Angled 1-Piece Implant

Preop photo shows short lower anterior teeth and porcelain chip at #24 with mobility, suggesting bruxism (Fig.1).  After extraction of #24, the initial osteotomy is close to the tooth #23 clinically; after establishing a 2nd osteotomy, it is close to #25 (Fig.2).  Lindamann bur is able to change osteotomy to acceptable degree (Fig.3), but the dummy implant tilts buccally.  To overcome the latter, a 10º 3x17 mm (15.5 mm in bone) implant is placed with 15 Ncm (Fig.4).  The socket gap is filled with allograft (Fig.5).  After adjustment of abutment height (Fig.6,7), periodontal dressing is applied instead of provisional because of low torque (Fig.8).  A provisional is fabricated 5 days postop when the periodontal dressing is dislodged prematurely probably due to bruxism.  The provisional looks thin incisally 18 days postop (Fig.9 <) and perforates 2.5 months postop with apparently sinking (Fig.11 arrow).  Since the implant appears to have been osteointegrated (Fig.10), impression is taken with shade guide selection (A 3.5, Fig.12).  The patient is concerned about the trajectory.  He asks what we should do if we need an implant at #25.  Ideally a new osteotomy should have been created (Fig.13 red arrow) once the initial drill is withdrawn (black area).  There is 1-2 mm bone buccal and lingual to the 3 mm (narrow) implant 3 years 3 months post cementation (Fig.14,15).

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Xin Wei, DDS, PhD, MS 1st edition 04/06/2017, last revision 01/22/2021