Immediate vs Delayed Implant Placement?

It looks like a great case for immediate implant. What are the width and height? Don't use this for your first implant case or first immediate implant case with free hand. You could also make a surgical guide and just do it that way. I will definitely do this a immediate case. Thank you for sharing

I do not think there will be sufficient bone to immediately place the implant and there will be no bone on facial on the implant. I would extract and socket graft plus graft across the entire anterior quad to thicken that bone as the CBCT shows that bone is thin too and hes at risk of losing those if left as is

in my opinion you can do both ways. If your patient is aesthetically demanding and has a high smile line, i will be more conservative. Extract, and graft. let it heal well. take a new CT have a Surgical guide made and place the implant in the right position. Giving the fact he has a thin buccal bone, i would plan for additional grafting at the time of implant placement. Option two would be do Ext., immediate, placement and GBR, but do not provisionalize this case in my opinion OR if you do, be very careful with occlusion. Dr Tarnow used to say, "do one miracle at a time" . So don't try to be hero, Try think for long-term stability and minimizing the risks. 3-4 months extra time, won't break it. But if it gets complicated you will be spending a lot more time and money trying to fix it. GOOD LUCK.

Either way will work. There is no need for expansion. Be cautious with occlusion.

Lets face it,the implant is not going where that tooth is. It will be to the lingual and deeper. The buccal plate will be thin so don't break it getting the tooth out. Graft and likely use a sulcus former to support the tissue. then wait 5 months. The ankylos implant is perfect for this situation as it can be placed a little deeper if necessary. In my opinion the implant should be at least a millimeter from the buccal plate lingually.

Isn't that what all the anterior teeth look like on CBCT (LOL)? Very thin to nonexistant buccal plate. Not a great case to start doing anteriors, as others have mentioned. I would be inclined to extract, place the implant to the palatal to engage the heavier bone, graft the buccal gap/defect, place a cover screw and bury for 4-6 months. You really need to be careful where you place the top of the implant platform with respect to the adjacent CEJ's and try to stay close to the 3mm rule. It would be helpful to have some clinical photos of the patient. What type of tissue (thick v thin), lip line, adjacent teeth, etc. These can also help you determine best practice. On another note, I'm curious what material others would use to graft the buccal? Autograft, allograft (cortical v cancellous bone), growth factors, membranes, etc??

I would extract and graft. Maybe even membrane is called for if facial wall is gone after extraction.

I just had a case like this. I elected to xb and graft because I just didn't want to take the risk. But that's just me being conservative. I believe either way could work.

Plz check the bony profile as it is class 2 div2 malocclusion, I can see the dento alveolar segment aligned palatally. In this scenario , the implant needs to be placed further palatally , away from buccal bundle bone and this could make the prosthesis too close to the lower incisors. Make sure the final outcome is not unfavourable wrt the occlusion. Note: plz consider orthodontic evaluation and possible treatment if the outcome seems unfavourable.

Like most have said, both approaches will work. In fact I’m surprised that no one has mentioned “socket shield” with immediate temporisation as a great way to preserve the bone, preserve the tissue contours (ie, papillae) and reduce the likelihood of the dark titanium “root” look. I would plan for both technique options, attempt the socket shield technique and be ready for no or super thin buccal bone requiring you to bone graft and ct Graft in the event you need to extract and/or fracture the buccal plate. Lastly...actually “Firstly”, do this one with a seasoned mentor able to perform all of the above for the patients sake. Great case !

With Class 2 Div 2 occlusion and non existent labial plate, My choice would be to graft at time of extraction. Without clinical photographs, its difficult to say whether you should also graft the soft tissue of not. See if patient will entertain Ortho as an option. Good Luck.

If you will Google Osseo News, top contributor Dr. Gerald Rudick, you will see an article I published and sent in a while back with photographs entitled "A Novel Approach to Repair Severe Damage in the Esthetic Zone". This is exactly the situation you are facing, and will take you through step by step to obtain a very satisfactory result.....good luck.

There is no facial plate for socket shield. Exo and graft are probably the best options unless you are a credentialed experienced surgeon. The site would need the Ice Cream Cone technique espoused by Tarnow and a palatal pedicle graft. The CBCT shows no facial bone, an osseous dehiscence that may be large.

Clinical pics are a must to decide on the preferred plan. The preferred implant treatment is dependent on various factors like knowing the phenotype, smile line, patient demands, thickness of buccal bone & dehiscence or fenestration if any. In other words, knowing the esthetic risk of the individual. Once the esthetic risk is determined ( high, medium or low), the treatment can easily be carried out. There are many techniques for eg ice cream cone, dual zone grafting, contour augmentation, socket shield, socket preservation, soft tissue augmentation, but they need to be appropriately selected to avoid esthetic disasters & also keeping in mild long term labial bone maintenance.

I would not recommend the socket shield technique on a RCT treated tooth ("what lies beneath"?) Extract, graft with membrane PRF if you do it and wait 4 months then guided surgery to place the implant. I prefer to sleep at night this is not a "slam dunk" case.

This is an excellent case for immediate placement and even immediate load if your experience allows this. Extract the tooth with least trauma using luxators (no buccal approach during elevation!), place implant PALATALLY and the large gap buccally packed with xenograft or allograft.