[Jedediah]

If there is enough bone and biology around it and the body heals well should be straightforward. You’ll just have to remove bone that heals over the top which is a good problem to have and it’s pretty straightforward.

[Jedediah]

Lots of different options and ways you can do this procedure but you need to remember what is best in your hands and what you are best trained and comfortable to do. Reinforced ptfe could be done but is much more extensive of a procedure and tissue manipulation are key for success and you would need to keep that in for a minimum of 5 to 6 months not 6 weeks. for #20 you could just do a socket preservation and put a resorbable collegen barrier membrane on the buccal and come back in 5 months or so and place an implant on #19,20 (if #19 has sufficient bone width) and then do a new crown on #18. If not enough bone on #19 you could do implant bridge as discussed from #18 to #20 but much better to keep #18 if restorable and if no need to extract. I would not do an immediate implant on #20 b/c you would need to bury implant too deep and would be difficult to do well looking at the cross section b/c of buccal placement of the socket and very thin buccal plate with dishiscience. Hope this helps. Good luck!

[Jedediah]

Typically, there can be very good outcomes, and there are some great research that supports shorter and/or narrow implants in specific cases. It depends on the implant system and your ability to fully torque those restorations as you do your normal diameter implants and if that’s the case they typically have a very favorable outcome. However, do you want to make sure that they’re sufficient bone and biology around the implants otherwise you will have failures just like other size implants.

[Jedediah]

The discrepancy in height doesn’t bother me. However, the width of the bone is definitely a concern as it is very thin. Ideally, ridge augmentation would greatly improve the outcome long-term of that implant and what could be placed in terms of size. Definitely a more narrow implant would be best with the existing bone and even better a ridge augmentation to help build up more bone and biology for your future implant.

[Jedediah]

More lingual placement on 47 and site 45 looks very narrow so may have the most predictable outcome performing GBR in area prior to placement and I would go with shorter implants to allow more subcrestal placement which will also allow more restorative space. I also typically prefer individual implants but in this case an implant bridge may make more sense for the pt. And/or minimize treatment for patient as the middle site has the least bone width.

[Jedediah]

Being grafted again alone does not necessarily decrease success rate. However, if the patient is showing a consistent delayed healing and/or poor reaction to treatment and there might be some underlying issue that is affecting overall healing, and that would be an account when doing further treatment.

[Jedediah]

Hello William,

Based off the limited info I see here it doesn’t appear the pt. Has sufficient bone for either of those procedures for long term success of the implants. Ridge augmentations possibly to improve success and have sufficient bone and biology for the implants or possible another route such as Zygo’s and/or ptero implants. Either way depending on your experience, skill, and comfort level this is definitely not a straight forward full arch case and has very little bone to work with for a predictable and successful outcome.

[Jedediah]

Very easy to remove if needed by just reversing it out with your torque wrench and implant driver. However, I agree with Adis that it’s a bit too soon to throw the towel in. First, I wouldn’t ever use silk sutures and they do collect a ton of plaque, bacteria, and food and are not very hygienic. Monofilament sutures will keep site cleaner. Possibly food irritated area and after you clean and irrigate area you might follow up the next moth 2 weeks at a time and take an X-ray and the patient may continue to heal and implant may be ok even if not ideal healing. Also, reverify medical history, pt. Smokes? Vape? Marijuana? Etc. If it does fail we want to do our best to know why even though despite our best efforts sometimes we don’t. Typically, if I remove and graft I will wait and full 6 months or more to have more mature bone at that site b/c no sense rushing things when patient doesn’t heal well just to have another issue again. Best of luck and let us know how it progresses.

[Jedediah]

Also, if you place the implant slightly more lingual and upright the implant slightly more lingual in terms of angulation from buccal to lingual, I don’t think you’ll need additional grafting in that area potentially

[Jedediah]

Hey doc,

The shorter implant you selected should be fine. There’s actually great research that shows almost the same or very similar success rate with shorter implants compared with normal length or longer implants. However, if you have sufficient bone width it’s best to go wider if you’re going shorter to help compensate to minimize the stress of the implant. To do a large grafting procedure just to get a 1.5mm longer implant doesn’t seem good enough to put the patient through that.

so the implant is not extremely deep you could do some alveoplasty on the lingual Crestal portion of the bone so it is a little bit more even. I don’t believe the nerve is in the way, even though it is somewhat close It appears there sufficient room there where you should be fine, but in any case, if there is potential nerve pressure or damage that can always lead to paresthesia, whether short term or long term so you always wanna explain any potential with the patient briefly.

[Jedediah]

My pleasure

• This reply was modified 7 months, 2 weeks ago by  Jedediah.

[Jedediah]

Many ways you Can design to help improve your stability. Seeing that it is tooth born guide it should be very stable and you could do one screw fixation towards the gingiva side of the guide close to where you’re placing the implants. You also could have three fixation screws to have a more robust fixation one on the lower left and lower right quadrant as well as one towards the lower interior. They would be planned where there’s sufficient bone away from the roots of the teeth.

[Jedediah]

It looks like there’s great interproximal Bone so that’s what you should lean into on a case like this. You may have to go slightly wider to get really good engagement on the mesial and distal walls and remove some of the lingual portion of the bone socket just slightly so that you can maintain a good 2 mm buccal gap so you have sufficient bone around the implant and you’ll not have to worry about a ridge augmentation.

• This reply was modified 8 months, 1 week ago by  Jedediah.

[Jedediah]

My pleasure. Have a happy Easter.

[Jedediah]

Looks fine. I would agree with Doug. Leave it alone. It will continue to improve and settle back down over time. In the future try to place a wider and taller healing abutment to better shape the tissue and make it easier to prevent tissue from healing partially over the healing abutment that can creat food traps and less ideal healing it will also be easier to suture the tissue the way you would like day of surgery.