Would you graft this case or place deeper?

The other teeth appear to have a poor to guarded prognosis and probably should be extracted and a definitive full arch treatment plan instituted.

The patient is periodontally compromised, however, stable. He is aware that it may be the case in the future, but for now we're keeping his teeth.

The problems you have to solve to get this singular implant to work and be healthy are evident with this patient's entire dental arch. Please take another look with your patient at their long term goals and prognosis. Bruxism and Periodontal disease will visit your newly placed implant and it will be compromised in a few short years or sooner. Be careful with this one.

The answer to your questions depends on the prosthetic goal. If your goal is an ideally positioned crown, that is easy for the patient to clean and maintain, then you should graft, either prior to or simultaneous with implant placement. If your goal is to have a compromised crown position that will make it difficult for your patient to clean and maintain, then go ahead and place the implant "deeper." Of course, by placing it "deeper" you will also be guaranteeing future issues with the adjacent teeth. Remember, the facial aspect of the prosthetic platform should be 2-3 mm apical to the desired gingival margin position for NON-platform switched implants, and 3-4 mm apical to the desired gingival marginal position for significantly platform switched implants, deeper placements usually in anterior sites.

This situation is well fit by a Bicon implant placed against the lingual plate, perhaps with a slight Buccal tilt which would place the fins below the Buccal plate. Some granular grafting could be placed over this, but the higher lingual plate is well tolerated by using a slightly longer titanium abutment which would place the shiny tissue compatible abutment against the lingual plate while allowing some Buccal preparation to lower that crown margin. Once depth is pre-established with end cutting bits, the final - side cutting only - bits will snug up against that Lingual plate, moving each subsequently larger bit pushed to the Buccal to the exact needed diameter.

Place at the ideal position and graft at placement if necessary. I would be more concerned about the quality/quantity of the attached gingiva at the implant site. I don't see the patient's periodontal condition as an issue as it was clearly stable enough to undergo ortho treatment.

In a case like this, I would flatten the ridge about 1 mm . enter with a spade and enlarge the osteotomy with a versah burs, you could expand the ridge as well if you have an expansion kit. you can easily place 3.7-4.0 fixture. Periodontally needs to evaluated.

You can create 4-6 mm of attached tissue by treating the site as a normal tooth extraction site. The Bicon implants fit 2-3 mm below the bone, a slight layer of granular graft over that, then a half collagen plug sewn over that with inverted cross sutures. The collagen plug falls out in a few days, leaving a “hole” similar to a fresh extraction site. The attached tissue grows over this (be certain to leave a strip of attached tissue on both flap edges) exactly as the tissue grows over a tooth extraction site. You can increase the Buccal width of attached tissue by cutting the uncovering flap slightly more Lingually.

I just can’t see how you would proceed with that case as a single implant. Clearly tooth #20 is hanging by a millimeter of attachment. Sit back down with your patient and talk about their options

Great case where the practitioner understands he/she has a decision to make that may compromise adjacent teeth and is taking the appropriate measures with what they have. Implant patients are not perfect. They obviously need the tooth replaced and a bridge will not be an option at this point. Since perio is stable, my main concern is future stability of adjacent teeth rather than exo and more implants. I would place implant 1mm subcrestal. You will be left with a facial defect on approx2-4mm of the implant. I would perform onlay graft (allograft over the implant and xenograft facially for bulk) and long lasting collagen membrane and close for 4 months. A non resorbable ptfe membrane will be ideal but you need to keep it 2mm away from adjacent teeth. May not be practical with the space you have. Make sure your able to attain primary closure and make a few openings through your facial bone with a #2 round bur for good bleeding into your bone graft. You should regain that lost facial bone and will be doing a huge service for future maintenance and hygiene. Preserve as much keratinized tissue as possible. There are various healing abutments with the implant system you are using that will allow you maintain your graft and membrane in place and provide stability. Great case. Please update us with your results. Good luck and thanks for posting.

I agree with Dennis, this case is periodontally involved and a single implant in that area has a very poor prognosis. Regarding Manuel advice, I placed Bicon implants for over 15 years (a very good system) and I also place now Quantum that can be placed below the crest, at the crest or above the crest. Again I would not place them either.

I think the responses to this post illustrate the problem with the current state of "opinion based dentistry" or better yet "profit based implantology". I am going to give you the benefit of doubt and assume the stability of the remaining dentition has been evaluated. I am in my 20th year of dentistry and 14th as a periodontist. I have no problem with the bone loss on the adjacent teeth as they may very well have been successfully treated and have no signs of active disease. A tooth/teeth with a history of disease and successful treatment even with clinical mobility are necessarily a problem. You and the orthodontist clearly felt this patient was a candidate for ortho treatment and thus set up the case accordingly and now you are dealing with a single missing tooth. The only image is that of the quadrant yet people are proposing All on Four etc.. Once again I am going to harp on the manufacturer's profit based implant training that is offered. I think you are right on with your conservative plan and I would not be surprised if the patient's remaining dentition does not follow them to the grave.

While I agree with those who’ve related the initial need for a comprehensive diagnosis and treatment plan, my response related to the narrower question by the poster concerning that, had one decided to place an implant in this site, would grafting or deeper placement prevail? As for the prior need of complete stabilization of the remaining dentition, once the major active infection is controlled, many weak teeth will stabilize after nearby implant placement.

I agree with Dr Kim and Dr Manuel's last statements. I have to remind you that probing scores, mobility and BOP will tell you alot about prognosis. Unfortunately you will have mobility when the hardware comes off, so true prognosis at this time is tough to gauge. I agree: "how can one say Full Arch Treatment' without ALOT more information???? Why would anyone draw that conclusion with this amount of data?? I'm glad you are noting the patients goals. I presume you are also telling him the downside to leaving periodontally compromised teeth that may or may not go 10 years. I'll remind us all that we don't treat people equally, as some want minimal treatment, some go for a version of maintenance and some want the most predictable care. Having said that, if you have proximal bone on the buccal that is deficient(as it appears on the CT slice), you'll get a better result if you do GBR first then as a second stage place the implant. You can always add more bone at the second stage, yet with 36 years of placing thousands of implants, I've learned the occlusal/buccal bone will resorb due to lack of thickness if you try to do both at once ( due to lack of vascularity) and you won't have an easy/predictable way to grow more bone or establish keratinized tissue after the restoration is in place.

Place really deeper, like outside the mouth. Terminal dentition, braces are splinting the teeth for stability. I’d recommend another path and stop wasting the patient’s time and money.

who in the world would do ortho on this patient? If I cant trust those teeth enough to use them as fixed bridge abutments, I wouldnt trust them to surround the implants. Personally, Id say, " Mr Smith, I dont trust these teeth enough for you to spend that much money on them. Lets stop ortho, place this implant and add 3 others for an implant retained immediate denture. This is where we'll be in a year or two anyways."

Dear Colleague, for longevity and play safe, I would rather GBR first, second by implant placement, this will give more predictable outcome