Repair Apical Buccal Plate Internally Prior to Implantation

An apical fistula develops at the tooth #7 lately (Fig.1 >).  There is purulent discharge from the distobuccal sulcus (*) when an anesthetic is being infiltrated.  The affected tooth is also buccally displaced (Fig.2).  When the tooth is extracted, the apical buccal plate is found to be defective centered by the fistula (Fig.3, apparently concave buccal surface).  PRF is necessary for the repair of the bony defect.  Blood drawing fails, probably due to small veins associated with the skinny lady.  When an osteotomy is being created palatally, the palatal bone feels vibratory and thinner.  The osteotomy is then re-created more buccally (Fig.4: 2.7 mm drill in place).  By the time a 3.8x16 mm implant is placed (>35 Ncm), the apical buccal gap is too small to be inserted by Osteotape (collagen membrane impregnated with Osteogen).  Allograft is placed in the remaining gaps in the two-step manner.  It would be much easier to pack the membrane and bone graft (small amount) against the apical buccal plate inside the socket prior to implant placement.

A cemented abutment is placed for an immediate provisional (Fig.6).  The nervous patient does not tolerate the procedure well.  The external repair of the bony defect is abolished.

The patient returns for restoration 6.5 months postop (Fig.7).  The fistula has disappeared (Fig.8).  She is not pleased with black triangles when the definitive restoration is temporarily cemented (Fig.9 arrowheads), although a black triangle is present between the central incisors (Fig.10 <).  In fact the provisional should be fabricated to elongate the interdental papillae before impression.  The crown is dislodged a few days later and permanently cemented 7 days later (Fig.11,12 (8 months postop)).  There is no buccal plate atrophy.  The black triangles reduce 10 months (Fig.13) and 1 year 9 months (Fig.14) post cementation.   Bone increases distal 4 years 2 months post cementation (Fig.15).

Return to Upper Incisor Immediate Implant #31

Xin Wei, DDS, PhD, MS 1st edition 04/20/2016, last revision 04/16/2021