Patient has premolar (#28) with vertical root fracture, radiolucency surrounding the root , and 10mm pocket on lingual. Would you graft this case at time of extraction? or wait and graft later? what time frame and grafting protocol would you utilize?
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Not really sure why you would need to graft this. The adjacent implant is already pretty apical to this fractured tooth and it would be doing you a favor to lose some vertical height here post extraction to accommodate future restoration. I think if you will just let nature remodel in this case it will be fine and then you can remove the poorly designed abutment/crown restoration on #29 and restore it with a mesial cantilever. It looks like the restoring dentist opted to use the fixture mount/impression coping as a final abutment which is not ideal so extract #28 replace the ill designed restoration on #29 with a cantilever and save your patient some resources. No future restoration for this patient will benefit from having 4 adjacent implants either…
Even if you are opposed to the idea of a cantilever and opt for another implant at #28 you will still want to place it at the same approximate depth as the adjacent implant so no need to graft. Rather than grafting you will be doing the exact opposite, osseous resective surgery, to flatten the ridge.
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My concern is the off-axis forces from the cantilever could cause failure on #29. As far as losing vertical height not being a problem, I see what you are saying, but how about the horizontal dimension of the ridge? wouldn’t it be easier to reduce too much vertical height than trying to augment a thin ridge if patient wants an implant on #28 down the line?
I would agree the cantilever plan suggested above could work fine as long as occlusal contact is just right. In my hands I would extract the premolar, clean the expanded socket and graft at the same appointment using a mineralized allograft. The implant could then be placed 6 months later.
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what is the opposing dentition like?
CUD?
i would graft at time of extraction. allo/xeno/collagen or PTFE membrane, no tension primary closure w/ PTFE sutures. looks like the site is missing buccal/lingual walls. wait 6-9 months for bone consolidation. Most likely u didn’t place/restore implant #29. so finding parts would be a challenge. sometimes i don’t want to deal with implants i didn’t place. I understand. easier just to focus on the problem tooth #28. instead of opening a pandora box. And if you did make a cantilever 28-29, and the implant #29 fracture. then you would be in a worse situation. then hindsight is 20/20. So from that aspect. i would just focus on #28. instead of doing a cantilever crown to cover #28.
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