BIOBRIEF

Bone Grafting and Immediate Implant Placement in the Maxillary First Molar Region

Waldemar D. Polido, DDS, MMS, PhD

Wel-Shao Lin, DDS, FACP, PhD, MBA

THE SITUATION

Patient presented with unrestorable left maxillary first molar. After data collection with Cone Beam Computed Tomography (CBCT) and intra-oral scanning, and clinical examination, the situation was considered favorable for minimally traumatic extraction and immediate implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Additional Risk Factors: Roots were divergent, and intra-radicular bone (septal bone) was excellent, with more than 5 mm of remaining apical bone to achieve optimal primary stability.

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THE APPROACH

A fully guided approach was utilized, with an immediate provisional Computer-Aided Design (CAD) and Computer Aided Manufacturing (CAM) crown. Alveolar socket gaps were grafted with Geistlich Bio-Oss Collagen®, after implant placement. The provisional crown was used also as a socket seal, optimizing healing. After 3 months, a final ceramic crown was delivered. A one-year and a three-year follow-up show excellent clinical contour of the alveolar bone, and integration of the implant.

Pre-operative occlusal view showing the involved tooth’s condition.

Pre-operative periapical radiograph capturing the cross-section of the involved tooth.

Comprehensive Digital Planning for Implant Placement – A multi-view CBCT and 3D reconstruction showcasing precise anatomical assessment and guided surgical approach.

Geistlich Bio-Oss Collagen® placement, demonstrating the material packed around the implant within the socket.

Immediate provisional crown, occlusal view showcasing restoration alignment technique.

Immediate crown periapical view, reflecting the initial stability of the implant and prosthesis.

Final crown occlusal view, illustrating the restoration’s integration and final crown periapical view, emphasizing implant stability post-restoration.

Occlusal view at the 3-year post-implant placement, highlighting tissue health and crown durability. Periapical CBCT view at the 3-year post-implant placement, providing insight into bone stability over time.

“Immediate implant placement and loading in molars is a feasible technique, with excellent long-term outcomes, if case selection is adequate, treatment planning is optimized by digital technology, and proper surgical and restorative techniques are applied.”
— Waldemar D. Polido, DDS, MS, PhD

THE OUTCOME

This case shows a three-year follow-up of an immediate implant placement, using Geistlich Bio-Oss Collagen® as a graft material on the gap. Careful tissue management, minimally traumatic extraction, and proper planning, including guided implant surgery can optimize treatment outcomes.

Immediate implant placement usually requires a bone graft to fill the gap between the implant and the socket walls. The use of bovine granules with the addition of porcine collagen (Geistlich Bio-Oss Collagen®) has demonstrated long-term stability to maintain alveolar contour and optimal bone level and soft tissue support around implants.”
Waldemar D. Polido, DDS, MS, PhD

Waldemar D. Polido, DDS, MMS, PhD

Dr. Polido is an Oral and Maxillofacial Surgeon with MS and PhD degrees from the PUCRS School of Dentistry in Porto Alegre, RS, Brazil. He completed his residency in Oral and Maxillofacial Surgery at The University of Texas, Southwestern Medical Center in Dallas, Texas. Currently, Dr. Polido is a Clinical Professor of Oral and Maxillofacial Surgery at the Indiana University School of Dentistry. He is also the Co-Director of the Center for Implant, Esthetic, and Innovative Dentistry at Indiana University School of Dentistry in Indianapolis.

Wel-Shao Lin, DDS, FACP, PhD, MBA

Dr. Lin is a tenured Professor and Chair of Prosthodontics at Indiana University School of Dentistry. He earned his DDS from Chung-Shan and Surgical Implant Fellowship at the University of Rochester (2010). He holds a PhD in Educational Leadership (2020) and an MBA in Healthcare Administration (2022) and is currently pursuing a Master’s Intelligence. Dr. Lin specializes in dental implants, digital dentistry, and AI applications, with over 120 peer-reviewed publications. A Diplomate of the American Board of Prosthodontics and Fellow of ITI and ACP, he also serves as an associate editor for the Journal of Prosthodontics and maintains a clinical practice at Indiana University.

WEBINAR

BIOBRIEF

Alveolar Ridge Preservation with vallos® Mineralized Cortico-Cancellous Allograft

Hanae Saito, DDS, MS, CCRC

Andrew Tong, DDS

THE SITUATION

A 68 year old female patient was referred from her general dentist for persistent minor discomfort on #31, suspected endo-perio lesion. Upon the examination, deep probing depth and grade 1 mobility were noted. Radiographic interpretation indicating a large J shaped lesion and possible root fracture. Patient had missing #30 and #32 has been mesially drifted and left a restorative space more than > 13 mm mesio-distally.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system/Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

* The esthetic related risk factors are not needed for this case. Restorative space of more than 13 mm may be an additional risk factor.

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THE APPROACH

A successful treatment outcome comes with proper selection of the technique and materials. In order to facilitate an implant supported restoration in the site with > 13mm mesio-distal space, a staged approach was selected, with alveolar ridge preservation (ARP) performed using an atraumatic extraction technique and vallos^®mineralized cortico-cancellous bone allograft chosen as the material.

Preoperative radiograph of #31 with guarded prognosis due to potential root fracture and infection.

Atraumatic extraction was performed and intact furcation bone is noted.

vallos® mineralized cortico-cancellous bone allograft was placed.

A collagen plug was used to cover the bone allograft

Immediate post alveolar ridge preservation radiograph.

Healing at 2 weeks prior to implant placement.

Healing at 4 months prior to implant placement.

Implant was placed with 32 Ncm. Post implant placement radiograph.

6 months after the implant placement, the final restoration was delivered.

“Ensuring atraumatic extraction techniques, regardless of whether it’s in the anterior or posterior regions, is crucial for preserving the integrity of both hard and soft tissues. Equally important is the selection of biomaterials that not only offer structural support but also possess bone regeneration properties.”
— Dr. Hanae Saito

THE OUTCOME

The planned treatment of replacing a tooth with a dental implant in the regenerated alveolar ridge was achieved. By employing secondary intention healing following ARP and utilizing a lingual paracrestal incision, adequate keratinized tissue was preserved on the buccal side of the implant-supported restoration.

Removal of the infection and maintaining the ridge dimension for the implant supported restoration in the site with > 13 mm mesio-distal space were required.”
Dr. Hanae Saito

Hanae Saito, DDS, MS, CCRC

Hanae Saito, DDS, MS, CCRC serves as a clinical associate professor and oversees the Dual Perio-Pros program and predoctoral periodontal education within the Division of Periodontics, at the University of Maryland School of Dentistry. She is a Diplomate of the American Board of Periodontology. Dr. Saito obtained a Master of Science in Clinical Research and a certificate in Periodontics from New York University College of Dentistry. Additionally, she operates a faculty practice focused on periodontology and implant dentistry.

Andrew Tong, DDS

Andrew Tong, DDS earned his Bachelor of Science degree from the University of Maryland at College Park in 2015 before completing his Doctor of Dental Surgery (D.D.S) degree at the University of Maryland School of Dentistry in 2019. Following this, he undertook a General Practice Residency at the Newark Beth Israel Medical Center in New Jersey from 2019 to 2020. Dr Tong now practices general dentistry at Tong Dental Care in Gaithersburg, MD. Concurrently, he is pursuing a Master’s degree in Periodontics at the University of Maryland School of Dentistry.

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BIOBRIEF

Immediate Mandibular Molar Transition

Dr. Peter Hunt

THE SITUATION

The case here is typical enough, a failing mandibular molar with a vertical sub-osseous fracture. Traditionally, the replacement process can take three or more surgical exposures (extraction and regeneration), (implant placement), (second stage exposure) and more than a year of therapy.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Immediate molar replacement requires atraumatic removal of the fractured tooth, careful socket debridement and development of a channel for an ideally positioned implant. The implant then needs to be placed down in the bone channel with the implant platform positioned just below the socket walls. It needs to be stable. Channel deficiency augmentation is achieved with Geistlich Bio-Oss Collagen® which is covered with a collagen matrix, Geistlich Mucograft® with the edges tucked under the gingival margins and sealed over with tissue glue.

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.

A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.

An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.

A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.

After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.

Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.

The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.

After 3 months of healing, the top of the gingiva former is exposed and the situation is ready for Emergence Profile Development. This is quite standard.

4 months later following Emergence Profile Development.

An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

“The patient desires an implant placement for a fractured mandibular molar, as fast as possible.”
– Dr. Peter Hunt

THE OUTCOME

This single stage replacement protocol has proven to be simple, safe and highly effective providing the socket is fully degranulated and the implant is stable and not loaded in the early healing stages. It works well when a gingiva former is immediately placed into the implant instead of a cover screw, Geistlich Bio-Oss Collagen® is packed around the implant to fill the residual socket, then covered with a Geistlich Mucograft® and sutured. There is no need for flap advancement to cover over the socket.

This procedure really just merges a socket regeneration procedure with implant placement. It’s a simple and effective procedure which has now become quite standard for us.”
Dr. Peter Hunt

Dr. Peter Hunt

After graduate training on an Annenberg Fellowship at the University of Pennsylvania, dr. hunt helped start up the University of the Western Cape dental School in Cape Town, South Africa. he returned to the University of Pennsylvania where in time he became Clinical Professor of Periodontics. later he helped start up Nova Southeastern‘s dental School where he was Professor of Restorative dentistry, Post Graduate director and director of Implantology. he has had a private practice in Philadelphia focusing on implant and rehabilitation dentistry since 1981.