Change Position of Osteotomy for Immediate Implant

The root of the tooth #28 is mesiobucally deviated clinically (Fig.1).  After extraction, osteotomy is initiated in the disolingual slope of the socket (Fig.2 *).  When a parallel pin (Fig.3) and 4.5 mm tap (Fig.4) are inserted, there is more space mesially (*) than distally.  After a 4.5x17 mm implant (Fig.5 I) is placed (>50 Ncm), the mesial space is filled by bone graft (*).  A 3.5x3 mm abutment (Fig.5,6 A) is placed and prepared for an immediate provisional.  Fig.6,7 show that the implant and abutment are positioned favorably for restoration; there is a space between the implant and the buccal plate (Fig.7 *).

The patient returns for definitive restoration nearly 5 months postop.  The peri-implant space has not disappeared (Fig.8 arrowheads).  It is painful to remove the immediate provisional, which in fact has minimal contact with the opposing.  The implant fails to osteointegrate.  Other possible reasons for failure are bone manipulation (change in position) and multiple missing teeth (bruxism).  He reveals that he has diabetes.

The implant is removed.  A 5x20 mm Tatum tapered tap achieves stability at 17 mm.  A 5x13 mm almost cylindrical bone-level implant is immediately placed with insertion torque > 50 Ncm (Fig.9).  Since there is space apically (Fig.9 >), the implant is placed lower (Fig.10) with bone graft coronally (arrowheads).  This time a 5.5x5(3) mm healing abutment (A) is placed; there is clearance with the opposing dentition.  The implant appears stable clinically 5 months postop with apparent osteointegration (Fig.11).  When an implant is placed at #21, a healing abutment will be placed to avoid micromovement of the implant.  Progressive loading is necessary.

Return to Lower Premolar Immediate Implant 4 13 21, 25

Xin Wei, DDS, PhD, MS 1st edition 11/03/2015, last revision 08/06/2018