D2 Bone in Upper Bicuspid Edentulous Area

A 45-year-old lady is nervous about dental treatment.  The missing tooth #13 was replaced by a 3-unit bridge.  The latter is sectioned because the posterior abutment has caries.  PA in Fig.1 is taken when root canal therapy and build up are finished.   Fig.2 shows the wide edentulous area with a single-unit crown being tried in for #14.  Osteotomy is initiated with the crown in place without cementation, since it is easy to determine the mesiodistal position (Fig.3 red lines).  Without the crown in place, osteotomy tends to be distal.  In this case, the osteotomy is later attempted to be moved distally with Lindamann bur and deepened to 14 mm from the gingival margin (Fig.4).  A 2.5 mm reamer is being used at 50 RPM to increase osteotomy with difficulty.  Drills have to used at high RPM instead (Fig.5 4x14 mm).  A 4.5x14 mm tissue-level implant is placed with insertion torque >60 Ncm (Fig.6 I); a 4x3 mm abutment (A) is placed immediately for an immediate provisional.  Fig.7 is taken 7 days postop to show the gingival recipient site formed by the provisional.  The patient is so afraid of X-ray that the next one is taken 1.5 years post cementation (Fig.8).  It appears that dense bone bundle forms between the crest and the 1st implant thread (adaptation functional change, arrowheads).  The bone density continues to increase 2 years 8 months post cementation (Fig.9 *, 10); the bone has grown into the area between the 1st 2 threads (arrow).

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Xin Wei, DDS, PhD, MS 1st edition 03/20/2016, last revision 01/19/2018