Lecture 4: Soft and Hard Tissue Considerations for Future Implant Placement

Saving Teeth

  • If you can save the tooth, don’t think about an implant!

    • Endodontic TX

    • Endodontic surgical TX

    • Endo Retreat

    • Periodontal TX

    • periodontal Regeneration

  • Before removing any tooth (except 3rds) you should have a plan and give options to your patient

Ridge Preservation

  • How much shrinkage horizontally and vertically, grafted vs non grafted

  • Do we always need a graft?

  • Do we need a graft?

    • Ridge changes 1 year after single tooth extraction

    • greatest loss was ridge width

    • Greatest loss happens in the first 6 months to 1 year

    • Ranges is the major problem. Loss of width can be unpredictable

    • graft is the key to predictable management

Minimum Required Bone

  • Mesial and distal: 1.5mm from natural teeth and 3mm between implants

  • 2mm safety zone from anatomical structures8mm long implant, 10 mm from IAN canal

  • Facial bone: 1 mm facial and lingual

  • Bone graft in minimum exposure of implant threads, submerge and primary closure

  • Platform of implant: 2mm bellow the CEJ (3mm for ant teeth)

Do we always need to graft?

  • Type of the bone and Maxilla vs Mandible:

    • type of the bone may not matter as much as the thickness of the walls

    • thickness of facial bone!

    • Facial fenestration, dehiscence, loss of facial bone, infection around the tooth

Ridge Preservation

  • The key is to preserve buccal bone, the thinnest wall!

Bundle Bone Resorption

  • Lamina dura, cribriform plate, bundle bone

  • Bundle bone resorption after tooth extraction

    • Bundle bone will be resorbed when the tooth is extracted

    • same result for immediate implant

    • bundle bone replaced by woven bone

    • Atrophy of the edentulous ridge will occur following tooth loss. The contraction of the ridge cannot be prevented by placing an implant in the fresh extraction socket

Ridge preservation and implant placement

Defect Types

  • 4 wall defect is the most predictable site to graft

  • 3 wall defect → when there is no facial wall

  • When the ridge is completely collapsed → no wall defect! →vertical GBR (very difficult and not predictable)

  • We don not have 4 wall defect around an existing tooth, the 4th wall is the tooth!

Grafting after extraction of tooth with infection

  • Is it a contradiction for grafting?

    • No!

  • Tooth with infection usually have more bone loss (Radiolucency on the radiograph)

  • No bone graft in case of infection that has spread to facial spaces or patient has systemic symptoms such as fever

Different Materials

  • Different Graft types- Adv and disadv

    • Types of Grafts

    • More predictable outcome

    • Less number of the walls → More bone resorption

    • Thinner walls→ more bone resorption

    • infection around the tooth→ more bone resorption (larger defect)

  • Do we need a membrane? What are the types?

    • Soft tissue grows much faster than bone tissue

    • soft tissue encapsulation of the bone graft

    • Types of membranes:

      • Resorbable

        • Collagen (Tendon) vs Synthetic

        • cross-linked vs non cross-linked

          • Cross-linked membrane will last longer

      • Non-resorbable

        • dPTFE (Titanium reinforced / no Titanium)

        • Good for maintaining spaces

          • big grafts cases or missing facial bone

    • DO NOT MEMORIZE THIS CHART

Different Techniques

  • Flap or flapless

  • Ice cream cone technique vs grafting of the facial out side of the socket

What to expect after ridge preservation, implant placement and sinus augmentation

  • Why do we graft after extraction?

  • What will happen if I don’t graft site #14?

  • Ext and Internal sinus augmentation? Min 5 mm is needed for internal

Soft tissue around implant

  • Peri-implant mucosal thickness and marginal bone loss

  • >2mm of thick tissue at the time of implant placement results in less marginal bone loss

Ridge Preservation vs Ridge Augmentation (GBR)

  • Make sure you plan ahead to avoid ridge augmentation