Fracture of Buccal Cortical Plate: What To Expect?

I would say that you will probably loose at least some of the buccal plate, so probably some grafting in the future to improve the cosmetic of the area ( i dont really like or trust hydroxyap and tricalcium without prp). The implant will osseointegrate (most likelly)as usual. best of luck

You will most likely be fine. I do not use TCP and Hydroxyapatite so I can't comment on these materials. But when I have encountered situations like this, I graft with DFDB and place amembrane. At the uncovery appointment I will find bone on the buccal of the implant with no longterm (2years) problems.

I would expect failure.

The fracture should heal uneventfully. If the buccal plate of bone is of sufficient thickness you shouldn't have any long term complications. However, if it is thin expect recession or loss of buccal bone, which would happen irregardless of the fracture. If you placed the bone graft over the fracture this will aid the thin bone. I've had thread exposures on the buccal plate of laterals that I grafted with HA at the time of placement and bone grew over the threads with no short term or long term complications. I wouldn't load the implant for at least 4-6 months to allow complete healing of the fractured area. No way would I immediately load, or place any type of abutment on the implant during this period. Either a removable stayplate temp or a bonded temp should satisfy the pts. cosmetic concerns during this time. I wouldn't have a cuspid guided occlusion and have the pt. wear a night splint.

I think that the implant will probably be fine. When the buccal cortical plate is thin,either anatomical or by surgical management, the possibilities of threads exposure increases, which you can eventually repair with osseous grafting. We normally use Puros, Nu-Oss, Bio-Oss with or without autogenous bone with acceptable results. On membranes, for minor defects, I have a preference for the OSSIX due to its properties and easy management, for larger defect we need to support the membrane to secure an adequate bone thickness buccally. You can achieve this with titanium reinforced membranes which are relatively inexpensive or with titanium screw placed at strategic locations to avoid the membrane collapse at the intended site. One point to evaluate is that your implant is not exposed apically due to the curvature of the apical area in relation to the most coronal aspect of the alveolus at crest. If the plate is perforated at this level in most cases you can palpate it or it will show through the mucosa, if the implant is solid and you determine that this area needs repair you can do all at once, you should rule-out this possibility with you diagnostic tool of choice. There is an excellent DVD on these matters from Dr. Sasha Jovanovic available from Global Institue for Dental Education.

Hairline fracture may not be a problem. You didn't mention whether this was an immediate implant or what caused the fracture. You also didn't say how thick the buccal plate of bone was in the area. Some implants will integrate very well even if the coronal half of the buccal plate is missing provided it is properly managed with bone augmentation procedures and follow up care.

Nothing to worry about majorly. If you graft the area with BIO-OSS but prior to that definitely perforate the cortex making bleeding points so the osteogenic cells could bathe the graft, following this cover the area with BIOGIDE or a titanium membrane fixed with screws or tacs. The bucal plate even if thin or partly perforated is not an issue if the 3 other walls are firm enough to integrate the implant.

Dr. Callan, I have seen you lecture and read some of your research, I am surprised that you would expect failure in a situtation like this. Has this been your clinical experience?

I have about a hundred of cases all photograhed(over the last 4 years) where major defects (nearly the length of the implant) and ridge splitting cases where obviously the buccal plate is both thin and cracked have been sucessfully repaired and loaded using TCP products alone.Sure they are technique sensitive to use but the results are impressive ,and in some extreme cases I have raised a new flap at 9 months to show a solid buccal plate ,thus you will be fine especialy if you had good closure and wait a little longer (6 months) before loading. Best of luck

Dr. C. did not mention whether he did a full thickness gingival retraction, or whether he detected the fracture by feeling the buccal plate of bone fracture through the closed soft tissue. If the gingival tissues were not retracted, the blood supply was not interfered with and he can expect good healing. With so many of us doing flapless osteotomies, how can you know whether or not the bone is fractured? People who break their limbs and have simple fractures, without exposure of the bone to the atmosphere, usually have a cast to set the fracture, and the healing is uneventful. I suggest a 6 month healing period is required before uncovering the implant.... the fact that less force was required to place the implant is immaterial, as the implant will not be immediately loaded. Gerald Rudick dds Montreal

i did a posterior maxillary implant, during the osteotomy , had a fracture of buccal plate at the surface of alveolus, i had placed TCP ,but after healing period of a month ,i still see two threads exposure ,although implant is stable and no bone loss even in IOPA ,PLEASE ADVISE

The thickness of the buccal plate and initial stability would be my first two concerns as already mentioned. I have had a few instances now that call my attention to the thickness of the plate. Thin plate...then wait. If the implant was placed, then I think a buccal graft at the time of placement would be indicated. I am conservative and I really like primary closure best. Im not in a hurry with my patients, and still on the learning curve after 3 years. Go slow...the bigger the defect..the longer to heal. Good advice from all. Think Ill get the DVD mentioned. You cant have enough CME at your fingertips these days. Great way for quick reference...Bill

Review Dr Myron Nevins article in J Perio Dec 2006. 'A Study of the Fate of the Buccal Wall of Extraction Socket of Teeth with Prominent Roots'. Very informative