Immediate Implant for Heavy Smoker without Local Use of Antibiotic

A 49-year-old man (HY) is a heavy smoker (2 packs a day) and grinder (loves to eat something tough).  The tooth #3 has severe gingival recession (Fig.1,2, scalers needed).  After watching his mother's implant surgery, he requests immediate implant.  There is severe bone resorption around the affected tooth (Fig.3).  The palatal root apex (Fig.4 dashed lines) is superior to the sinus floor (arrowheads). A 2nd PA taken at different angulation with lower voltage shows that there may be enough bone to support an implant (Fig.5).

Fig.6a is an illustration of the socket after extraction (bucco (B)-palatal (P) section).  The septal (S) bone may be longer than the palatal wall.  By time sequence, this case will be the 1st case of the control group of local antibiotic study.  After extraction, the socket will be packed with gauze saturated with 2% Xylocaine with 1:50,000 Epinephrine.  Hemostasis helps remove infected granulation tissue and identify anatomic structures of the socket.  Most likely, osteotomy is initiated in the palatal wall of the septum obliquely (Fig.6b).  Once penetrating the wall, the trajectory of the pilot drill will be changed so that the coronal end will be in the center of the socket (Fig.6c).  With combination of osteotomes and reamers (Fig.6d,e pink), the sinus floor will be lifted (green lines); at the same time, the osteotomy will be shifted palatally by itself due to the slope of the palatal wall of the septum.  Finally a bone-level implant is placed (Fig.6f, 7) with bone graft covering the exposed threads (red circles).  Place Osteotape inside the socket against the gingiva prior to bone grafting.

The gingiva at furca (i.e., septum) will be the buccal one for the implant.  Hemorrhage from this tissue (Fig.3) will be stopped by applying a special gauze, which will be fixed by an immediate provisional and perio dressing.

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Xin Wei, DDS, PhD, MS 1st edition 08/06/2015, last revision 04/28/2018