Graft Materials for Immediate Implant

The tooth #3 has severe gingival recession due to fracture of the mesiobuccal root (Fig.1 arrowheads).  When the tooth is extracted, the septum (Fig.2 S) is deviated distally (Fig.3 arrowheads).  Osteotomy for immediate implant is initiated in the center of the septum with the coronal end of drills (Fig.3) and implant (Fig.4 I (5x12 mm)/abutment (Fig.4,5 A (7.8x5.5(2) mm) in the center of the edentulous space as much as possible.  Prior to implant placement, mixture of allograft and Osteogen is used for sinus lift (Fig.4 *).  After implant placement, Osteogen plug is inserted into the 3 sockets (mesiobuccal, distobuccal and palatal) until the plateau of the implant, while Collagen plug (Fig.5 C) is placed in the socket between the implant plateau and the abutment margin.  It is hoped that the former facilitates bone regeneration, while the latter gingival regrowth (to correct gingival recession).  No bone graft appears to be placed in the sockets.  The collagen plug is kept in place by fabricating an immediate provisional (Fig.6 P).  While the latter is setting, effort is exerted to push the acrylic apically (arrowheads) to cover the gingival defect and laterally into the undercut of the neighboring teeth to obtain retention of the provisional (*).  Therefore the provisional is locked in place.  No cement is needed.

One month postop, there is a gap underneath the buccal wing of the immediate provisional (Fig.7 >).  If bone graft had been placed, the gap would have been smaller.  Although the wound heals normally (Fig.8,9), bone graft would have had better tenting effect in preventing buccal collapse.  After provisional removal, the buccal margin is shown to be supragingival (Fig.8), while the lingual equigingival (Fig.9).  When the patient returns in a month, a smaller abutment with shorter cuff should be used.  The provisional will be relined one more time.

In fact, the patient returns 4 months postop.  The provisional perforates at the occlusal surface, but there appears to be new bone formation in the mesial socket (Fig.10 *).  Remember no bone graft being placed in the mesial socket (instead Osteogen plug being used).  When the abutment is being changed to smaller one (6.8x5.5(2) mm), the gingiva around the implant looks healthy, although recessive (Fig.11,12).  The gingiva is healthy 2 months post cementation (Fig.13).  The patient is pleased with improved mastication with the implant.  When the patient returns nearly 7 months post cementation, bone density immediately next to the implant (including sinus lift) increases (Fig.14).  Mesial residual cement or porcelain to close the gingival embrasure (Fig.15,16) is inaccessible because the crown margin (especially buccally) is more cervical than the abutment margin (Fig.17).  The tooth #2 develops mild periodic pain without deep pockets 13 months (Fig.18) and 2.5 years (Fig.19) post cementation of the crown at #3 with dense bone formation (*) next to the implant.  In fact the mesiopalatal pocket of #2 is deep with tenderness (Fig.20 *, due to #2 palatal root fracture or #3 periimplantitis due to shallow placement with poor trajectory?), while MB porcelain of #2 is chipped.  Water pik is recommended.  CT is apparently needed.  Fortunately the discomfort between #2 and 3 disappears when the crown at #2 is redone (Fig.21).

Return to Upper Molar Immediate Implant, Posterior Immediate Provisional Buccal Root Exposure Husband

Xin Wei, DDS, PhD, MS 1st edition 01/05/2016, last revision 12/03/2020