Atrophic Ridge & Staged Provisionalization
When the patient returns for implant placement (2nd visit after initial exam), he reveals that he is a dental phobic. He requests placement of 4 implants in the upper left quadrant, instead of 2. Narrow ridge is unexpected in the canine and premolar area (Fig.1). Limited bone height at #13 (Fig.3 arrowheads: sinus floor) is found when initial drills are in place (Fig.2,3). A 2-piece implant (4.5x17 mm tissue-level) is placed at #10 after extraction, while 1-piece implants are placed at 11 (3x17 mm (tissue-level, 15 °) and 12 and 13 (bone-level, 2.5x12 mm; Fig.4,5). In fact the 1 piece implant at #13 is not completely placed (Fig.5). It is removed, the apical 3 threads are cut off (Fig.6 <) and the remaining implant is re-inserted. The insertion torques of the 4 implants are ~ 60, ~ 35, < 35 and 15 Ncm, respectively. After adjustment (Fig.7), immediate provisionals are fabricated at #10 and 11 (Fig.8, later splinted with composite), while perio dressing is applied around the implants at #12 and 13 and the provisionals at #10 and 11. There is no nasal hemorrhage postop. Although the perio dressing is loose 1 week postop (Fig.9), it is not removed. When the upper lip fissure (Fig.9 <) heals, provisionals at #12 and 13 are planned to be splinted to the other two ones. Two weeks postop, the upper lip fissure heals, the perio dressing dislodges and the implants at #12 and 13 are stable (Fig.10). After abutment height adjustment, a splinted provisional is fabricated over these 2.5 mm 1-piece implants (Fig.11).
The patient returns for final restoration 3.5 months postop; it appears that the implants have osteointegrated (Fig.12,13). After reprep, there is no gross buccal plate atrophy at #10 (Fig.14).
At the time of cementation, the crowns at #11-13 do not contact the gingiva (Fig.16). One month post cementation, the gingiva appears to have grown coronally (Fig.17).
Six months post cementation, the tooth #9 becomes symptomatic. Is it possible that the implant at #10 is too close to the root of #9? It is asymptomatic after pulpotomy, but the tooth fractures equi/supragingivally. Two PAs taken while RCT show osteointegration at #10-12 (Fig.18,19). While the bone density increases at #10 regular implant, there is minimal bone loss around the 1-piece implants 13 months post cementation (18 months postop, Fig.20,21). The gingiva remains healthy 19 months post cementation (Fig.22).
Return to Upper
Incisor Immediate Implant, Upper Arch Immediate Implant,
Posterior Immediate Provisional,
Xin Wei, DDS, PhD, MS 1st edition 09/27/2015, last revision 08/05/2018