Socket Preservation Post Exfoliation

A 65-year-old woman seeks treatment after exfoliation of #18 (Fig.1).  It appears important to have implants at #18 and 31 for longevity of restoration or implants at fractured teeth (*).  The implant restoration at #31 will have challenge because of the supraeruption of the opposing tooth (arrow).  The socket at #18 is large, shallow (Fig.2) and not healing.  After debridement, bone graft will be placed, followed by 6 month membrane.  Space maintenance will be installed for periodontal dressing stability.  Prepare PRF if the vein is large enough.

To increase bone density, use a large 8/9 mm trephine bur to harvest ramus block graft on the right with depth of 3 mm (Fig.4 red circle) after SRP in the lower arch and transfer to #18 socket (Fig.3 pink), fixed in place with a screw (probably 6 or 8 mm tenting one, yellow) after filling the socket with particulate bone graft (Vanilla, white circle). 

Steven: Wait couple of months and take another CT ,check again maybe need another grafting.  Another approach is to alter the trajectory of the implant bypass the IAN and use the angled abutment to restore the case.

You sound like a seasoned implantologist.  I should consult you more often.  How to alter the trajectory?  Free hand?  Take intraop CT?

After the pilot drill, take CT to verify.

Good idea.  Before I had CT, I intentionally perforated the lingual plate lightly and re-adjusted the trajectory.  Now the lab declines to make guide in this situation.  It appears still risky.

Return to Lower Molar Immediate Implant, Trajectory Xin Wei, DDS, PhD, MS 1st edition 04/27/2019, last revision 05/12/2019