Two-Step Bone Grafting

A 56-year-old lady (TF) has multiple missing teeth with atypical trigeminal neuralgia.  Suddenly the tooth #7 develops pulpitis.  It is difficult to find the canal initially (Fig.1).  The tooth fractures 2 weeks after root canal therapy (Fig.2-4).  Note the anterior deep bite (Fig.3).  Place an implant palatally (Fig.5 black circle) after socket treatment with Clindamycin.  A 18 mm long implant is required for primary stability (4 mm in the new bone, Fig.6). 

After implant placement (Fig.7 (*: implant well)), bone graft is placed (Fig.8 red circles) around the implant post healing screw (brown cylinder) placement.  Then the healing screw is removed and an abutment is placed (Fig.9 pink).  Due to the presence of the gingiva (Fig.10 yellow), the access to place the 2nd batch of bone graft (white circles) is limited (arrows).  Therefore the 2-step bone grafting is critical.

On the other hand, when the abutment is placed first (Fig.11), bone graft to be placed should be limited (Fig.12,13 white circles).  The most important area to have bone graft (the coronal threads of the implant) cannot be reached.

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Xin Wei, DDS, PhD, MS 1st edition 03/11/2016, last revision 01/19/2018