Slight Buccal Concavity: Should I Place the Implant at an Angle?

Do you have a scan if new to the game ? as this will help . Raise a full flap to get a good view of the ridge and help assess the extent of the concavity. In ths area ( upper first molar) it is better not to angle if you can help it thus here maybe better to place slightly more palatally . If you do perforate the plate always graft the site covering any threads exposed.

Hi, Why a 5, use a 4 diameter and avoid part of the problem. Place the implant in exactly the position you really need it to be to obtain the best solution aesthetically and oclusallly wise, then do everything needed (graft hard and soft tissue etc) and dont compromise, that way you will never see the case as a faillure or as a case you could have done better... this cases(implants) stay with you for many years and is not a pleasant situation when you look a case that you could have done better in the past and know is just a constant reminder of that.

Dr W, Buccal concavities on the Maxilla are common. In the long run, the best thing to do is to keep your implants centered and upright to the load. Sometimes a smaller diameter will avoid a problem, but if you are working against a thin buccal plate, it is not difficult just to place some plate perforations lateral to the exposed implant and then place Synthograft. You may need a collagen membrane if the granules will not be well localized otherwise. Also, you could place a short implant, if the concavity is high enough up from the ridge. while you should be prepared to place a graft, you can try to avoid it in general. The Bicon system has expanding tips, so you can stop two or three sizes (1 to 1.5 mm) below your target width and gently expand the bone .5 mm at a time with gentle tapping. Also, while prepping the site with reamers, hold your finger against the buccal bone to feel when the reamer gets close. If you have smaller diameter implants on hand, you can stop and put one of those in. For example, the ideal Bicon short implant for an upper molar is the 6.0 x 5.7, but you can put a 6 x 5, or a 5 x 6, or a 4.5 x 6 in a molar loaded spot. You can put the Bicon implants in a sea of Synthograft with no problem as long as the implant is immobilized and sealed from the oral environment. There are many free "Webcast Replays" on the Bicon site which will prove helpful, even if you use other brands.

Also, you could ream the site until you feel the reamer approaching the Buccal Plate and then switch to the Bicon Hand Reamer set. These reamers have only one cutting edge and you can selectively cut only the palatal half of the prep site once you start to get close to the buccal plate. You just put the reamer in with the blade facing the Palatal and turn less than 180 degrees, then rotate back to where you started and repeat until the desired width is achieved.

I agree with most of the above. Using a bone condensation technique can help widen the crest if necesarry. Don't compromise on placement and angulation. Learn to do grafts in a case like this it should be very easy and wichever technique or compromise you use there is allways the risk of perforation and thus you should allways have a backup. Good Luck

Hi I will just add to what someone as experience as Dr. Fairiarn has said.do not surprise yourself on the day CBCT with radiographic stent from diagnostic(which can later be used as surgical stent) will help you to decide with angulation/positioning, emergence and size of the implant. implant always serve better in bone so you can always give angle as far as you are willing to accept cement retained restoration with appropriate emergence. I personally try to avoid cement retained where ever i can. hope it helps

correction: Fairbairn

All Good ideas previously posted. Remember its not a race. Once that implant is finished its in there for a long time so do it correctly fom the start. 1. Graft The site as a first step(remember your a beginer-don't do too much at once) 2. Graft with either a particulate (bio-oss, dynagraft,etc) or a block graft if the concavity is very large) both covered with a membrane. 3. Go back 4+ months later and then place the implant at the correct angle And the true Golden Rule applies-never be afraid to say I CAN'T DO THIS MYSELF. Nothing is worse that a lawsuit. Thats why periodontists and oral surgeons do advanced training.

Agree with most of what has been said but you really didn't provide anyone with the most important information. That would be how much bone width do you have ?? how did you come to the conclusion that a 5 mm width would be OK ? You clearly don't have a CBCT , so did you use calpers ? For the 5mm width , you have to be certain of at least 8mm of bone width occlusally . So first make sure you have that and go for the 5mmm even if you have to incline it palatally a bit . You can easily correct any misalignment with a custom abutment later . Otherwise use a regular platform and get a better alignment .

Why not use an osteotome and condense the bone and expand the ridge at the same time and place the implant in the proper axial position. Remember you can have cantilevers B-L.

Good day - all fair comments. If you removed the tooth you would know best what it was like at the time of removal.The less grafting I do the happier I am and the better for the implant. Consider using an angled implant eg Southern implant. Also dont even consider the so called "flapless" scenario. Open a proper flap to ensure you will see any perforations on the bucal plate - and plan that flap so you can release it if necessary for a graft - preferably not bio oss - rather bone! Take your time and good luck.

It is very common for the buccal crest to resorb. You will have threads exposed at the crest unless a ridge augmentation is performed first no matter what angle you place the implant in if the resorption is significant. I support Dr. Goldberg's advice but most importantly if you are new to implants why not place the simple implants yourself and send the more difficult cases to someone who will send you back a properly placed implant with healthy support? Greg Steiner

if you decide to palatally placement of fixture be careful not more palatally of adjacent teeth.

I agree with Dr. Cason. It was suggested to me that when starting to place implants, to raise a full thickness flap for the first 50 that you do. That way, you really get a feel, not to mention a direct visualization, of the entire procedure. If you had this experience behind you, I would say, and I do almost 100% of the time, to do a flapless procedure. In fact, a flapless procedure is preferable whenever possible. The intact gingival and periodontal tissue and lack of interrupted blood supply act as a natural membrane for any grafting you may need to perform, the over all healing and post op experience for the patient is far better and crestal bone resorption, and bone resorption, in general, is reduced. To your question on exposed threads, sure, place grafting material over them but do not overly fret if you have probe-able threads in the end. Especially if the threads are covered by gingiva. Is it ideal? No. Is it solid and functionable? Absolutely. Inform patients confidently that this, while not absolutely perfect, should be just fine if they keep it clean, which is what you would say anyway. You can be confident because you are informing them of the truth. If you are working in an esthetic area, it's an entirely different ballgame. I would suggest you refer those out until you feel confident/have a patient that you have a little "leeway" with.