Keratinized Tissue M

The keratinized gingiva at #29 is slightly lingual with torus mandibularis (Fig.1 *).  4 mm tissue punch through metal sleeve makes a superficial mark (Fig.4).  To save the keratinized tissue, a lingual flap is designed as shown in Fig.4 insert (black line; avoiding the torus *).  Osteotomy involving 4 mm cortical drill is related to <10 Ncm insertion torque of a 4x11 mm implant; a healing screw is placed (Fig.5 S).  After removing the torus and placement of bone graft and collagen plug (Fig.6 *), the lingual flap is sutured in place without tension because of the torus resection (Fig.7 *).  Later the wound is covered by periodontal dressing.

The extraction socket of #31 has a thin septum (Fig.2), which is removed partially with 12 mm bone trimmer (Fig.3).  After placement of a 5x9 mm FC implant (~40 Ncm) and 6 mm bone profile drill, a 5.5x4(2) mm abutment is incompletely seated (Fig.5 <) and later is changed to a 4.5x1 mm temporary abutment (Fig.6, 8 T).  The latter is used to fabricate a provisional, which in turn supports the distal papilla (Fig.8 *).  The gingiva is slightly erythematous immediately post periodontal dressing removal (3 weeks postop, Fig.9).  Take CT to confirm whether the cortical drill helps keep the #29 implant lingual.  Use a profile drill at #29 if crestal bone loss is not obvious.  There is bone coronal to #29 implant 4 months postop (Fig.10).  Upon incision, the ridge is rounded (Fig.10'), but the implant appears to be buccally placed (Fig.10'' (post high speed handpiece and 5.5 mm profile drill)).  The latter is confirmed by CT (Fig.12, as compared to design (Fig.11)).  In spite of use of cortical drill coronally, the implant is still deviated buccally due to contrasting deferential bone density linguobuccally (Fig.13).  By comparison, there is no such bone density differential involving an immediate implant at #31; the implant is placed in the socket without contacting the buccal or lingual cortices (Fig.14).  The final implant is the same as expected (Fig.15).  To avoid implant deviation in the lower premolar region, leave the root in place until osteotomy is finished.  Five months postop, the temporary and healing abutments at #31 and 29 change to pair ones (Fig.16).  Since there is limited clearance from the crestal bone, smaller abutments are used with the apparently same degree of seating (Fig.17).  The abutments are prepared due to the mesial (#31) and buccal (29) tilt before impression.

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Xin Wei, DDS, PhD, MS 1st edition 01/28/2020, last revision 09/19/2020