Narrow space between teeth #9 and #11: advice?

A 2.5X15mm implant will perform well for many years if there is 1mm occlusal clearance. Be sure the crown matches the contralateral anatomy. Placement needs to be exact, facial bone, within the arch line, etc. Flanagan D. Journal of Oral Implantology 2008 17(2):182-191 FixedPartDentSmallDiamImplant Flanagan D.Journal of Oral Implantology Very small diameter implants 2006 32(1): 34-37 Flanagan D. J Oral Implantol 2011 Mar 37 (sp1): 123-132. Mini Implant Review- Mascolo Flanagan D.J Oral Implantol-2015 Aug 41(4): 138-143.Mini implant post. mandibular

You definitely need pre-prosthetic site development and if you prefer, ct guided placement. Nothing larger than a 3.0 diameter. If the CT allow for ideal placement prosthetically, you may be able to do a one piece implant.

In the esthetic zone with this defect anatomy, you definitely need pre-prosthetic site development: mineralized allograft/Gem 21 Liquid, slowly resorbing membrane, c.t. graft under the facial flap. 4 months later, guided surgery. The Strauman 2.9mm diameter Bone Level Tapered implant would be a good fit. The Zirconia/Titanium alloy provides a very robust implant.

It is hard to comment without better analysis of the CT scan. While all other comments are relevant, the ultimate decision will need to be determined by the minimum bone distance between the adjacent roots and your proposed implant. I cannot determine this distance with the radiographic information you have provided but it seems to be too little. You would expect an 18 year old patient to have a life expectancy of another 60 years. So whatever you do needs to have longevity. Most importantly, treatment should not compromise the adjacent teeth (ie cause alveolar bone loss). As mentioned I cannot determine the required space but I have doubts about these issues.

He's 18 Y.O., which is kind of young for a life-long, and or difficult to remove implant should the need arise. Why not consider a bonded (Marlyand) bridge? he could get a lot of life out of it.

Check the article written by Bjorn Zachrisson. Age 18 with compromise site not worth to do implant. JMO

I agree with a Maryland bridge for a kid

I agree with Dr. Flanagan. The small diameter single stage implants work really well in these situations. Keep your temporary out of occlusion and definitive restoration in 4 months.

Modified Maryland bridge. Two small rounded box preps in the adjacent teeth ( distal on the central and mesial on the canine ).Be sure the connector surface area is wide enough for thickness and strength. The lab fabricates the bridge with wings. The wings in this technique ARE COMPLETELY INTERNALIZED within the box preps. For cementation create small undercuts in the box preps prior to resin cementation. This bridge will never come loose. Patient can decide on implants later when old enough.

It can be done predictably. Preplan your prosthetic angulation leaving as much bone on the buccal crest as possible, an plan to graft the middle threads and apical area. If the roots of the adjacent teeth converge, plan to use a shorter implant. I have had 5 year success with platform switched implants in these narrow areas, being mindful not to encroach on the pdl space of the adjacent roots. Here would be my generic surgical plan: 1) lay a papilla preserving (not sparing) flap as described by Zucchelli; 2) place 1 vertical releasing incision on the distal aspect of the flap and enlarge the base of the flap at least 2 line angles away from the implant site; (consider a mesial releasing incision only if the gbr will be extensive; 3) place the implant in the ideal 3-dimensional position, being mindful of the vertical position, which will be significantly subcrestal in most congenitally missing lateral cases (3-4 mm apical to where you intent the final gingival margin to be); 4) release the periosteum towards the apical extent of your flap, ensuring you can pull the buccal flap margin at least 4-5 mm past the lingual flap margin; 5) prepare the recipient site by injuring the buccal plate with scalpel or drilling dry between the implant and roots, and placing the autogenous shavings directly on the exposed threads.; 5) trim and place your membrane 2 mm past the bony defect and 2mm short of your incisions, except the crest, where you should leave 1 mm of bone exposed, in order for the periosteum to reattach to the bone; 6) place your graft material of choice (mine is i-prf with small mineralized cortical chips or i-prf and bovine) under the membrane; 7) place a deep apical criss-cross mattress suture to "smush" the membrane against the recipient bone, starting the suture on the buccal, at least 10 mm from the buccal flap margin; 8) place an interrupted suture on the mesial crestal corner, then one on the distal crestal corner, then on the gingival corner of the releasing incision(s); 9) place sutures 1.5 mm apart to close any remaining wounds until light pressure does not express any blood from the wound. I would administer a single preop does of antibiotics (1 gm amox) and intraop 4-8 mg dexamethasone iv or im, or postop tapering dex regimen po, 8 mg day of, 4 mg next day, 2 mg following 2 days, and mild narcotics. Suture removal in 2 weeks and routine grafting postop instructions. All of this can be ruined by an aggressive uncovery procedure. When uncovering, repeat the Zucchelli papilla preserving approach if you need to augment the site at all, or else, use a perio probe to locate the cover screw and then a high speed hand piece with a coarse diamond to access the cover screw, but leaving more tissue on the buccal. Then place an appropriately sized healing abutment the "smush" the tissues slightly facially, preserving the buccal contours of the site. If you raise a regular full thickness flap here, you will be left with permanent black triangles. Hope this helps.

I would place a small diameter implant along with bond apatite synthetic bone in the buccal area, and no membrane. Primary closure (sutures very tight) I have done it before

Don't do it! Ever looked at an adult age 30-40 years who had an implant placed in the esthetic zone when they were a teenager? You will start out with a crown that is aligned and then as the tissue levels change, the alveolar bone changes, and the teeth settle in to occlusion, you will have an esthetic failure. I restored a few cases on post ortho teenagers in the eighties. Don't look so good now!

As others have mentioned, it is difficult to assess based on the images and information given. However, 18 is young for implant placement (especially in males) unless you can verify that growth is complete. I would suggest evaluating that first and temporizing with a bonded Maryland Bridge (you likely will only need one wing and place in on the central not the canine, much better area for bonding). If growth is complete and you have adequate mesial distal width for a narrow implant (3.25/3.75) I would recommend placing the implant and grafting the buccal at the same time. Search Papillae Sparing Incisions in the Esthetic Zone by Tarnow et al. There are several versions of this paper and it directly applies to your case. Best of luck!

In my honest opinion, this patient is too young for titanium. I’ve seen growth occur into the early 20’s. Hold off as long as possible since this is in the esthetic zone

i would plce one piece 3mm compressive implant with nasal floor perfo. drill slightly palatal flapeless single drill.whole procedure would take 10 mins.keep crown out of occln.

For those who keep bringing up the age of the patient, obviously everything depends on factors that are not shared by the author of the question. Assuming this colleague has ascertained growth is not a major issue, advice to place a Maryland bridge is not helpful. How do you even know a Maryland bridge can be placed here without prepping the adjacent teeth? Also, I have had 70+ year old patients who have had continued eruption of natural dentition adjacent to the implant. While solutions may present their own challenges, they are not impossible.

In this case I prefer use one piece with narrow diameter and my experience in this important and mini implant for tin and thick is very good

The incisors seem proclined already. Try considering a referral to orthodontics and see if they can close the space or open some space to accomodate for an appropriate size implant. Secondly the size of the lateral incsior on the contralateral side should be kept in mind if you end up giving a small tooth the esthetics would be highly compromised.

Thank you all for such a multitude of sound advice. And s special thanks to Dr Kim for your intimately detailed procedures outlined. This is what makes this site so collegiate. I am grateful. At the moment I elected to graft the buccal defect and will talk with the orthodontist to confirm that the patients growth is not a significant factor. Since he was referred to me by the orthodontist I believe that to be the case. The most significant factor was the interior distance. I am reviewing all comments and will make my decision as the graft matures. The parent is certainly willing to wait. Thank you all again for a most rewarding response. If I can get him to return in the immediate future I will post a pic. If you need any other documentation I will be most happy to accommodate. Sincerely Bill

My observation, of the limited CBCT image shows limited space mesial distally , ( less then 6mm ? is very narrow , and may get crestal bone loss or poor bone integration even around a narrow implant . Could lead to failure, I have had this happened twice , in my early placement years ( late90’s) , where the narrow implant did not integrate well and spun out at stage 2 during cover screw removal.This was because I was pushing the limit and I freehanded w/ less experience in an ultra narrow site, maybe overprepped site, no primary stability..and less then 1.5 mm space from implant to adj teeth...However , consider the super narrower implants 2.8/2,9 w/ a guide If you have adequate m-d space, then today, I have changed my approach with this case, For sure it would be a narrow implant 3.0 mm range may be 2,8 mm and longer ( up to 16mm ) can be placed without traditional membranes/ particle bone . I would use autocompaction versah protocols to move my bone Buccal-lingually and expand ridge , followed w / the narrow fixture placement. You can also place a buccal graft if any of the crestal threads are exposed or if bone is thin in that zone. If I needed to first develop the ridge wider , then I would again use osseodensification drills to internally expand ridge , and move cortical plates apart and then , graft the autocompacted , wider osteotomy site. Revisit in 3-4 months to place a fixture in a wider ridge. I get 2-3 mm ridge expansion with osseodensification on single sites and if expanding wider ridges , ( multiple implants ) piezo split ridge with desah burs. This option is predictable as you are not placing membranes and hoping your particles stay in the area or you can avoid the use of more stable but technique sensitive options like membrane tacs ,or allogenic block grafts, alloplqstic material , or other stable augmentation scaffolding methods. I would use a surgical pilot guide stent at the least as you have to be plum correct in your trajectory and spacing , less thinking w/ guide! There are many options, this would be one. Thank you for posting nice case. And revisit with a wider

Just read your post to graft and wait , and seek advise from ortho specialists . Best and wisest of decisions, Dr woods, Good luck, keep us posted of Case Dr Flanagan, many thanks for your study links on mini/ narrow implants, will try to look them up , Thank you .