Extraction for Efficiency

To facilitate treatment, the 78-year-old man agrees to have the tooth #18 with mesial inclination extracted for immediate implant.  Osteotomy is initiated in the mesial wall of the C-shaped socket of #18.  The osteotomy at #19 is initiated as distal as possible, since the ridge is atrophic mesially (Fig.1).  Implants (4x13 and 5x11 mm at #19 and 18, respectively) are placed with insertion torque >35 Ncm with clearance from the Inferior Alveolar Canal (Fig.2,3 (red dashed line)).  Abutments (5.5x5.7(4) and 5.5x4(4) mm) are placed to make it easy to approximate the wound (without tension) and close the socket as much as possible (after bone graft *) and to hold periodontal dressing in place.  The distal crest of #18 is trimmed prior to placement of the abutment.  The periodontal dressing remains in place 1 week postop due to its having been pressed into the abutment wells (Fig.4 *).  When the dressing is removed 2 weeks postop, the wound is healing.  A splinted provisional will be fabricated in another 2 weeks.  The abutment at #19 is changed to 6.5x5.7(3) mm one 1.5 months postop.  Two months postop (Fig.5), pain and swelling develop distobuccal to the mesially inclined #31, probably related to overuse.  The provisional at #18 and 19 is converted from nonfunctional to functional by adding more acrylic to the occlusal surface of the splinted provisional so that the patient can eat more on the left to alleviate discomfort on the right.  There is no bone loss 3.5 (Fig.6) or 9.5 (Fig.7) months postop.

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Xin Wei, DDS, PhD, MS 1st edition 12/05/2016, last revision 10/01/2017