Narrow or Regular Platform Implant?

I would go for the regular diameter implant, because 6.5 mm width is more than enough for a good placement. If you are not sure, start your osteotomy more palatal, where few exposed threads do not play any role.

Wouldn't it be wise to have a CT of the maxilla first, then you will know for sure about the bone density? Why go in without knowing for sure?

Even with 6.5mm this isnt enough bone for a 3.5 diameter implant. You would ideally want 2mm for both buccal and lingual walls this adds to 7.5mm. In the maxilla you should be able to obtain adequate width by ridge expansion. Either with expansion drills or with osteotomes. This would be a much better option than grafting exposed threads. Good luck!

Following Linda's advice.... Why don´t you ask for a CT Scan first?? It will give you all the information that you need for the case and you are gonna be sure about wich implant platform use. Even if the CT shows that you don´t have enough bone for a 4.3 diameter, you will able to planificate your treatment with more confident and having more predictible results.

DR. Meniga, exposed threads on the palate do play a role. that is really not a correct thing to teach our brother here who is a beginner. I can imagine here that he is placing an implant coated with ti-unite, won't mention any names. even in thick palatal tissue, exposed threads cause problems. lets teach our beginners good technique. exposed threads are not okay. expand, graft, but don't leave exposed threads. ti-unite drives soft tissue crazy, even if it's on the palate and you can't see it.

I would go for a slightly palatal implant, slightly more burried so there would be no exposed palatal threads. I also use my osteotomes for all my implant procedures. They guarantee me excellent primary stability and alos compress buccal wall buccally further reducing any risk of exposure. YOu have to go very wrong to have palatal exposed threads. Good luck Jean

Ah yes sorry, definitly a regular platform implant!

i think the platform would not matter much than the way the implant is placed... meaning placing a narrow platform completely without any exposed threads and in sound bone all around would be far better than a regular platform with exposed threads n then grafting. Also you'll have to consider prosthetics, the load on maxillary first premolars would not be very demanding if the patient has rest of the dentition in good health.

Hi Guys, i think really pre op ridge caliper measurements would be helpful; at 2,5,10mm . CT, is it indicated with ball bearing stents? maybe in the lower mandible certainly there are no referral criteria yet in the UK. In reality at 2mm you very rarely have more than 5mm width, fact. Placing palatal means yes prosthetically it will look nicer due to more attached gingivae,but you implant will have a cantilever potentially in the bucco-palatal dimension, resulting in non axial load and bone loss. I would always try and stay to np in aesthetic zone and for premolar sites. Typically in the aesthetic zone i use np, but quite often still only have 1-1.5mm bone so bone augmentation with bio-oss bio-gide routinely. But overall i am tending toward a slight palatal placement of the platform these days.

Hi, Sb oral surgeon, why don't you react to Linda or Dr C? How can you do a precision osteotomy after having a CT to "know the bone density"? Or, if "6.5 mm isn't enough bone for a 3.5 diameter implant", then we need to graft almost every healed site, which means that the patient needs two or three surgeries. Of course there are different approaches for different implants. In this case some colleagues would do computer guided flapless procedure, the other one would use 3 mm implant (in the 6.5 mm bone!) to be "on the safe side" - which is both wrong. If Dr. F is using Replace Tapered implant I would recommend the bone preparation for the narrow implant and an investment in NB tapered osteotome to expand for regular size implant without exposing the threads anywhere. Then, with a good primary stability our colleague can go for immediate nonfunctional loading with a temporary. Satisfied?

dr meniga my comment was directed towards this statement "where a few exposed threads do not play any role". exposed threads of an implant - even palatal - cause problems. i've ssen this creep up on some of my earlier cases where at first exposed threads under palatal tissue were tolerated. it does lead to problems of peri-implantitis, chronic inflamation, and increased bone loss. let's teach good technique and sound surgical principals. remember that beginners are reading these posts. osteotomies should be planned for no exposed threads. if you need to graft, expand, reduce implant diameter, get a CT scan, or whatever, then do it. just don't leave exposed threads. these will come back to haunt you.

I have concerns about some of the recommendations posted here. Firstly a Medical Cat-Scan has radiation equivalent to approximately 1000 days of background exposure. Better would be to use a Cone-Beam Volumetric Tomogram which has approximately 10 to 15 days of background exposure. But even this is generally not required for a maxillary bicuspid as described in the posted question. At 6.5 mm. of overall width it is highly likely that an implant can be placed. The question is what width. This is where inventory comes into play. In a situation like this I recommend having a range of implant widths on hand as well as an inventory of surgical techniques in your skill set. It sounds like you are using Nobel system. If it is Nobel Replace you have 3.5 and 4.3 as you have stated. However if you also have Nobel Speedy then you will have a 4.0 diameter. If you have other systems on hand you may have a choice of 3.75 as well. On exposure of the site it will be apparent what you have to work with. Pick the implant diameter that works best. My second concern is the posting about leaving implant threads exposed. This is unnecessary and is just not appropriate. If you need to augment at the same time this can be done. If you need to dilate this can be done. The bottom line is that in order to be versatile, one implant system alone has limitations. I recommend more than one. One implant system design simply cannot accommodate every situation. Having multiple systems and broad inventory may be costly, but this is inevitable if one is to become a player in the implant placement business. You also need to have the instruments to dilate as well as holding on hand different product inventories and methods, in order to augment.

Palatal threads do we mean dehiscence or fenestration? dehiscence always graft and fenestration palatally i would not if always in good zone of attached gingivae Plus palatal augmentation how well does it work?!

Dear all, I am happy that I forced the discussion with my provocative answer, because a lot of different opinions came out. For replacing a premolar of course it is better to have a regular sized implant. Our young colleague obviously has system with 3.5 or 4.3 implant diameters only. Shoud he buy additional surgical kit to place a Mark IV or split the ridge and graft the site before or simultaneously with the implant insertion??? Even if he did a mapping or has a CT scan he can't be sure in a ridge quality before opening the flap. FINALY, I WOULD SAY TO THE DEAR COLEAGUE WHO IS STILL WAITING FOR THE SIMPLEST ANSWER TO HIS QUESTION: if the width and the density of the bone does not allow the use of tapered RP NBC osteotome for the expansion after NP tapered drill, to be at the safe side use at least 13 mm long NP tapered implant and place it deap enough to allow for a good emerging profile of zirconia abutment.

Can anyone explain me the problem of having a few threads exposed, even on the facial? With tis surface, at least what NobelBiocare says, you have fibers from the soft tissue atached to the implant. You have no probing depth, and no pocket. But you need atached gingiva. If you don't have then this is a problem. You will get recession and mucosistis. But I insist that this is not the ideal surface to have it.

Thank you very much for the last statement, I didn't feel good after the previous posts and definitely agree with pfb colleague.

Dr.F. I would like your reaction, please!

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