Delayed bone grafting of an extraction site: how to go about it?

This depends on your experience and skill set , But my routine for these case over the last 12 years or so is to allow for soft tissue healing of 3 weeks then carefully raise a site specific flap retaining the adjacent papillae. Then comprehensive curretage of the site is performed and you can keep some of the granulation tissue attached ( if possible ) flapping it lingually to use later for improved soft tissue healing . You can use CHX irrigation as well ( the eveidence is very contradictory as to effect on fibroblasts ) then create the osteotomy into the bifurcation residual bone . Done with care this will provide a reasonable primary stabilty for the Implant . Finally graft both the mesial and distal root socket sites with a fully bio-absorbable patriculate graft material ( preferrably bonded with CaSo4 ) . Suture closed ( if you have granulation tissue you replace over the graft material ) careully with Vicryl and leave to heal for 10 weeks . At that time load early checking with Osstell to benefit from another increased host bone metabolism as a result . Do generally 2 cases a week like this , works well to preserve not only the hard tissue dimansions but the attached gingiva as well . Peter

I see this unfortunately on a regular basis and I have to retreat these cases. These cases usually have no buccal plate with bacteria present from the failed endo. The buccal plate needs to be regenerated with a barrier membrane usually non resorbable or long standing resorbable and the area disinfected with a 1064 laser to kill the buried pigmented bacteria. The flap needs to be primary. Not a case for a novice. What may happen is if the site preparation is not done optimally the implant will develop a Periimplantitis and you will either be continually grafting this or removing the implant within 3-5years. Regenerating the buccal plate is a good idea and perhaps a bridge may be an option. You are starting with several disadvantages to overcome from the failed tooth. If I could see these cases at the extraction phase often this can be avoided in experienced hands. So just remember my advice as this case progresses, see where it goes over the next couple of years.Often posters take offense at this advice but I unfortunately see this happening a lot, my advice is honest based on experience and judgement. Good luck. Also all the granulation tissue needs to be removed if it is not treated with the laser since it is contaminated along with the first few mm of surrounding bone.

1064 nd/yag? Interesting, which company and what parameters? Certainly sexier than a bur, probably a lot cleaner?

I have a similar case. I did an emergency atraumatic extraction yesterday on tooth # 13 and the patient has scheduled for an implant placement in 2 weeks. I didn’t have time to place the implant yesterday and he was swollen considerably from the infected tooth. He was already on antibiotics and there was no suppuration or apical lesion. I simply curetted the socket thoroughly and let the blood clot form with no additional treatment. The socket is a perfect 5 wall with total boney enclosure and intact buccal plate. I will have good soft tissue closure for the placement. My question has to do with the placement appointment. It seems to me that the socket will be closed and the internal will be in the early stages of healing. If I place the implant flapless using tissue punch and simply screwing the implant into the socket will it react the same as if it were an immediate placement? If I waited 3 months it would fill with bone,,,why not place as is? I thank you all in advance for your advice.