Localized Bone Grafting

In order to make implant restorations look natural, we have to know prior to surgery where in the 3-dimansional space the future tooth needs to be, in order to satisfy esthetic as well as functional requirements. This sometimes forces us to employ grafting techniques of one form or another, especially when there is not sufficient bone available (due to resorption) to place the implant properly. Below is an example, where an implant was placed and a localized In-Situ grafting procedure done at the same time. Again, please bear in mind that the images are somewhat graphic in nature.

In the pre-operative picture on the left you can see that this patient is missing a central incisor. Clinically there appears to be just a minor defect, hinting a straightforward placement of the implant. The image on the right shows the initial incision.

To the left we see the bony ridge after the tissues are reflected somewhat. From this angle the ridge seems to be adequate. However, when we place an indicator pin (used to gauge the angulation after the initial pilot hole is drilled) and shift the angle so that we look directly onto the incisal edges of the teeth, we see that the bone ridge is very thin (arrow).

Once the implant is inserted into the bone it has threads exposed, as you can see on the left image (arrow). Sometimes we have to take this into account in order to place the implant in the proper position. If we placed it a little more to the inside (where there is plenty of bone) the future esthetics and the implant’s biomechanical loading characteristics would have been compromised. The exposed threads are covered with some Autogenous Bone (collected from the bone drills) and the graft site is then covered with a membrane (white).

To the left you can see the implant during the Uncovery Procedure, where a the membrane is removed and a healing collar placed. Here you can see the membrane still in place (arrow). On the right you can see the implant with the healing collar in place and the membrane removed. Notice that the threads are now covered (arrow) with a bony substance (still very immature bone, which will mature in the future).

The image on the left shows the tissues sutured around the healing collar. Prior to actually placing the healing collar, an impression was taken for a temporary crown, which will be fixed to the implant at the time of suture removal, ten days later. To the right is a clinical image of the site ten days after the uncovery. At this point the sutures and the healing collar are removed and the temporary crown is placed.

The picture above shows the soft tissue condition after the temporary (acrylic) crown had been in place for about eight weeks. At this time the tissues were mature enough for a final impression to be taken and a permanent porcelain crown to be made. To the left you can see the final porcelain crown in place. Notice how we achieved even gum architecture around the implant, blending in fairly well with that of the natural teeth.