Immediate Implant Placed too Labial gets saved by Soft Tissue: No Graft Needed

Last Updated: May 29, 2019

70 y/o female with fractured #8 was replaced with immediate implant/provisional. Final restoration was completed 4 months later and a 3 year post-op photo is included. The implant was placed, by me, too labial in my opinion. Because the patient had adequate quantity/quality of attached tissue the case was saved. In this case no bone graft material was used, which is rarely needed in my opinion, but soft tissue saved the case. At some point I think we need to start respecting the value of soft tissue!!

18 Comments on Immediate Implant Placed too Labial gets saved by Soft Tissue: No Graft Needed

Comments Closed

New comments are currently closed for this post.

MAZ

05/29/2019

Do you have any cbct data? I’d be willing to bet there isn’t a buccal plate and the implant / abutment is holding the buccal gingiva out.

Timothy C Carter

05/29/2019

I did this before I had a CT machine. But it doesn’t matter because soft tissue serves as a barrier and when it is dense it prevents problems. That has been in function over7 years now with no problem.

Andy K

05/29/2019

Look good to me. If not broken, don’t fix it!

Dr anooshah hajiheshmTi

05/29/2019

Nice job , the stability of fixture in this case is because of rhomboid shape of incisive canal ! As u can see integrated at mesial border of fixture

Timothy C Carter

05/29/2019

Let us not forget that the treatment for problematic exposed roots is a “ Soft Tissue Graft” not a “Bone Graft”. The reason is that it provides a barrier and protects.

Timothy C Carter

05/29/2019

If you don’t believe me than please divert your attention to Dr Danny Melker and his 40+ years of documentation of the importance of adequate soft tissue.

Ernesto Lee DMD

05/29/2019

The reason why everyone avoids grafting bone over exposed implant surfaces is because there have been no good options until now. Risks include poor augmentation outcomes and the esthetic sequelae from exposed abutments or implant threads. The reality is that this can occur not only from buccal implant placement, but also from bone remodeling or the aging process. Until now, clinicians have resorted to a wait and see attitude (called supervised neglect in other scenarios) hoping that no probing depths and suppuration will develop. But what if there was a better option? One that is predictable and poses low risks? We have been proactively grafting these surfaces for over 3 years, and have human histology as proof of concept. To view a gallery of cases cases please visit www.smartbonegraft.com

mark

05/29/2019

I learned something today about soft tissue...thanks !

Dr Dale Gerke, BDS, BScDe

05/29/2019

This looks like a good result. Can you tell me why you think the implant was placed too far labially? Was this because of aesthetics, or position of the implant or platform, or radiographic evidence, or pocketing? I agree that the stability of gingival tissue depends on soft tissue, but I am wondering how you concluded in this case that the good result was due to soft tissue rather than labial plate support? What exactly do you mean by "the case was saved"? I am also wondering exactly what you are suggesting. Are you saying that if there is no labial plate, we do not always have to graft? Or are you suggesting that a thin (less than 1 mm) labial plate does not always need grafting? Or are you saying that you need good attached gingiva before you implant? You have said: “Because the patient had adequate quantity/quality of attached tissue the case was saved. In this case no bone graft material was used, which is rarely needed in my opinion, but soft tissue saved the case.” I think your point may be important but it is ambiguous. I would be grateful if you could clarify these points.

Timothy C Carter

05/30/2019

Probably the best explanation I can give is related to teeth...... When a tooth has no attached gingiva and/or recession we recommend a soft tissue graft. Why not a bone graft since the exposed root lacks bone? The reason is because bone grafting, with or without a membrane, over an avascular root is extremely unpredictable. With soft tissue we know it provides a strong seal and can survive over an avascular root when only 80% of the graft is covered by the flap. Since we all recognize the importance of a "soft tissue seal" around a tooth shouldn't we assume, at least until proven otherwise, that the same applies to an avascular implant. Yes with a thin buccal plate thick soft tissue will save you.

Dr Dale Gerke, BDS, BScDe

05/30/2019

Thank you for your comment. I start to understand the point of your discussion. I think there are some key issues: 1 if gingival tissue covering an implant with no bone is going to work then it needs to be the right type of gingiva. eg thick, keratinised and possibly the right genetic make up 2 irrespective some buccal bone would be desirable 3 I suspect that the type of implant surface is critical. I think we have all seen deep (irreversible) gingival pockets around implants (especially buccal) where the implant surface is rough/threaded (or both) and not able to be properly cleaned. A successful outcome in such a situation is unlikely long term 4 in the case you reviewed, I still suspect there was buccal bone present (albeit possibly thin). This is why I requested radiographic evidence of what was on the buccal aspect of the implant. Without this knowledge, it is impossible to say accurately whether the gingival tissue survived because it was strong, thick gingival tissue (and maintained well) or whether there was buccal plate that was assisting the stability 5 with these points considered, I am not sure your comment that "soft tissue saved the case" can be presumed because it may be that bone was involved also Therefore while I understand and agree that soft tissue is important (indeed critical) to the success of an implant, I am not certain that you can say your case proves the point that soft tissue is all that is required unless you can show that no bone was present. It would be unwise to jump to a possible false conclusion. Irrespective of the above, I repeat that this case shows a good result and your surgery was well done.

Ernesto A. Lee DMD

05/29/2019

The only reason why anyone will settle for soft tissue over an implant surface is because the achievement of hard tissue is unpredictable. We have the solution. Visit www.smartbonegraft.com and view the gallery of cases. We are presenting the S.M.A.R.T. technique to a crowd of 5,300 at the Spanish Society of Periodontics (SEPA) this week, and at the Quintessence International Symposium on Periodontics and Restorative Dentistry (IJPRD) next week.

Dr. Gerald Rudick

05/29/2019

Stop blaming yourself...you did a great job...….you have recognized what could have been a potential problem...which it is not......next time you will think a little more before you enter the bone...….but this is well done.

Ernesto A. Lee DMD

05/29/2019

It’s good to be introspective. Only way of getting better.

Terence Lau, DDS

05/30/2019

A nice tase to lean from. In addition to adequate soft tissue, it looks as though the implant has plenty of "running room" for emergence correction which also may have helped.

CRS

05/30/2019

Thanks for teaching a wise old oral surgeon about the soft tissue seal, I’ve referred cases like this to my periodontist colleague for a bail out. Gap in my training and I appreciate your insight, seen cases with great bone fail due to poor soft tissue. Thanks for posting.

Ernesto Lee

05/30/2019

There is a difference between the wound healing process with and without flaps. There is also a difference between traditional GBR and growth factor mediated regeneration. The fact is that bone can be regenerated predictably over implant and root surfaces. But it takes the right techniques, biomaterials and biologics. I realize my opinion is on the bleeding edge of things and challenges the status quo. At the end of the day however, there’s a patient with a problem sitting in your chair. What are you going to do? Watch? Start all over again? If you want to learn more about it, I will be presenting the technique next week at the IJPRD meeting in Boston.

Timothy C Carter

05/30/2019

There is probably validity to what you say (I routinely use PRF and have incorporated many products over the years) and clearly you have an invested interest in the growth factor mediated approach. I agree that there is some good potential there but it all comes with additional cost and soft tissue is readily available, inexpensive to obtain, and proven over decades of documentation. If we are going to ask an implant to serve as a tooth we should probably treat it like a tooth!!!

« immediate implant placement 030618 immediate implant placed leave it or remove it »