Buccal Placement

When the residual roots of #14 are removed, the septum looks as usual (Fig.1).  It consists of 3 parts (struts; Fig.2): buccal (B), mesial (M) and distal (D).  It sounds reasonable to start osteotomy in the center of the septum (Fig.3 white circle).  If the osteotomy goes on smoothly, a relatively small implant (4.5 or 5 mm) can be placed in the middle of the septum, stabilized by the 3 struts (Fig.3).  If the small implant is not expected to achieve primary stability, the osteotomy can be increased until medium implant (6-7mm) is placed, preferably away from the buccal plate, which is thinner and lower.  The 2nd type of the implant is supported by the buccal strut (Fig.5 B), the mesial, distal and sometimes palatal socket walls.

For this case, the septum is approximately 6 mm tall.  When 2.5 and 3 mm reamers are used, the osteotomy starts to deviate into the distobuccal socket (Fig.6 blue circle) because of a slope in the DB socket (Fig.7 arrowheads).  To reduce further deviation, the osteotomy is increased mesiopalatally (Fig.8 blue circles using Lindamann bur) after removing the last reamer (black circle) prior to inserting 4.5, 5 (Fig.10), 6 and 7 mm taps.  The last tap achieves fairly good stability, but the osteotomy is unavoidably moved buccally.  Due to a small error, a 8 mm tap has to be used for stability (Fig.11 the whole socket is obliterated (arrowheads)).  When a 8x14 mm implant is being placed (Fig.12), it is approaching the buccal plate (Fig.9).  Bone graft as well as collagen membrane is routinely placed.  An immediate provisional is fabricated (Fig.13 P) to close the sockets; perio dressing (D) is applied for complete seal.

It appears that osteotomes may be able to control ostoeotomy shifting better than reamers.

The patient has an automobile accident postop and cannot return for final restoration in time.  When he returns for #30 RCT (Fig.14 * (caries)) 5 months postop (Fig.15), he reports that he has chewed with the provisonal.

Return to Upper Molar Immediate Implant; Posterior Immediate Provisional

Xin Wei, DDS, PhD, MS 1st edition 04/27/2015, last revision 09/26/2015