Simultaneous implant placement and socket graft and cantilever: thoughts?

If there is no buccal plate an immediate would not fare well here. I personally would extract, graft both sites to build width and have the patient wear an Essex . In a young patient with a high lip line in the asthetic area care should be given to optimal site preparation . A cone beam is need to determine the width, I would probably use motorized spreaders to gain width and graft. I would avoid a cantilever 8-9 area works better with the lateral cantilevered to the central. See Misch's book on treatment planning.

Agree with CRS. Looks like high frenum pull as well. Frenectomy, GBR, then implants evaluate if ctg is needed aswell.

HI Simon , sure the tooth is mobile ( big peri-apical area , occlusal issue and OH ) but due to tha age of patient and high lip line ( an area I get many referrals ) I feel it be best to retain this tooth and place only 1 implant using cantilevers to temporize . And yes a frenectomy is essential with possibly the use of a soft tissue screw to reduce the effects of mucular pull . Good RCT and a fiber post should be the best route forward. Peter

No Buccal plate is not a good site for an immediate. I suggest you extract, graft both sites, scan and place 2 ideal implants. No cantilever.

This appears to be an extremely difficult situation both cosmetically and functionally. From the radiograph there appears to be close root proximity between 9 and 10 so, with no buccal plate and root proximity, it would seem an immediate implant would be highly contraindicated. I'm a prosthodontist, not a surgeon, but I would have to deal with the soft tissue and cosmetic consequences. Also, the #8 site does not appear overly wide for a second implant. Why not extract, graft to rebuild the ridge then make a four unit FPD? I know we all want to do implants but this situation may be more amenable to conventional dentistry. If implants must be done then graft 8 and 9 sites to ideal widths then place two 3.5mm implants.

As much as we implantologists are out to save the world, and believe that everyone with some disposable financial assets could be a candidate for our chosen profession..... we must wake up and admit we cannot help everyone with dental implants From the limited visibility of the photo and radiograph, it is obvious that this 32 year old woman has serious dental problems. The adjacent tooth with the crown has an endodontic problem, there are root caries under the crown, and the periodontal tissues look inflamed ,as well as you stating mobility in an adjacent tooth....now this is only one tiny area of her mouth that she is concerned about....what lies behind, that is not visible....could be a lot worse. There is nothing wrong with good prosthetic rehabilitation..... the esthetic result in this case could possible outweigh what the implant treatment might bring, and is certainly more affordable ...think about it.... Gerry Rudick Montreal, Canada

You should go for dental ct first to evaluate the bone width and night. Stabilize the implant into nasal floor to achieve adequate initial stability. You can do it flapless. If possible, avoid cantilever and add one mini implant at missing central incisor position. Read my book "Clinical Implantology" to see several such cases in the chaps- nasal floor elevation, immediate implant with socket grafting.

there is no buccal plate means there is high chance of esthetic failure after 2 years, better go with gbr(intra socket as well as extra socket ) +ctg , wait for 3 to 6 months and then implant

There appears to be an occlusal issue here judging by the recession and abfraction as well as the root position of the central. I would tend to agree with Dr. Rudick's position and tend toward traditional crown and bridge as the best approach.

Bone grafting 4 mg place Implant more palatinal, bone graft bucal and cover with membrane wait for 6 MONTHS DON'T LOAD IMMEDIATE WITH CROWNS. Use max 10mm Implant check nasal floor

Or do a fixed partial and don't wait at all. Two visits at a good restorative office. Let me see.. B Vinci

What is pts medical hx and hygiene status ? Immediate everything seems to be something I would personally steer away from, but then again I'm conservative as heck. Spreading and grafting and waiting - should give a better assessment for rehab in a few months. Outcome will be better IMHO, not quicker but better. Does this patient have a mindset to be patient ? Bill

What is so wrong with saving this tooth , she is 32 ....... good RCT , fiber post ( enogh material for a good ferule ) . I know this is an Implant site but... Sure OH , occlusal balance etc are needed but we would definately save it . Peter

Some excellent posts here, and I agree that traditional c&b is always an option. To be honest not enough information here, it appears that the adjacent teeth are virgin and you may not want to cut them down. The crowned tooth looks like it is splayed forward and it needs a root canal. The fact that there is no buccal plate means it should be removed. Occlusion is also a factor. The problem when a patient presents like this I always wonder is it poor oral hygiene vs poor restorative work or a combination of both. A panorex would be very helpful to look at the entire picture. If the hygiene issue and perio/occlusal issues are not addressed then any treatment choice will fail. A cone beam would also be helpful to determine buccal plate at both sites . I would flap open the site remove the tooth and expand onlay graft the sites to restore the width of the alveolus, place an Essex while healing. Whatever restorative option is used later the bone has been replaced for either a fixed bridge or implants . You can't go wrong replacing what was lost. Also you tend to get patient buy in explaining tha you are replacing what was lost vs a quick fix. A good bone foundation is key for future hygiene under bridgework or implants and will restore natural contour. I don't get the negative connotation for grafting, time etc if done correctly it benefits both patient and restoring doctor. Maybe we shoud stop showing all these graphic bone graft photos and just do the work. Sell the result not the technique. Thanks for reading, grafting has always been good to me and my patients, it forgives a lot of sins!

Placement of an implant at site 8 with a cantilever pontic is fine as it appears that you can get a long implant in site 8. I would recommend a pilot drill at the site to depth then use ostetomes to widen the osteotomy till close to implant size then use the implant to do final compression this will make the bone quality better. My real concern is when 9 is extracted there may not be any bone on the mesial of 10 and socket grafting is imperative to avoid loss of 10 over time