Possible Buccal Plate Perforation at the Site of #9

Note the apical buccal concavities at the sites of 8 and 9 (Fig.1 *).  The severity of the ridge atrophy is manifested by the buccalized Incisive Papilla (Fig.2 *) after pontic removal.  Following incision, the initial osteotomy with 1.2 mm pilot drill appears to perforate the buccal concavity at #9.  When the osteotomy is redirected, the buccal plate vibration is undetectable.  The insertion torque at #9 is <25 Ncm, while that at #8 is >45 Ncm with the same 1-piece implants (Fig.3,4: 2.5x14(2) mm).  The postop buccal plates at #8 and 9 look bulging, probably associated with bone graft and collagen membrane placement (Fig.4 *).  The patient returns 2 weeks postop with concern over a palatal swelling, which in fact apparently does not exist.  There is palatal perforation of the provisional palatal to #8.  The abutment at #8 is adjusted (Fig.5); the provisional is relined and recemented (Fig.6).  Gingival recession at the tooth #10 remains in spite of trimming of excessive composite (*, as compared to Fig.1,4).  The retainers will be sectioned between #10 and 11 to determine whether the tooth #10 is salvageable or not.

Since the patient is going to travel abroad, he wants to have definitive restoration as soon as possible (Fig.7: 1 month 3 weeks postop).  After gingival retraction cords, the implant at #9 is found unstable.  Impression is taken for splinted restoration.  The tooth #10 has increased periodontal ligament space (<), while the crowns at #14 and 15 have not cemented.  Ten months post cementation, the splinted crowns at #8 and 9 remain stable with healthy gingiva; it appears that the tooth #10 needs extraction and implant (Fig.8,9).  Take photos preoperatively to show the healthy gingiva around #8 and 9 splinted crowns.  CT taken 2 years post cementation shows that the implant at #8 is placed in the middle of the alveolus (Fig.10 (B: buccal)), while the one at #9 is buccal (Fig.11).  A smaller (2.0 mm) and shorter (10 or 12 mm) implant may reduce the chance of buccal perforation.

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Xin Wei, DDS, PhD, MS 1st edition 02/17/2017, last revision 05/23/2019