[Surgery]  45 Immediate

I placed this implant 4 months ago and am restoring it today.


First image is at the date of placement. I removed the tooth and placed the implant right in the socket 1mm below buccal bone. PRF and cortical cancellous mix. Coverscrew and PRF membrane over the top. The second image is 3 months post placement, ISQ shows we have integration but I notice some ditching. Does not seem to be progressive 1 month later at the uncovering appiontment however is this caused from tissue invasion or lack of using surderm?




by Chad Denomme at Fri, Dec 16, 2016 2:37 PM

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Chad Denomme Replied at Sat, Dec 17, 2016 9:40 PM

Hi guys, The tissue is healthy and the ISQ buccal and mesial readings were both in the 70's. Yes I could see the coverscrew during healing through a small hole. Due to mental nerve approximating the apex I didnt go deeper with the implant rather relied on the walls for primary stability. I placed a 11.5mm long implant, so I guess next time a 10.0 would have been better in order to be further below the buccal bone. If they are a thin biotype should I even consider making sure I am even 2mm below buccal crest. Ho Young I think you are right about the BW which I will use next time, and Im just guessing but I may not even be 1mm sub crestal as I try to remember the day of surgery. Can you guys clarify a few things (The only course I have not taken yet is immediate anteriors) Focusing on immediates in these lower premolar sites when utilizing walls for stability as mental nerve is the big consideration and I do not always have CT. Not to mention ease of placing an implant in most of these sites without having to go more apically. Can you comment on the following criteria in terms of trying to achieve the best results: 1. 1-2mm subcrestal for placement (buccal plate is reference). 2. When placing usually for stability a 4.0mm diameter is ideal, however when placing do I want more of my jump gap on the buccal or is right in the middle make a difference. Jump gap was a big thing that Hebel talked about if its too big can be a problem but he doesnt use PRF. Dr. Kwon has sort of said smaller implants in immediate sites or maybe placed properly so no impingement on the buccal wall. What is optimal? 3. Whats the difference between placing implant in this case with no graft, and healing abutment versus doing the same thing with particulate healing abutment and surederm. In terms of clinical results is particulate necessary? If no then we don't need surederm to hold in graft, but then can tissue invade around the coronal portion of the implant. Maybe to make things simple keeping my comments in mind how would you do these cases. Thanks Chad

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Mark Kwon Replied at Fri, Dec 16, 2016 7:08 PM

Hi chad, Few q's: 1. How's tissue health? Good attachment? 2. Hows ISQ reading? Was there exposure of cover screw during healibg phase? Often times that csn lead to marginal bone loss. Slightly deeper placement next time. If the tissue is healthy, I wouldn't worry too mych st this time. - mark

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Ho-Young Chung Replied at Fri, Dec 16, 2016 4:04 PM

Hi Chad, That you for your post. I don't have the privilege of seeing the pre-op condition but considering the tight space you had, your mesiodistal position for an immediate implant is very good. immediates in any area of the mouth is difficult. the bone loss that you have had is called marginal bone/crestal loss due to biological width of implants. Your PA at time of placement and your eyes might have appeared that the implant was sunk 1mm deeper than buccal plate when in fact, I would postulate that the fixture was placed supracrestal of buccal plate. My experience has been that your eyes will lie and so will the PA (both due to angle). BW is typically a better indicator of position of your implant in vertical dimension (won't show you entire fixture but level of connection is more important). The bone loss that you have may be self-limiting but that's not a guarantee. This site is unlikely to be successful with a graft no matter what method or material you use. I wouldn't recommend dethreading and smoothing out the coronal portion as the walls of the NP fixtures are thin already. clinical decision is up to you. I personally would remove this implant and place it deeper (but not too deep). There is a saying "place it as deep as you need to and as shallow as possible" This could be a very good case for a mentor to do over-the-shoulder procedure with you (if you have this opportunity available in Ontario). Cheers, Ho-Young