Does your patient have a thin biotype? Was there any infection during the healing phase? If your patients has a thin biotype, you will commonly see tissue recession of about 1.5mm. 3mm seems excessive that's why I ask about infxn. Was the buccal wall intact after the extraction?
I have recovered by removing the crown, flapping, using citric acid over the implant, bone grafting, and subsequent soft tissue grafting. Prferably VIP-CT (Dr Sclar technique. Let it heal for 6 months and then uncovering.

I agree with all of the above especially burying the implant when it is grafted. One thing not mentioned, if the implant is placed too far to the buccal take it out, graft, and try again.

In regards to your concern of things going south, I would say that I would be concerned about the occlusion and was the implant being overloaded. Of course, as the other guys mentioned above, the implant being too far facial can and will have long term implications. I agree with hogandds-this can be a limited success surgery and the patient needs to be well informed on the front end. Do they have a high smile line? This "repair" surgery can lead to scarr tissue, etc. that the patient needs to know about. Key point: make sure the patient is well informed on the front end and if things go great, then you will come out looking good! Good luck!

good information, thanks!

Typically when we place implants into the maxillary arch in immediate situations we are dealing with a very thin buccal plate at the crest. Any contact of the implant withi thin bone can lead to bone loss and thread exposure over time. The best way to manage this at placement is to place osteotomy more palatally (which may require the osteotomy drills to be run along the palatal wall of the extraction socket) and leave a small gap between the fixture and the socket wall on the buccal. The lit shows that a gap of 1mm or less will fill without any graft material being placed. The clot will fill the area, organize and become bone leading to a thicker crestal bone at the buccal. Now how do we handle this situation now that some bone loss has occured? IMHO I would flap the area. Detox any exposed threaded using Doxycycline paste made from a capsule of Doxy and a few drops of saline (apply only to threads only) then treat bone and implant with citric acid rinse completely (this is Mefferts technique) place Dynablast osseous graft putty (http://www.keystonedental.com/regen/dynablast/) over the exposed threads and then a resorbable membrane such as Oramem sustained (www.Salvin.com its equal to Biomend extend but less costly) pull the gingival margin more coronal then desired as you will get alittle tissue shrinkage. allow to heal and you will be fine long term.

Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, DICOI
General Practitioner
Leisure World Plaza Professional Building
3801 International Drive, Suite 102
Silver Spring, MD 20906
301-598-3500
301-598-9046 (fax)
www.maryland-implants.com

Dr. Kurtz

I agree with your comments
"Typically when we place implants into the maxillary arch in immediate situations we are dealing with a very thin buccal plate at the crest. Any contact of the implant withi thin bone can lead to bone loss and thread exposure over time. The best way to manage this at placement is to place osteotomy more palatally (which may require the osteotomy drills to be run along the palatal wall of the extraction socket) and leave a small gap between the fixture and the socket wall on the buccal."

However, most people over compensate and place it to far palatally and then it becomes a restorative problem. I think we are beginning to see less and less immediates being done. Misch, NYU, Loma Linda all now lecturing on the ills of immediates. I don't see why people are such in a hurry that they cant wait 3-4 more months and place the implant ideally in a socket graft situation vice playing with and immediate. So we will agree to disagree.

Great comments though.

By the way I love Dynablast, great stuff.

Some degree of resorption of the buccal plate will always occur after extraction, certainly due in part to the resorption of the lamina dura, into which the Sharpey's Fibers insert. To minimize the bucco-palatal extent of the resorption, grafting between the buccal socket wall and implant with a mineralized allograft or xenograft works well. To minimize the buccal soft tissue changes which produce a flat or concave profile, rather than the desired convex profile, gingival augmentation works well, especially when using autogenous tissue. As to the exposed threads, if the implant is within the confines of the alveolus, then the exposed threads can be reduced and the implant surface treated as described above, then grafted, again with a mineralized material to reduce volume change. A membrane is then used...I prefer autogenous connective tissue, since its blood vessels tend to anastomose with those at the recipient site within 3 days and thus speed healing, compared to using a collagen membrane. If the implant is beyond the confines of the alevolus, the usual result is partial exposure of the implant despite surgical repair. Immediate implants in the esthetic zone can be very challenging and can end up costing a lot in terms of patient satisfaction, finances and frustration.

One way to avoid the complications is to not do an immediate. I have seen recession time and again by placing immediates in the anterior smile zone. Graft and delay.