Particulate Graft: Place Implant and then Pack?

It sounds to me like you have not done any or many immediate placement implants with bone grafting. The esthetic zone is a dangerous place to do your first one or even to practice on. First, you must be VERY exact with the implant placement if you hope to have an esthetic restorative result. Then you have to address the bone graft and soft tissue concerns. How much of the facial plate is left? Are there corners to give you at least a three-wall bone structure for the graft? If yes, then your materials are fine but must be placed properly. You may even need to steal a piece of CT from the retro-molar pad to bulk out the facial connective tissue. There are a lot of technique instructions available online to review. At the very least, I would talk the case over with someone near you that is experienced in doing implants in the esthetic zone. If you have time, do some bicuspids and molars with the same technique, even though it may not be necessary to do the same grafting, to gain working experience before going into the 'zone' where a mistake can come back to bite you.

The patient may have a low lip line but they have fingers that can raise it - and they will when they describe what they don't like! Good advise from ssargent.

1.'Bundle bone belongs to the root', this means an unpredictable bone resorption in the cervical portion. 2.in thin biotypes recession formation is frequent 3.the concavity probably means all of the buccal bone has gone. My advice (mostly derived from ITI) is to go stepwise: extract and leave to heal (with membrane or colllagen sponge if you like); then reconstruct the soft tissue and then the bone with a block graft; then place your implant slightly deeper and more to the palatal than the natural tooth for emergence. In these cases you can only work with real grafts, no substitutes will result in sound bone buccaly from the implant. Good luck.

One the tooth is extracted, Check to see if the Buccal plate is intact...if so, then go ahead and place the implant (assuming no infection present), but keep your implant palatal and away from from the buccal plate. You can pack particulate between the implant and buccal plate. However, if you remove the tooth and the buccal plate has fenestration or dehiscence, well you may want to consider socket grafting and returning to the site in 4 months. If you decide to proceed, again place the implant more palatal, keeping it away from the buccal plate, and then place your particulate over top of the buccal fenestration, then membrane over top. You want to attain primary closure, without tension on your tissue, as you want your graft to be tension free and stable(immobile). If you can, get autogenous bone chips from a site, place the chips on the buccal plate that is fenestrated (assuming it is), and then allograft particulate, then membrane, and primary closure, tension free. Would be better. Good luck

Dr. Aptekar, I do this the same way except I place "Osteogen", a particulate graft material, first. Then I place the implant. I can still feel the implant going into the osteotomy. I do not worry about any microgap issues.