Severe bone loss on 13: Best course of action?

It’s not very clear from your description about how much the canine region has shrunk in at this time. With the tooth removed and the crestal bone lost then it may well be considerable. Once the tooth is out then the thin labial bone tends to resorb very quickly, so the deformity is liable to get worse and worse. A “Cantilever forwards” type of restoration, which is one option you mention, may not be a good solution because the contact of the pontic on the gingiva is liable to be unsightly and become more so as the region resorbs more. It’s also not good if the canine pontic is expected to provide canine guidance. In situations like this it is usually better to place an implant at the time of the extraction. It should be placed towards the palatal and the “Channel Deficiency” between the implant and the labial wall of the socket should be filled with a slow resorbing bone graft. Soft tissue grafting at the crest as well is useful to maintain the soft tissue complex. It is more difficult to come back at this later, but to regenerate the lost bone relatively well will require releasing the soft tissue complex, “tenting” and of course hard and soft tissue augmentation, as well as placing an implant. It's quite complex and difficult for even experienced implantologists. If it is not possible to place an implant at the time of the extraction, then some form of “Socket Regeneration” should be provided, at least until an implant can be placed. It is quite a big subject and this is a very short overview, but I hope this helps. Good luck with the case.

Cantilevers always make me nervous. Never had good long term predictability with them although at the time of placement they seem like an easy and convenient answer. You pay later for all that off axis force, believe me.

If you have to ask, then you should avoid immediate placement in this situation and will probably get more predictable results from the following steps: 1) extract site only, thoroughly debride, but no graft; wait 4-6 weeks 2) re-enter site w/ full thickness flap after keratinized mucosa has regrown, being careful not to inadvertently perforate the flap at any point in handling it; be conservative with your releasing incisions as you can always make them deeper 3) Place implant without debriding the site again, and place cover screw 4) "peck" at the buccal plate around the bony defect to create superficial defects, which will initiate RAP effect 5) trim a collagen membrane to extend 2 mm past bony defect 6) advance flap by releasing periosteum, so you can stretch the buccal flap margin at least 5 mm past the lingual flap margin 7) after bleeding subsides, place membrane against buccal flap and place bone graft 8) place graft into defect and "bulging out by approximately 20% by intended volume. 9) tuck membrane 2 mm past lingual flap margin 10) secure membrane with deep apical horizontal mattress suture, starting the suture 10 mm apical to the buccal wound margin, in order to maintain vestibule and apply pressure against membrane, being careful not to scrunch up the membrane 11) close all incisions with interrupted and/or continuous sutures no more than 1.5-2.0 mm apart to prevent blood from exiting wound margins, which implies saliva will not enter wound Hope this helps.

Option 1 as the canine is always best to have an implant not a cantilever . I use standard protocol which I published a few years ago to keep to predictable and successful . Extract leave for 4 weeks for soft tissue healing then place and graft simultaneously , loading at 10 weeks . see Pubmed for protocol Regards