"It is Ugly to Lose a Back Tooth"

Before returning to clinic for root canal therapy, the 48-year-old female patient insists that she just needs a filling, because the upper right molar is rough.  On reexami-nation, a crack line is noted in the tooth #3 (Fig.1 ^).  Immediate implant is offered, but the patient is not satisfied.  "It must be ugly to not have a back tooth".  Immediate provisional is discussed, but not guaranteed. Atraumatic extraction produces a flat, relatively large septum (Fig.2 S).  Osteotomy is initiated in the septum (Fig.2 insert circle).  CT (Fig.3) reveals that the bone density in the zones 2 and 3 of the septum (where the osteotomy will be formed) is lower than zone 1 (250 vs. 750 Hounsfield units).  Bone expansion is necessary for primary stability.  The septal height is 9 mm (Fig.4).  Initial osteotomy is formed by using a 1.6 mm pilot drill 6 mm deep (Fig.5 white arrow).  As sequential expanders (from 2.6 to 3.8 mm) are being used, the depth is also increased gradually (Fig.5 insert red outline) so that the sinus floor are being lifted (open arrow) with minimal disruption of the thickened fragile sinus membrane (M in Fig.3). 

When the 3.8 mm expander is withdrawn, the osteotomy is found to have been deviated buccally (Fig.6 O).  Then taps are used to form threads and test stability.  Stability is achieved when 7x17 mm tap is inserted with possible penetration of the sinus floor (Fig.7 T).  When the same sized implant is placed (Fig.8), the insertion torque is between 50 and 60 Ncm.  An abutment is placed immediately (Fig.9,10 A (6x3 mm)) to support an immediate provisional (Fig.11,12).  The patient is grateful when she see it.  She returns for follow up 7 days postop.  The gingiva around the provisional looks healthy (Fig.13).  The provisional is removed on purpose to trim the margin, particularly lingual.  The buccal socket has healed (Fig.14), while the lingual socket has reduced in size (Fig.15).  The exposed particulate bone graft (*) is stable in the socket.

The patient returns 2 months postop because of dislodgement of the provisional.  When it is placed, it looks cosmetically pleasing (Fig.16).  When it is removed for trimming (Fig.17), the non-keratized gingiva (*) is apparently forming in the original palatal socket, buccal to the keratinized palatal gingiva (K).  The palatal margin of the provisional is trimmed and adapted to the implant margin (Fig.17<) so that when the provisional returns to place, it does not presses on the non-keratinized gingiva (Fig.18; >: junction between the keratinized and non-keratinized gingivae). We hope that the nonkeratinized gingiva may become more mature quick.  Follow up PA happens to show apparently increased density of the sinus lift (Fig.19 *). The distal gap seems to have been closed, as compared to Fig.8.

Four and a half months postop, radiographic changes (Fig.20) remain as promising as before (Fig.19).  The same tendencies exist 10 months post op (5 months post cementation, Fig.21).  CBCT is taken 7 months post cementation (M).

The gingiva remains healthy around the implant crown, buccal (Fig.22) and palatal (Fig.23), 2 years post cementation.  CT is retaken 4 years post cementation when the patient complains of recurrence of right nasal obstruction (Fig.24).  In fact the latter is probably related to nasal septal deviation (M).

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Xin Wei, DDS, PhD, MS 1st edition 08/21/2014, last revision 03/15/2020