When to Place Bone Graft Prior to Immediate Implant Placement?

A 57-year-old man has had brain tumor surgery.  There are existing removable partial dentures.  The tooth #10 fractures equi-gingivally (Fig.1,2).  After atraumatic extraction and socket disinfection, a 2 mm pilot drill is used to initiate osteotomy 17 mm in length (Fig.2').  The latter is extended to 20 mm and enlarged with 2.5 and 3.0 mm reamers at 20 mm and 3.5 mm reamer at 17 mm (overprep, as indicated next).  When a 4.5x20 mm tap is placed, there is not much resistance (Fig.2").  The autogenous bone (harvested from reamers), mixed with Bicon Synthograft, is placed in the buccal and mesial portions of the socket prior to placement of a 4.5x20 mm implant (Fig.3 I; 40 Ncm) in hope to increase primary stability.  After insertion of a 3.5x5 mm abutment (A in Fig.3) and finishing crown preparation, more graft is placed in the remaining socket gaps (Fig.4,5 arrowheads).  An immediate provisional is fabricated to cover the socket opening (Fig.6). 

There is minimal buccal plate collapse (Fig.7 arrowheads); the mesial and distal socket gaps appear to have been filled new bone (Fig.8 arrowheads) 5 months postop.

Two weeks later, a definitive restoration is cemented with minimal metal margin exposure (Fig.9 ^).  Bone density around the 1st three threads of the implant is particularly high 1 year 3 months post cementation (Fig.10 arrowheads).  There is no margin exposure.  Bone density continues to increase 2 years (Fig.11) and 3 years (Fig.12) post cementation.

With a male senior with medical condition (possible malnutrition), osteotomy should have been under prepared: 2.5 mm reamer at 20 mm, 3.0 mm reamer at 17 mm and 3.5 mm at 14 mm.  Force should be applied palatally while using the reamers so that the implant will be not tilted too buccally later. The 1st sign of soft bone can be detected with the pilot drill (easy drilling: no resistance).  This should be applied at #15.

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Xin Wei, DDS, PhD, MS 1st edition 08/01/2015, last revision 01/19/2018