New Implant Patient: What do I do with all the extraneous bone particles?

How to handle the tissue would depend on the gingival contours. Delayed temporization usually results in loss of buccal and vertical recession. A photograph and the name of the graft material would allow us to provide a more knowledgeable opinion on how to achieve the best result. The graft material was placed for esthetic reasons and removing it would likely collapse the gingiva. I often place granules over implants for esthetic reasons and I have never had a problem with residual granules but it is a topic I am interested in hearing other opinions because we are in the process of developing a graft material specifically for esthetic grafting and I would very much like hearing others opinions on this matter. Greg Steiner Steiner Laboratories

Looks like the implant was placed a tad supracrestal and the grafting was put over to give a bit of protection . Seems to be quite thick mucosa in which case you want to leave as many graft particles as possible . Delicately expose cover screw , possibly use fine point of scalpel . Temporary abutment great idea as will let you confirm that the aesthetics will work . The grafting particles need longer to coalesce . The implant will probably stay slightly supracrestal and if the mucosa is thin consider a zirconium abutment .Should be fine , dave

Greg , I use 'easygraft' quite a lot but I do sometimes find particles , even after 6 mths . But the material does seem to work well . The downside is that there would be a lot of wastage if you used it as you suggest . So if you could supply a similar material in smaller quantities good on you . I did a course with Ziv Mazor a couple of years ago and he was experimenting with white-coated titanium granules . Dave

The implant should have been placed a little more apically. The graft was probably done to compensate for deficient bone at the time of implant placement. Those are two factors against an ideal restoration. If you find that the patient has a thin biotype, you may end up with a situation where the top of the implant platform will become visible over time. You need to warn the patient about this so that you don't end up having to take responsibility for the implant placement. I would try to augment at the time of uncovering, do not use a tissue punch. You could thicken the biotype and possibly place a non resorbable bone graft around the implant to avoid any recession of the tissues that would expose the implant. Good luck!

The graft seems to be of big particle so that's why it hasn't been reabsorbed. But that's not a big issue, don't try to remove it, because it is inside the gingival tissue. If a particle emerge, just take it out. Don't use a tissue punch, do a flap with a normal bisturi doing the incision over the ridge, but close to the palatal side, doing this you will win keratanized tissue moved to the vestibular side, and place the healing screw, wait for 3 or 4 weeks then proceed with the crown. It would be useful some images.

Like David Robinson I have used a fair bit of Easygraft ( not saying that this is Easygraft ) over the last 4 years or so and can show many cases that look similar . Just load and manipulate a soft tissue as you see fit , but leave granules , and when loaded there can be improvement of the bony situation in this crestal area . I have hunndreds of recorded cases using synthetics where after a year of loading the bone level is 1 or 2 mm HIGHER than it was at loading . How do I know it is bone , well all then material would have bio-absorbed by then. In fact just saw it yesterday on a cas ethat I grafted in Live Surgery at a big Dental show. Often amazes me still when I see this occuring , 1 or 2 years later , which buries the old theory that you lose 1 mm of bone at 1 year etc. Peter

The particles if sitting under the periostium will flack off easily when flapped those particles within the tissue may not be easily removed and I would just not worry what particles are left

Whoever placed the implant was definitely trying to compensate for slight loss of vertical ridge height.

Remove them when you uncover as long as the patient is not having problems or inflammation.

I agree with Carlos! When going back in for the re-entry i would graft with a highly mineralized bone grafting material that will have a longer resorption rate allowing for maintaining space and stability in the implant bed site. Whether allograft, xenograft, or alloplast, you have plenty of options for grafting materials on the dental market. I would also use a acellular dermis membrane to help with the guided bone regeneration and protect the particulate granulates from migrating from the surgical site. These membranes allow for you to go back in for re-entry without disturbing the bone regeneration process and does not allow any epithelial down growth.