How would you sequence this treatment for this implant?

A 17 year old boy came into my office today missing tooth #8. Supposedly it was knocked out by his brother 8 days ago. The CT scan shows that the buccal cortical plate is still intact but the gingiva appear traumatized buccally. How would you go about treating this? Should I go in and graft, place the implant and graft, graft and use coronally positioned sutures to move the tissue coronally?   I have placed many implants, but never had to deal with this kind of a  situation, so your advice would be much appreciated.  What do you recommend for a treatment sequence?

33 thoughts on: How would you sequence this treatment for this implant?

  1. Dr. Rayment says:

    That is a very interesting case. I would place the implant now in a slightly palatal position to engage that bone and graft the gap on the buccal to preserve that buccal plate. I would use an Essix type appliance to avoid putting any pressure on that ridge during osseointegration. Then I would plan on using a temporary crown for several months to “train” the tissue. I don’t expect that you will need to do a CT graft to bulk out the soft tissue as he has a thick biotype. Please share the follow up.

  2. Raymond Kimsey says:

    At 17 I wouldn’t place an implant. Perform a resin bonded bridge and wait some years. I have seen too many of these cases done late teens and early 20’s to have the other teeth move a few years later and then have uneven tissue.

  3. Alejandro Berg says:

    Don’t place an implant, graft if you can, bonded bridge and wait until growth is finished. At 22/25 you can place the best implant of your life by using fully guided surgery and ensure long term success.

  4. Dennis Flanagan DDS MSc says:

    This pt is too young for an implant. Graft and make him an Essix appliance. If you place the implant now any continued growth of the maxilla will progress beyond the implant/bone complex, it is not pretty. Remember males mature later than females.

  5. Adibo says:

    A Boy at 17 is an absolute contraindication for implant treatment particularly in the Aesthetic region.
    Agree with Kimsey, resin bonded bridge is the best solution.

  6. Paul says:

    Does the patient, his parents have anything to say? Perhaps solving the problem with an implant now and correcting if needed later is the proper answer. Let the patient and parents decide. Placing a bridge at this time is the worst solution and any removable a notch above worst.

    • KMEMA says:

      How would you propose to go about “correcting “ the problem later? Trephine the implant out, graft/augment the resulting defect, then wait and hopefully have enough bone to place a second implant? Why not wait until growth is complete , then place an implant that will serve the patient, hopefully, for a lifetime? Placing an implant in a child whose growth is incomplete is an absolute contraindication. Contributors were proposing a minimally invasive resin bonded bridge as a temporary measure, not a PFM FPD.

      • Joe Merheb says:

        Completely agreeing with KMEMA!
        Perhaps that participants who are advising to place an implant now, should refrain from working in the field of implantology at all…
        Implant therapy is not just about screwing a screw in the bone…

        • Matt Helm DDS says:

          Joe Merhab you couldn’t have hit the nail on the head more directly if you tried! At the risk of being misjudged here by the others, I will add to your excellent comment and go one step further: perhaps those participants advocating for an implant now, lacking sufficiently sound scientific knowledge, don’t even deserve a Dental license??? Sounds excessive? Perhaps. But it is meant to drive home the point that we don’t treat teeth, nor implants: we treat whole human beings!

    • Brian says:

      Good point. Let the parents decide what is most appropriate treatment. They’re ones with the dental degree and license, right!?

    • Matt Helm DDS says:

      Paul, I just couldn’t help but jump into the fray here. Please do humor me: how exactly is placing a bridge at this time the worst solution??? I would very much like to hear your clear, science-based arguments for an implant at this time, what prognosis you envision, what problems you see in the future, and how you would correct said problems. I want to hear your clear arguments as to why exactly you see an implant now being to the patient’s long-term advantage, as opposed to waiting until growth stops! I would also like to hear your thoughts regarding the very likely possibility that, if an implant is placed now, the patient will most likely be subjected to additional surgeries when, in fact, he would only undergo one surgery if the implant is placed after growth stops.

      We all know — or should know — what happens to implants and soft tissue in the anterior aesthetic area when placed while growth is still ongoing. Heck, mpedds even confirmed inasmuch in his post based on long-term clinical experience, if anyone worth his science even needed such confirmation. They shouldn’t. This case is as clear-cut-and-dry as it gets!

      A bonded composite or Maryland bridge is actually the only and best solution right now, above and beyond any removable, or any implant! I’m not claiming to be the holiest of hollies but this is supported by the totality of facts in this case. Let’s not forget this 17-year old kid also has a life and a social life. Doesn’t he deserve to be spared the embarrassment of a removable or an inesthetic implant? Has anyone considered the psychological effects of such embarrassment on him? We’re all arguing as if we’re in a vacuum, but what about the overall, long-term welfare of the patient?!?!

      Oh, and also please do tell me how the Doctor would explain to a jury why he allowed the patient and his parents — who do not have Dental licenses — to dictate treatment against his better judgement!?! Need I remind you, and all those advocating for an implant at this time, that we don’t practice in a vacuum? An implant placed now can “go south” so badly in a relatively short time, that it’s not even funny, and it can very conceivably generate a malpractice lawsuit. I already stated in one of my posts below that even I, as a professional, feel that an implant now would be skirting the edge of real malpractice. I don’t know about those practicing outside the US, but in the US a case like this has the potential to blossom into a nightmare down the road. And anyone not mindful of that (and of the patient’s best interests) should take heed. This is how I see it, without trying to browbeat anyone into my way of thinking. It is always better to err on the side of kindness!!!

  7. Matt Helm DDS says:

    it would have been very good if the avulsed tooth had been saved and brought in by the patient. I could have been replanted.
    That said, I wouldn’t place an implant on 17-year old for the same reasons stated above.
    Graft, being mindful this is the primary aesthetic area, i.e. making sure you fill the socket enough to allow for some resorption over time and still have adequate ridge height to obtain the proper aesthetic gingival height and contour when the implant is finally placed.
    I also tend to lean toward a bonded bridge, because an Essix appliance will sort-of destroy any kind of normalcy in this kid’s life. A removable flipper would also work, but I lean against it for the same reasons. He will have to live with the solution for a minimum of 6 years. Imagine his embarrassment if he has to remove anything in order to eat, when he’s on his first dinner date with that girl whose attention he’s been trying to get the whole academic year. Just my two cents. 🙂

  8. mpedds says:

    I tried a few teenage anterior implant cases back in the 1980’s. After 10 years or so they all became esthetic failures as the dento-alveolar complex changed, as well as tissue levels. Don’t do it! We call this dental practice for a reason. There is nothing as valuable as critiquing your own cases after many years!

    • Matt Helm DDS says:

      Mpedds you are to be commended for the most honest post here, and for sharing your decades-long experience so openly. It is invaluable and not to be contested. Sound clinical judgement based on hard-earned experience never goes out of style!

  9. adam says:

    Unless you have a wrist radiograph proving growth has stopped (which unlikely it has) placing an implant is dental suicide. I have a number of patients with missing laterals etc that unfortunately are in holding patterns until I can prove to myself that growth is not going to be an issue. Females you might have a chance, males I personally wouldn’t even think of it as a treatment option.

    Grafting maybe but it will probably have little impact over a long period of time with the volume of bone, it will make it look initially better and may work.

  10. Sam latif says:

    Would not place it , even if patient begged me , too young for implant , graft the socket , do CT at the same time , fabricate Maryland bridge . More durable than resin bonded bridge.I would Waite for 3 years before I place implant .

  11. Matt Helm DDS says:

    All those (including myself) telling you that growth isn’t over and you shouldn’t place an implant are absolutely right! Growth won’t stop for at least another 4-5 years in a 17-year old male. Bone and tissue remodeling will continue during that time and, if you place an implant now the aesthetic result will be very unpredictable indeed! The only reasonable solution for the patient at this time is a bonded resin or Maryland bridge. What would you want in your mouth, knowing what you know?
    We are Doctors treating patients! We don’t just treat teeth and we don’t just screw screws into bone.
    By the way, have you also not noticed that there is a fracture of the labial plate at the apex on your CBCT photo? (Although this is a minor detail in the big picture.) And speaking of that 3rd CBCT photo, please read my suggestion below so that you can post proper photos in the future.

    Off-topic, on your photos, specifically your 3rd CBCT photo: instead of photographing the screen, and us seeing your fingers and camera in the background, next time make your life — and our viewing — easier by capturing the screen from within your computer. This way you will get a proper image, not the slanted image you posted in your 3rd shot, with your fingers, the camera, and the wall behind you showing because they are reflected on the screen.
    There are two ways of capturing a shot of your screen and saving it:
    1. Use the print screen function, which is the PrtSc key (after the F12 key). That will capture your whole screen. You can then paste that image into a Paint document and save it as a jpeg file (a picture file). If there is anything in there you don’t want seen, you can further edit that image by cutting the unwanted areas.
    2. Or you can also use the Sniping Tool of your Windows to capture a selected area of the screen and saving it as a jpeg. You’ll find the Sniping Tool in the Programs list that you pull up with the Start button at the lower left corner of your task-bar. It will be in Accessories.
    I may be too demanding here, but I personally think that anyone technically savvy enough to place implants should also be technically savvy enough to know how to use these basic computer functions that are readily available in any Windows computer.

  12. CRS says:

    Boys can grow till age 21-25 you know the alveolar bone of the adjacent teeth will also grow the implant does not move. Hope you know that. There is quite a bit of bone and soft tissue damage. Send case out to someone with more experience. Put the patient first use a local expert they will respect you for that, it’s not about you or the advice given in a blog.

    • Matt Helm DDS says:

      Indeed CRS! Although all the advice we’ve given him is accurate, it’s not even about what we say here, nor about his prowess as a Dr. Treatment should be evidence-based and have the patient’s best interests at heart. No Dr worth his mettle would listen to parents’ or patients’ demands if he knows it is the wrong thing to do! And the science and evidence are 100% irrefutable in this case. Yes, we all have that ego that we can perform small miracles, but there is no miracle to be had in this case, until nature takes its course and finishes the growth process. One should always slow down, take a step back, set one’s own ego as a clinician aside, and always act in the best interests of the patient. Always!
      Should I also add that placing an implant now, while the growth phase is still active — and when alternative treatment is readily available and accessible — is actually skirting malpractice principles for real? If I, as a professional, think that placing an implant now would be real malpractice, a jury is sure to think so even more.

  13. Yaron says:

    Thanks for all the responses. I completely agree with waiting for growth to finish and placing the implant later. This is exactly the reason I posted this case as there is very little discussion about implant placement at this very critical age. So lets agree that we need to wait for growth to finish, and lets get back to the question of how to deal with this site right now. There has been a suggestion of grafting the socket, if the buccal plate is indeed fractured, isn’t there a risk of further dislodging the plate during grafting. Should one wait for the tissues to completely granulate first and then go in to graft or just place a bonded bridge and deal with the tissue and bone discrepancies in the future?
    I know this hit a nerve with some of you but I would like to veer the discussion back towards how one should clinically manage this site as the soft tissues and the bone are clearly going to be deficient in 5 years time.

    • Matt Helm DDS says:

      Dr Yaron, let me first congratulate you for having your feet firmly planted in clinical reality. That said, there are many detailed aspects here which will warrant attention, but all of them can be overcome, nevertheless. Due to the length of this post I will have to break it up into 2 or 3 posts.

      Sadly, brevity is not my strong suit, so please bear with me while I share some clinical experience pearls, which I hope will serve as a good guide. Right now, you should aim to eliminate as many variables as possible, one of them being the soft tissue healing and, returning the patient to normal function in a relatively speedy manner.

      First, I personally tend to think that the fractured labial plate should already be stabilized by now, and have a strong enough bony callous formed that it will not move any more. This is supported by your very own timeline: you first posted this case on Feb 7 and stated that the tooth had been avulsed 8 days prior, meaning on Jan 31. Since today is Feb 11, this trauma took place a full 12 days ago. Bone, in most cases, heals enough at 12 days that the fracure is stable and immovable. I have had my own personal experiences with this, with two fractures of my own which could no longer be moved at 10 and 11 days, respectively – and I was way way past 17. This patient is young man, with a very active bone physiology.

      Second, the site is already half-healed. Note that at 8 days, the presumable time lapsed between the trauma and when you took the first photo of the traumatized gingiva, the socket was already half-closed as it had already granulated at its entrance. In my view, since this boy is still growing, you’ll want to have as much of his own natural bone filling that socket for the future, not grafted bone. You’ll have a much cleaner area of bone to deal with and you can always augment bone if need be when you’ll place the implant….

      Bone grafts and soft tissue grafts are great but I think that in this case, right now, both would constitute overkill, with rather unpredictable results. I would take a rather minimalist approach. You have the luxury of a quite a few years for healing.

      If this were me, I would simply do the following:

      After anesthesia re-enter the socket gently with a surgical qurette being mindful that you will probably already find the beginnings of a primary bony callous in the alveolus. Your first step should be assessing the stability of the facial bony plate, which I believe should be stable by now. Two ways you can assess this: gently palpate in the buccal sulcus, in the apical area of the fracture (on CBCT), and see if you feel any crepitation. If there is none, the fracture is well on it’s way to being fused. Another way, after you open the site (and I don’t advise a flap at this time) gently palpate the buccal bony plate from the inside with the back of a surgical qurette, while at the same time gently exerting equal pressure on its labial with your finger. You should be able to feel if the buccal plate is still fractured or moving, or if it has formed a primary callous strong enough to keep it in place. If it is already stable (as I think it will be) do your best not to disturb it with the rest of the procedure. You want it to heal in its natural position in order to preserve the buccal bony contour.

      Now currette the socket gently, avoiding the facial bony plate, but enough to cause good bleeding. Graft the socket without excessive pressure, using only collagen plugs, with enough plugs to overfill it and, as your last plug use one of those collagen plugs with a membrane on it. (You’ll find it on this site.) You are looking to create as much bone height and volume as you can on the alveolar crest, since some of it will resorb during healing, as well as with time…

      In my view, I wouldn’t use any bone grafting material and I wouldn’t do any soft tissue grafting just yet. Collagen plugs will promote the patient’s own bone growth, and the gingiva will have plenty of time to heal by second intention and fully cover the alveolar ridge defect. Right now, since the kid is still growing and will continue for a few years, I would prefer to have as much of his own natural bone filling the socket. Bone grafting can easily be done at the time the implant is placed.

      I would also not graft the soft tissue yet because you would be grafting into traumatized tissue anyway. To graft into healthy tissue you’d have to eliminate the traumatized tissue, leaving you with much less of the patient’s own tissue, and that would open up a can of worms. The soft tissue graft will be difficult, may well have to be redone anyway in the future, and will likely have unpredictable results. Leave the soft tissue alone, and let it heal on its own, by second intention, as it granulates to cover the collagen-filled socket.

      If before all of this you fabricate a Maryland bridge, you will have the luxury of being able to suture the soft tissue with some tension to pull it incisally, and bring it into close contact with the gingival of the pontic, by passing a couple of sutures over the incisal embreasures OVER the Maryland Bridge. It might sound unconventional, but I used this exact technique with great success in the case of an 18-year-old girl, some decades ago, in exactly this same # 9 area. She had come in with a very highly placed #9 impaction (deep in the palate)which had degenerated into a supra-infected cyst. She had already had a PFM bridge placed by the previous dentist who didn’t even detect the impacted #9 on standard periapicals. The impacted central incisor only became evident on a pano…

      Without removing her fixed bridge, I raised a full-thickness palatal flap with a palatal access incision lingual to the pontic and around the cervicals of #6-11, removed the impacted #9, but then, I was facing a huge void in the #9 area (under the pontic) which would have left a considerable space between the #9 pontic and the alveolar crest. Needless to say this was unacceptable. Keep in mind that we didn’t have all these great bone augmentation materials of today. Bio-Oss, with its fast-setting ability would have been a God-send. So in order to fill the large bony void I packed the socket with as much Gelfoam as possible, over filled it, and sutured in such a way so that I pulled the remaining crestal tissue incisally from the buccal, and into intimate contact with the #9 pontic, by actually looping the suture over and around the incisal of the patient’s existing bridge. After these primary sutures, and after repositoning the flap and making the requisite sutures at the adjacent teeth, I worked my way to suturing the rest of the palatal tissue margin from the lingual to join it with the buccal tissue. As the labial crestal gingiva was now firmly attached to the bridge, it also pulled the palatal crestal gingiva right along to achieve good final contact with the gingival of the pontic. It worked! When I removed the sutures at 5 days I had no space between the pontic and the gingival crest, and that pretty situation persisted through over 5 years of recalls. After final healing there was no space between the pontic and the gingival crest. So you might want to use a similar trick now. Only you’ll be the judge of what you can do, and are willing, to do…

      As for the Maryland or composite bonded bridge, that is a challenge in and of itself, which will best be resolved by possibly having the patient go to the lab, or bringing the lab tech to your office, so they can establish a really accurate shade match. Or, if you have an electronic shade matcher, that would work too. But you’ll still need a talented dental tech to perfectly match the #8 anatomy. You can leave the gingival of the pontic a bit short, to allow room to overfill the socket. If you fall short after healing, you can always add a little composite from the lingual, if need be, to close whatever space is still there. But if you’ve overfilled the socket so much that the pontic won’t seat, by all means judiciously reduce from the gingival of the pontic in such a way that it will not put pressure on the site but will have good contour to guide the healing process to the proper height and shape.
      That said, I will await your results on this with great interest. And I do mean GREAT interest! Please do keep us posted and good luck!
      End of my 4 comments. GOOD LUCK!

    • Matt Helm DDS says:

      In my haste I omitted the most important detail regarding that case I mentioned of the 18-year old girl with the impacted #9 high in the palate. All subsequent follow-up x-rays throughout the 5+ years that I was able to follow the patient showed that there was abundant healthy bone formed in the socket . This was the patient’s own bone, mind-you!
      We all know that Gelfoam is primarily purified porcine skin and is resorbable in the surgical site. It is excellent for controlling bleeding (it is also used in spinal and orthopedic surgery) and, since it’s so absorbant it helps to create a very healthy, voluminous clot — the very basis of bone formation.
      In fact, since my very first days of practice, I made it my habit to pack all my post-extraction sites with as much Gelfoam as would fit in, and place an x-suture so that it stayed in place. I always had an eye toward preserving bone and its volume and never crimped the socket post-extraction like everyone else did, even before I ever placed implants. This technique has always served me well. Bleeding was limited to maximum 20 minutes post surgery; not one of my patients ever had late post-extraction bleeding and I never had a dry socket — repeat, never! And I do have some decades of clinical practice behind me!
      It is with this experience in mind that, in this particular case, I very strongly advocate the promotion of the patient’s own bone growth during this final growth stage in his life, as opposed to placing myriad grafting materials which may not yield the same result. My two cents. 🙂

  14. Robert Wolanski says:

    Some great comments here. Without any question, this case is not to be implanted at this time, All of the experts agree on this. The only thing anyone would learn about this patient by implanting now is how much growth they still had left to the millimeter. Dr. Helm, you are on a roll with excellence, scientific as well as compassionate insight. I do want to point our however that as stated in the initial presentation, I seriously doubt the facial plate is intact. I use the word intact to describe hard tissue that is not either bruised, fractures or effected in any way that will result in unpredictable healing. If you have questions about how to restore an upper front tooth, by far the most challenging for so many reasons, please send it to someone with the experience to create the best outcome for the patient. There are just so many nuances on an unforgiving case like this that it is more likely you will fail than succeed.

    • Matt Helm DDS says:

      Dr Wolansky, you always impress! Your assessment of the complicated and multifaceted issues here is correct in absolutely every way! Our – I’m sure equally competent – colleagues’ comments, while mostly accurate (except of course for the few advocating an implant), seemed like they were made from inside a bubble, without taking into account the practical life and social aspects of that kid’s everyday life.
      Indeed the biggest challenge here by far will be achieving the proper cosmetic result in the medium term, while at the same time ensuring adequate ridge height and contour for a proper cosmetic result with both the Maryaland bridge and a future implant. That’s a tall order to shoot for right now, but I believe it is doable with a judicious and conservative approach, much more so than with an aggressive bone and tissue grafting protocol now. I have described in detail how I would approach the defect, in my post below to Dr Yaron. I will be very curious what you will think of my “antics”, in a similar case that I described, at a time when none of the bone grafting materials of today even existed.
      Personally, as you’ll read in my post to Dr Yaron, I favor a conservative approach at this time, intended to generate the patient’s own bone and healing of soft tissue, without a soft-tissue graft and no bone-grafting materials now. There is the luxury of time here, to allow the patient’s own growth process to fill in natural bone and healthy tissue, which may not even have to be grafted later.
      And by the way, thanks for the serious compliments,. I appreciate them immensely! It’s nice to see that someone still appreciates my kind of big-picture thinking which, I feel too often is being shunned for the sake of oversimplification. And while I may have been a bit lengthy, I did so because I feel very strongly about the welfare of our patients and I felt that, with some of the “sterile” comments here, someone had to light a fire and bring the real issues to light. Thank you again!

  15. Doc says:

    Yaron: Thank you for presenting such an interesting case.
    To answer your question as to what steps I would take to treat this 17 year old male patient. If the tooth was lost 8 days ago, I would wait approximately 6 weeks for soft tissue growth. At 6 weeks, I would bone graft with xenograft and a collagen membrane. Depending on the soft tissue at 6 weeks, I may even add a soft tissue graft. Explain to the patient that the likelihood of a second or even third bone graft is high since there will be at least 7 years of healing.

    • yaron Miller says:

      Thanks, that is what I was planning to do. Would you ever consider suturing the papillae with coronally positioned sutures or just deal with the soft tissue later. If one were to do a soft tissue graft as mentioned below, should this be done first after the socket graft or at the same time as the socket graft.

      • Doc says:

        Not sure I can answer this question with certainty. Based on the photo that I see, I would wait 6 weeks and have patient come in to assess. I would be inclined to suggest GBR and soft tissue graft at the same time but at this time, it all depends on what I see at the second visit at about 6 weeks. Keep in mind, this is not a socket graft, it is guided bone regeneration, replacing lost tissue and not preserving the dimensions of the socket. Personally I do not see an intact bony plate here. I understand what the CBCT shows but that is a 1mm slice that you are showing us. Clinically you have vertical and horizontal bone deficiency.

  16. Timothy C Carter says:

    Connective Tissue graft. Always address the deficient soft tissue first. When I was a perio resident we had to demonstrate competency in soft tissue grafting prior to being allowed to place an implant.

    • yaron Miller says:

      Agreed this is a neglected area in implant training and its hard to find hands on courses on live patients. As mentioned above, could you go into more clinical specifics detailing how you would do the connective tissue graft with reference to timing. Would you wait for the tissues to heal and then do a tunnel connective tissue graft or is it possible to do the connective tissue graft at the same time as the socket graft?

      • Timothy C Carter says:

        IMHO there is never a bad time to augment soft tissue but I would do it as soon as possible. The beauty the connective tissue graft is that you don’t have to completely cover it by advancing the mucosssa and this obliterating the vestibule. Regarding technique I would keep it simple and just do an envelope, tuck the tissue in and suture with your material of choice ( I use 4-0 chronic gut but that is just my opinion since I do not like to remove sutures). You could tunnel, rotate a pedicle, etc… just depends how difficult you want to make it. Fabricate the provisional. , either removable or fixed, with a “polished” ovate Pontic and use it to develop the sit for the future. This is actually easy to manage as long as the soft tissue is bulked and the provisional is ovate. I actually receive a lot of removable provisionals from restorative docs when I do similar cases that have genetic mod Ridge lap Pontiac’s and I just add acrylic to make them ovate and site development worthy,

    • Matt Helm DDS says:

      Dennis mah man, Gelfoam is made from “purified porcine skin, Gelatin USP granules, and water for injection USP” as stated in the Upjohn foldout. Old news. Note the “purified porcine skin” as the first ingredient. Theoretically, you stand corrected — but only theoretically. Practically, the argument is moot because collagen is collagen. And where does collagen come from? ….! You’re a smart guy, you get the idea. 🙂

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