Implants in Two Sites with Little Bone Width: Is My Graft Material Sufficient?
I have a healthy, middle-aged female considering implants in #11 and 12 sites [maxillary left canine and first premolar;Â 23, 24]. CBCT shows very little bone width in these 2 sites (together with retained root). I am considering placing 2 x MIS SEVEN 3.3mm x 10mm implants (with splinted crowns). At time of implant placement there will be exposed buccal threads in the coronal 2/3rd of implant fixture. My aim is to use only CaSO4 (Bondbone) to graft over the buccal exposed threads and submerge for 5-6 months. I have used Bondbone a few times already, but not sure whether this is pushing the limits of the material. Can someone with more experience using Bondbone let me know whether this is beyond it’s capabilities for regenerating bone in this case?
(click images below to enlarge)
![]23-24-a](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/12/23-24-a.jpg)
![]CBCT 23 -24 region](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/12/23-24-b.jpg)CBCT 23 -24 region
15 Comments on Implants in Two Sites with Little Bone Width: Is My Graft Material Sufficient?
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CRS
12/26/2012
It is really helpful to have the patient wear a barium ct scan guide to determine the ideal placement of the implant spacing otherwise you are just guessing. The retained root is an excellent space maintainer just remove and go deeper. The more anterior implant can have the alveolus spread and an onlay graft placed. I like to use an allograft vs synthetic. Nice case good luck.
usmansk@yahoo.com
12/26/2012
Go for ridge splitting with ridge dilator....place 3.3*10mm, leave for 6months,no need to put onlay graft...
CRS
12/26/2012
An onlay graft is very helpful since having at least 1mm of bone on all sides of an implant is good practice. Perhaps this is a good spot for bond one but will have to defer to Dr Fairbain. You can still use a barium surgical splint on the panorex, I don't understand how you determine where to put the implants without a clear picture of what the final restoration will look like, especially the width of the crown without a guide. My protocol uses the BTI technique with his expanders and PRGF allograft or a membrane for these narrow spots with very good success. Another reason for the onlay is so that you won't have a dark margin. Good basic treatment planning with surgical stents especially with a cone beam will keep you out of trouble instead of having your lab figure out how to restore the case and have to use custom abutments. You are actually just doing the wax up on the front end of the case. Later the stent can be used as a guide to uncover with a tissue punch. The guide also helps you center the implant along the long axis and get parallel implants for draw. We now have the ability to place the implants in the ideal positions vs taking the area of best bone with grafting or at least attempt it. With proper site preparation you can create the best restorations, it is just good crown and bridge which is what we were all taught in dental school. The final restoration dictates the implant placement. The only time I don't use a guide is single implants between teeth when there is not much room still I use a paralleling pin to line it up with an assistant at the patient's feet to sight the implant in sagittal plane. These are all simple steps to raise the level of care and actually save headaches in restoration,occlusion and periimplantitis due to poor site preparation and planning. Ok I 'm off my soapbox and am always wiling to help my colleagues to the best of my ability and to learn from them also!
a yong
12/26/2012
Thanks CRS for comment. Peter Fairbain, I am particularly interested in your opinion in this specific situation as I know you have a lot of experience using similar materials to CaSo4 (Bondbone).
Carlos Boudet DDS
12/26/2012
You may be able to succesfuly place implants in that area of deficient bone by grafting bondbone to cover the exposed threads, but in my experience, the long term results will not be stable and you will see a reduction in volume over time.
Ca(SO4)2 is fully resorbable and the only blood supply to that area would come from the periosteum. Adding xenograft (bovine bone) to the graft material may allow you to maintain the volume.
If you want stable long term results, the safest way is to develop the site first with GBR procedure and then place implants with enough bone surrounding the implant (1.5 to 2 mm minimum).
I know some of my well respected colleagues here have no problems grafting exposed theads at implant placement, but I tend to be more conservative and make sure the bone is there at time of placement.
I also would like to clarify, I only use bovine mixed, to maintain volume (does not resorb), but would not place it in an osteotomy site where I want vital bone for osseointegration.
Good luck!
Peter Fairbairn
12/29/2012
Hi Dr yong Iam skiing at the moment but this is routine case for expansion and then grafting withBond Bone mixed with what everyou like be it BtcP or and Tcp HA mix. Personally over a 10 year period I have found no issues with retention of bone without HA .So in my daily cases I would mix BtcP and Ca SO4 use as sharp pointed pilot bur then expand with an osteotome or expansion kit and graft buccally with the mix.
I feel bond bone is a great CaSO 4 but I feel you must always add a longer term material when grafting with it although it is fine by itself when being used as a membrane.
Patients physiology can vary significantly and thus some bio-absorb materials at vastly different rates hence safer to mix it when used as a graft material.
Nappy new year
Regards
Peter
a yong
12/29/2012
HI Peter. Hope the skiing is good! It's hot down here in Australia so no snow:)
What ratio of CaSO4 : bTCP mix do you suggest if used for grafting purposes? 50:50 ?
Peter Fairbairn
12/30/2012
About 60/40 to 70/30with BtcP being the larger portion then allow for setting prior to suturing by keeping blood off the graft.If you want applying a layer of Bond bone over the graft as well may be beneficial . Here in this case of yours you may have thin bone on the buccally or even perforate .Just graft over this area and ensure that it has hardened .
My mentor is an Aussie , Barry Ewards who developed a neat expansion tool in the 80s which we still use today to great effect.
Regards
Peter
a yong
12/30/2012
Thanks!
DrT
1/1/2013
Using any material to cover exposed buccal threads will only be successful if the fixture is within the alveolar housing of the teeth mesially and distally. I think this is a more important consideration than what material use.Diagnosis is the key. It may be that use of dilators is the preferred way to go in this case.
DrT
Baker k. Vinci
1/3/2013
Yuup, I'm afraid too many people get caught up in the materials and forget that the technique is a far more important factor. This material you all are using will be "old news" in 2-6 months . Just wait and see! Bv
Peter Fairbairn
1/2/2013
Strangely not necessarily , I have many scans at 7 or 8 years loaded where the new bone growth extends beyond the adjacent plate profile .
But it is better to initially stay within those protocols.
Peter
Baker k. Vinci
1/3/2013
Please don't attempt to ridge split this! Does your scanner give accurate measurements? If so, post those please . If there is ever a time for primary closure, upon grafting small defects, this is it. Personally I use autogenous block grafts, as well as autogenous and dfdb, but am having some success with the newer mineralized allograft as well. If only a bit of the buccal or lingual aspect of your implant is exposed, use a particulate. I personally do not think 3.3 mm is enough implant for this area. You can always come back and cosmetically augment with a xenograft. I have no experience with the material you are using. Bv
Peter Fairbairn
1/4/2013
Hi BV , good interview with Jimmy Page in the new Rolling Stone .
I agree with you on the materials aspect , it is ALL about techniques , hence often I show cases and people think it is a mirculous material , it is not it is merely development of techniques that encourage the bodies healing .
The materials are basically irrelevant in comparison to techiques . I also agree on the ridge splitting procedure here in this area , which requires great skill and is fraught with possible catastrophies. Hence subtle expansion and grafting to get consistent results.
The concept is effectively to "bond " the particulates to create graft stability and soft tissue cell occlusion yet still allowing the body to get optimal healing from the periosteal blood supply .
After 10 years it seems to be a sound idea.
Regards
Peter
Richard Hughes, DDS, FAAI
1/4/2013
This case can successfully be treated via the Tatum expansion techniques and using the Tatum instruments. Doing so will yield a more successful outcome than placing implants into grafted bone. One may consider using blade implants or an interdental subperiosteal implant.
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