Underprep for Immediate Implant in Senior Citizen

Fig.1-3 show subgingival fracture of the tooth #8.  With healthy gingiva, there is basically no periodontal sulcus (no ferrule effect).  After initial osteotomy with a 2 mm initial drill, a parallel pin is inserted to confirm the trajectory (no potential violation of the neighboring root or the Incisive Canal) (Fig.4).  The osteotomy is enlarged with 2/2.7 mm pilot and 2.7 mm straight drill for a short distance.  A Lindemann bur is used to remove the coronal portion of the palatal bone.  A 4x13 mm UF implant is placed as palatal as possible (Fig.5,7).  Bone graft is placed mainly in the buccal gap (Fig.6).  A 4.5 (3) mm temporary abutment  (Fig.8 T) is placed for an immediate provisional (*).  The implant is not so palatal that the coronal end of the temporary abutment is at the incisal edge of the provisional.  Two months postop, the provisional fractures at the incisal edge (Fig.9).  Another 2 months, she returns because a crown is dislodged at the lower right 2nd bicuspid (heavy bruxism, partial edentulism).  There is a labial fistula at the site of #8 (Fig.10 , 11<).  The gingival margin does not look healthy (*).  When the patient returns, check occlusal clearance with articulating paper and implant stability.  If the latter osteointegrates (no pain while torquing), make a large semilunar incision to expose possible buccal plate defect (Fig.12).  PRF may facilitate wound healing, considering possible osteonecrosis associated with female senior citizen taking osteoporosis medication.

When there is partial edentulism with bruxism, do not place a temporary abutment, since it is rigid.  Use a cemented abutment instead.  If the occlusal force is excessive, the provisional will be dislodged by itself, as a stress breaker mechanism.

Two weeks later, the patient returns for bone graft.  Preop PA taken with gutta percha shows that the point of the latter points to the 1st or 2nd coronal threads (Fig.15).  The immediate provisional and the temporary abutment are removed.  The infection appears to be derived from the buccal 1st 2 coronal threads (the implant appears to be placed not deep enough (Fig.5-8) or bone graft placed insufficiently).  Without incision, the exposed threads are cleaned with Titanium brush, Chlorhexidine and normal saline.  After placement of Metronidazole gauze, allograft (.5-1 mm) is placed in the affected area.  A cemented abutment (5.5x5(3) mm) is tightened for a new provisional.  Periodontal dressing is applied to close the buccal access.

One week post debridement, the periodontal dressing remains in place (Fig.13).  When the latter is removed, there is no fistula or gingival margin infection (Fig.14).  The gingiva remains healthy 1 month postop.

The patient returns for final restoration asymptomatically, 1.5 months post bone graft and 6 months post implant placement (Fig.16-21).  Trace of the fistula is apparently present without tenderness (Fig.17 >).

The final crown looks wider than its counterpart when the mesioincisal defect of the latter is not repaired (Fig.22).  The labial emergency profile of the crown at the cervix should have been more bulky (Fig.23 blue curved line).  There are incisal edge chips 10 months postop (Fig.24 ^).

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Xin Wei, DDS, PhD, MS 1st edition 12/11/2015, last revision 04/27/2017