Bone graft in preparation for implants: recommendations?

You might also consider a ridge split or bone compression. I’ve done this a lot in the mandible, avoiding a block graft altogether. Sometimes the buccal cortical plate will fracture but you’re no worse off, just graft in the newly created osteotomy and allow 4-6 months of healing. In this particular patient you would only place the implant in the #27 site and replace #26 with a cantilever pontic

I agree with placing just one implant and a cantilever. It works well. That's a tight squeeze for two implants.

It's always nice to have a single site procedure. The key to this case is the cross-sectional radiograph which shows that there are two separate plates of cortical bone in the region with cancellous bone in between. This does allow the potential for a single stage ridge split procedure. However, a two-stage procedure as described by Prof Ewers is often better and simpler. In this procedure the region is open flapped, then crestal vertical and apical cuts are made through the cortical bone. The flap is then closed. 30 days later the crestal region is re-entered and ridge expanders placed. The bone plate expansion is quite safe and simple. It allows implants to be placed at the same time. The defect is filled with Bio-Oss. Once placed, 3-4 months of healing is allowed before final restoration.

A block graft has a higher risk of resorption that can occur years later. GBR with tacs and TiPTFE membrane (cytoplast), corticotomy and growth factors are my first choice there. Ridge split is good and does require 2 surgeries due to typical bone density. I would position the implant slightly toward the cuspid so it took lateral and protrusive loads without having one pontic for the incisor.

Ridge splitting in such narrow area may have some substantial consequences. One of them is introduction of periodontal problems to the adjacent incisors. In my humble opinion there are limitations to restoring missing teeth with implants. Perhaps a conventional bridge would be the best solution for this individual. I wonder if the patient would understanding of the pros and cons well would agree to this idea of placing implant(s) to replace missing teeth.

I think ridge splitting is the best plan in this case, if you have experience in this procedure you might get away with single stage procedure , if not it's better to go with 2 stages procedure , grafts have lots of probable complications in addition to increased morbidity due to 2 sites operation.

Since the only "virgin tooth" in the area is the lower right first bicuspid, and all the other teeth in the area have crowns... the simplest and quickest procedure would be to remove some of those corwns, prepare the virgin bicuspid and make a fixed bridge...... ridge splitting is a possibility, as well as a ramus block transfer.....but why put the patient through all these procedures, when there is a simpler, less traumatic and easier fix?

don't cantilever. FP3 with pink gingiva centered between 25-26 or place two implants.

Consider preparing an osteotomy in the #27 position with lingual portion of the preparation 2mm from cortical plate. The implant could be placed same day, and the portion coronally not covered with bone grafted at that time. It appears that about 1/3 of the implant would require grafting, and, as long as the implant is stable, successful integration should occur. Just another way to skin this cat.

Implants appeal to me between virgin teeth. I am with Dr. R on this one. Nothing wrong with a nice bridge. Very predictable. Do an involved implant, things don’t go well you end up wishing you had bridged with a disappointed patient in the mix.