Plan is Executed

The buccal sub-retainer caries (Fig.1 *) at the site of #18 is confirmed while the bridge is being sectioned. 

Removal of the mesial curved root tip turns out to be difficult, requiring an early incision on the ridge (Fig.2 R) of #19 and bone removal mesial to the mesial socket (M) of the tooth #18.  The position of the osteotomy at the latter site is aided by an implant spacer of 4 mm.

The trajectory of the osteotomy of 14 mm depth is checked with a marked parallel pin (Fig.3: yellow dashed line: upper border of the Inferior Alveolar Canal) and changed accordingly (Fig.4: 4.5 mm tap).

After a 5x17 mm implant/abutment (Fig. 5 I/A) is placed in the osteotomy (Fig.4 O), collagen plug is inserted in the distal (D) socket of #18 and mixture of autogenous bone and Osteogen in the mesial (M) socket.  A typical socket preservation is done with collagen membrane and suture at the extraction site (Fig.4).  The purpose of the bone graft (Fig.7 arrowheads) is to cover the distal coronal threads of the implant (Fig.8 (preop CBCT sagittal section) between arrowheads) at the neighboring site.  This is an atypical immediate implant!

The abutment of the "immediate" implant is used to keep an immediate provisional in place.  The provisional covers the sites of #19 (Fig.9) and 18 (arrow).  Perio dressing (D) is applied for further protection and security against graft leakage.

When the patient returns 2 weeks postop, the perio dressing is dislodged (Fig.10).  There is mild discomfort, consistent with possible dry socket (^).  When she returns 1 month postop, the provisional is removed.  The wounds at the sites of #19 (Fig.11) and 18 (Fig.12) heal.  The yellowish material which looks like dry socket (Fig.10 ^) is in fact the discolored collagen membrane.  A new provisional is fabricated for #19 only.  In fact the implant is placed distally.  The definitive restoration looks cantilever.

Return to Lower Molar Immediate Implant, Posterior Immediate Provisional

Xin Wei, DDS, PhD, MS 1st edition 05/07/2015, last revision 09/08/2015