Immediate implants: Do you graft the space?

When immediate implants are placed there is almost always an unfilled gap and we are faced with the decision of graft or no graft. While there are many variables based on this presentation what would you do?

Immediate implants: Do you graft the space? 1

drtoast15 comments:


aminmo comments:

The buccal bone in the aesthetic zone (like in your image) is usually very thin, it will need bone graft support as otherwise it will be highly likely to collapse and cause concavity. I always place graft and it only takes few minutes

ydriller1 comments:

This implant is too large and placed too buccally. Implants in the aesthetic zone should be placed palatally, and the diameter of the implant should be selected to allow for at least 3mm of space between the implant and buccal plate. Grafting is absolutely required.

timcarter comments:

That is an interesting comment... I was always under the impression that a gap >2mm should be grafted while a smaller gap can be left alone. Of course this is just a guideline and perhaps the 2mm critical gap size is more of a function of the size of the instruments and graft material rather than having any biological relevance. I really can't imagine aiming for a 3mm minimum gap, as you suggest, in cases involving smaller teeth such as laterals. Also aiming for such a goal might encourage placing too small a diameter fixture thus compromising the emergence and leading to a toadstool looking tooth. I think we need to pay more attention to gingival thickness and proper emergence rather than obsessing over particulate materials.

ydriller1 comments:

Yes, when dealing with laterals it can be a bit more challenging but a 3.5mm implant has worked for me in most cases. The mean circumference for a lateral incisor is 6.64mm so placing a 3.5mm implant along the palatal wall would give you around 3mm of space. If you can't get 3mm then you have to accept 2mm. In this case you are showing a central and you have more than enough space for a regular sized implant. I don't really understand your comment about "too small a fixture compromising the emergence profile. What determines the correct emergence profile is the correct diameter of the implant( selected by assessing the total diameter of the socket), the correct depth of the implant, the correct palatal positioning of the implant and the correct shaping of the contours of the prosthesis that support the buccal tissues( temporary and final). I encourage you to read Dr. Jose Da Rosa's book which describes another technique but details all of the above really beautifully. Of course gingival quality is extremely important but you seem to have more than adequate attached, keratinized gingiva despite the high frenal attachment. In your second picture you can see how your fixture is placed too buccally which is not going to allow you to develop the s-curve to support your buccal tissue which is going to result in a longer visible clinical crown or recession. I'm willing to bet that if you take a CT in 3-5 years you will have no buccal plate. Thanks for sharing this case.

timcarter comments:

You are correct about having more than enough KG which is why there is little fear of the buccal plate being thin and/or going away. Thick connective tissue = thick plate. I agree that is too far buccal to be considered ideal and it is a larger fixture than I would opt to use today, this was done 11 years ago. My point is that we do not have to fill every gap with particulate material and understanding the biology of the surrounding tissue is extremely important. To your point about the emergence profile... If a small diameter fixture is placed at the same depth then the emergence profile will be compromised. We need to understand the surrounding tissue in order to make clinical decisions rather than rely solely on some textbook definition.

gregkammeyer comments:

Use an HA bone graft, as the buccal plate loss will need the extra support buccally.

richardhughesdds comments:

I usually place OsteoGen particulate prior to driving in the implant. This usually avoids jumping the gap and potential bone loss.

timcarter comments:

It appears that most people agree that a graft might be beneficial or at least make us feel better. I found this case from about 10 years ago and I shared it because of one often overlooked issue... While there is likely no one absolute correct answer it should be noted that the facial gingiva in this case is extremely thick. As a general rule thick gingiva=thick bone so the thickness of the buccal plate is most likely a non-factor in this case as the tissue is so thick it is folding over the facial crest. Today, having 10 more years of experience, I would attempt to place it slightly more palatal and a smaller diameter but that is why we document and discuss. I will attempt to post before and after pics... Hopefully they will be in order but I opted to place an immediate provisional and the final photo/radiograph was taken 4 years post treatment. Back in 2012 I was using cemented provisionals on PEEK abutments while today I opt to screw retain.

timcarter comments:

For clarification the case posted with before and after pics is not the same case as the one above though it is very similar. I was not able to locate the post-op photos for the original post so I shared a similar one. Back in 2012 we were doing all cement retained crowns and as such would intentionally place the fixture in a slightly more buccal position than for a screw retained. I am not defending the position of the fixture. The purpose of the post was to demonstrate that when there is thick connective tissue surrounding the site it heals much better and these grafts which we falsely claim are necessary can be reconsidered. I routinely place particulate grafts around my immediate implant fixtures but I like to think that I do so when needed and not as a matter of principal. Both of these cases were completed without the addition of any graft material and they both turned out acceptable. The reason they do not require grafting is because of the quality of the surrounding soft tissue. As far as the diameter it should be noted that this 5.0mm platform was platform switched to a 4.1 to medialize the abutment interface. In order to achieve the same esthetic emergence profile with a smaller diameter placed more palatal it would require placing the fixture slightly deeper so yes platform does impact emergence. Bottom line: Grafting the space is fine though not necessary when adequate soft tissue is present.