SOCKET GRAFTING WITH DELAYED IMPLANT PLACEMENT

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CASE STUDY BY DR JONATHAN COCHRANE

PATIENT HISTORY

A 45 year old, non-smoking male was referred by his GDP to me for an implant consultation. The GDP had reported an incidental finding of a deep, vertical periodontal pocket associated with the patient’s LL7 distal aspect (image 1) during a new patient exam in an otherwise non-periodontally affected mouth (images 2 & 3). Due to the extent of bone loss evident around the tooth as seen on the peri-apical radiograph, the referring GDP (and likewise informed patient) were of the opinion that an implant replacement would be highly unlikely to be offered and/or successful. 

TREATMENT & PROCEDURE

The diagnosis was classed as localised severe periodontitis caused by inability to clean effectively around the distal aspect of the LL7 tooth, the problem had likely been years in the making. However, once the tooth was easily and atraumatically removed (image 4), by luxating the LL7 mesial root distally, the extent of subgingival calculus was immediately evident; even covering the LL7 distal root apex! 

As there was concern re the granulation tissue/bone loss extent visible on the radiograph, only light curettage (image 5) around the extraction socket coronal aspect was performed – we did not wish to take any risk of disturbing the ID nerve. 

EthOss was then placed into the lightly prepared socket and over some residual granulation tissue (image 6). A mesial relieving incision was then made buccal to the LL6 distal aspect and the flap released, advanced and sutured (tension-free) over the EthOss socket preservation graft material (image 7). 


The 10-week follow-up peri-apical radiograph (image 8) clearly shows that EthOss was not pushed down deep into the extraction socket, yet we can still clearly see good bone turnover and new soft (keratinised) tissue maturation upon visual inspection (image 9). The ridge width had also been excellently preserved.

Upon surgical re-entry (at 10 weeks – image 10), the bone quality was soft at D4 but it was firm (images 11 & 12) enough to obtain 25Ncm torque primary stability for a 4.8mm wide by 9mm long Astra Tech EV implant placed in a restoratively driven position freehand (image 13) and restored with a healing abutment (1 stage surgery) (image 14). There was also plenty of new buccal keratinised tissue formation evident upon wound closure with resorbable sutures (image 15).

After a further 10 weeks healing (image 16) to allow for osseo-integration, a screw-retained monolithic zirconia crown with atlantis (patient specific CADCAM) abutment was placed into the implant and the missing LL7 tooth thus fully restored much to the patient’s delight (images 17 & 18). 


RESULTS
CONCLUSION

Upon obtaining the final restored peri-apical radiograph and comparing it to the 1-year follow up radiograph, we can clearly see that the EthOss graft has matured nicely and provided for an optimal result in supporting the long-term success for the LL7 tooth replacement with a dental implant and complete resolution of the original bone loss and granulation tissue radiolucency (results images 1 & 2).

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