Immediate Implant is Placed with High Torque as Planned

When the upper left 2nd molar is extracted, there are three shallow sockets, although the coronal portion is a single socket.  The septum has a slope, higher palatally than buccally.  When a 2 mm rounded tapered (RT 2) osteotome is initiated driven in, it has to be perpendicular to the septal slope.  Once it is engaged, the trajectory can be changed to the long axis of the tooth (or future implant).  The depth is between 17-20 mm, intended to penetrate the sinus floor.  RT 3 and 4 are used, but not RT 5, in order to increase primary stability of the implant to be placed.  The osteotomy is further enlarged by 4.5x20 mm tap at the same depth (Fig.1); the latter (T) has penetrated the sinus floor (^) with initial stability.  The taps that follow are 5x20, 6x20 and 7x17 mm.  The last tap has gained sound engagement into the osteotomy, but barely touches the sinus floor on the intraop PA (Fig.2).  A 7x17 mm implant is placed with insertion torque more than 60 Ncm (Fig.3).  Whether it has penetrated the sinus floor or not is not so important once the torque has been achieved.  Synthetic bone graft (Osteogen) is placed after implantation, because of oozing from the distal defect prior to implantation (Fig.3 D).  Hemostasis is obtained when the implant is placed.

Collagen Dressing is placed over the bone graft in the buccal and lingual aspects of the socket.  Chromic suture is placed to keep the dressing in place.  At last a short abutment is installed to hold perio dressing in place.

One week later, the lingual portion of the perio dressing is lost (Fig.5 L) while that around the abutment (Fig.4,5 *) and buccal portion (Fig.4 B)are in place.  It appears that the abutment stabilizes the perio dressing.  The latter helps wound heal.  The remaining dressing is left undisturbed for any presumptive further protection.  The dressing is off 9 days postop; the gingiva overlying the buccal plate at the site of #2 (Fig.6 *) is slightly lingual to that of the tooth #3.

The patient returns for restoration 12 months postop (Fig.7); there is apparent bone growth distally (<).  There is buccal gingival recession at the site of the implant (Fig.8,9 ^), possibly associated with buccal plate atrophy (Fig. 8 *, 10 arrowheads).  The implant should have been placed more palatally or a smaller implant used to reduce the chance of buccal implant thread exposure.

When the crown at the site of #2 is just cemented, there is an abscess associated with the tooth #14.  To save money, the patient does not get treatment as quickly as possible.  Instead, she waits for insurance to pay for the treatment.  In addition, she appears to be a bruxer.

There is no bone loss nearly 3 years post cementation (Fig.11); CBCT confirms the buccal placement (Fig.12).

Return to Upper Molar Immediate Implant, Dr. Wu, #6,15

Xin Wei, DDS, PhD, MS 1st edition 04/28/2014, last revision 05/29/2018