maintained by the patient. A double fail, in my opinion. After you determine the proper 3D location, then you can determine the proper implant size and what augmentation techniques are most appropriate.

    • Richard Winter says:

      Marcus and manny are both correct. Evaluate the prosthesis desired then decide on size of implant based upon occlusion, relative force factors and parafunctional habits. Why did this person lose the teeth? If you have room above IAN do some osteoplasty and place two to four narrower implants or block graft if a wider implant is desired. Either way you should splint the crowns and narrow the occlusal table of the prosthesis if narrower implants are used.

  7. Dr R Y says:

    agreed with Doc Marcus, Or just shave the alveolar ridge with bone filer to get an required width , 3.4 is ideal width if patient is having adjust sound teeth , if edentulous go for little more wider implant with same protocol, and increase the over lying with of gingiva by grafting

  8. Dr Amir Mostofi says:

    You need to do as follow and order:
    1) Use a tissue level implant (a wide and long neck works best in this case) and prefabably not a bone level implant. I understand you might not have access to the tissue level implants.
    2) Lean the implant apex max 10 degree lingualy.
    3) Choose a smaller diameter implant (if possible).
    4) Choose a shorter implant (if possible) and then subcrestal sinking or counter sinking the implant (if you have choosen a bone level implant).
    5) Flatten the crestal ridge slightly.
    6) Use GBR or ridge split as the last resort.

  9. MK says:

    Densah drills, 3.3 Roxolid or 3.6 Astra unless in molar region, graft, and go subcrestal 1-2mm…follow ‘Zero Bone Loss Protocol’ to make sure you have adequate soft tissue thickness.

    • #implantmike (Mikey E. Calderon) says:

      My apologies but, Densah not a good idea here. Let’s think of this. We need more width, more vascularization. Cortical bone cannot be condensed, and for more blood we need more vascular bone. So, onlay graft with decortication or slit with intraosseous graft is needed here. #implantmike

  10. Dr. Elijah Arrington III says:

    Osseodensification;Versah Burs will widen the ridge for you and you still can graft, if needed. Most times, I can use the burs in reverse and it widens. I do agree with ridge splitting (alveolar modification) as well. #morethan1onewaytoskinacat

  11. Vladimir Reznikov says:

    I would graft the BL deficiency first, utilizing either tenting screws or “sausage” technique described by Urban. Grafting material- allograft mixed with the bovine bone and PRF / collagen membrane.
    6 months later place implants in the correct position.
    Looking at the cross sections, I do not think that realistically Densah burs would do something. Way to much to spread considering that this is hard mandibular bone and that we want 2 mm of it on the buccal and lingual aspects for the good long term prognosis.
    The same pertains to the ridge split.
    Flattening the ridge and sinking an implant deeper…
    At least it way create a deep sulcus that might be difficult to maintain. It might, however work with implant in section #33.
    In #’s 36 and 98 the width is still inedequate around the sunk implant even for 3.7 or something like that. The implant will be already deeper and over the time the thin buccal plate at the crest of the implant will resort adding more maintenance issues.
    With all this said I agree with one of the comments suggesting referral to a specialist who is not simply trained but rather experienced in augmentation procedures and really can grow bone.


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