Larger and Longer Implant for Primary Stability

After sectioning the bridge between #5 and 6, the tooth #8 is easy to remove.  The socket is lined with a layer of granulation tissue with complete loss of the buccal plate. (Fig.1).  The ridge at #6 and 7 is irregular.  The initial depth of the osteotomy at #8 is 20 mm (Fig.2).  When a 3.8x15 mm UF implant is placed, it is deviated palatally with insertion torque of 20 Ncm (Fig.3).  It becomes loose when an abutment is placed.  Following insertion of 4 mm tap drill with low stability, a 4.5x16 mm implant is placed with >45 Ncm (Fig.4).  After placement of a 4.5x7(4) mm abutment and of a piece of PRF membrane against the buccal wall of the socket, Vanilla allograft is packed buccodistally (Fig.5 black *).  Post incision, the ridge at #6 and 7 is found to be narrow for implant placement; after bone graft (Fig.5 white *) and PRF membranes buccopalatally, the wound is closed; the retainer at #5 is removed (Fig.6,7).  An immediate provisional is fabricated between # 5 and 8.  There is no pain at #8 two weeks postop with buccal (Fig.8) and palatal (Fig.9) bulging (*, due to bone graft).  When she returns abroad in 3 weeks, fill the palatal defect (Fig.9 arrow) and create the gingival embrasure (Fig.10 black curved line for papilla formation).  Create an indentation in the distal portion of the provisional at #7 so that the width of #7 decreases while that of #6 increases (Fig.10 arrow).  Next add acrylic in the mesial portion of #6 (Fig.11 yellow).  Before harvesting chin graft, make cortical cut for the superior border of the graft and take PA to make sure that the cut has a few millimeters from the apices of the lower incisors.  Some of the bone graft remains distal to the coronal portion of the implant 5 months postop (Fig.13).  There is no bone buccal to the implant 5 months postop (Fig.14 *), although there is no apparent buccal plate collapse clinically at #8.  The atrophy at #6 and 7 seems to need block graft.  In fact the implant with periimplantitis is removed.

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Xin Wei, DDS, PhD, MS 1st edition 08/24/2017, last revision 07/26/2018