Immediate placement: Feedback to minimize complications?

Midline placement of a molar implant is preferable for the restoration. Implant surgery is restoratively driven I would have grafted the site obtained primary closure then placed the implant in the furcation after the graft healed.This implant seems to be placed deep, expect some dieback. Primary closure is not as easy as it looks. Sounds like an alveolar osteitis I would have administered Toradol IM, and kept the membrane in. Removing it just negated the surgical procedure and compromised the graft. Staging this would have allowed for soft tissue closure.

I prepare osteotomy in the furcation while the roots are still in place. Section the clinical crown off first, prepare the crestal area with large round bur taking away the root surfaces that will be in the way of the implant bur. This creates a guide for the osteotomy to follow and it puts your implant dead center of the restoration. It also keeps the osteotomy burs from catching on the root surface when going to depth. I then bone graft mesial and distal. I have couple of different techniques from here. Sometimes I place a PRGF membrane, abutment and make a temporary crown out of occlusion with a very small occlusal table. Sometimes I place PRGF, healing abutment and a collagen membrane with a small punch to pull over the healing cap(middle) and outer margin trimmed to fit socket. I would stay away from primary closure in this case - you miss out on an opportunity to gain some attached tissue with a socket graft. You are better off bone grafting and placing dental implant in a two stage approach if you don't have a reliable immediate implant protocol. By the way, I prefer placing implant 2-3 mm apical to the CEJ of adjacent tooth for proper emergency. From what I see here, the implant could be submerged about 1-3 mm farther. Also, there appears to be a mass of bone graft material about the healing abutment 2 mm about the crest of bone. That is sure to die and/or get infected right away. You can only grow bone to the height of the existing bone. Put it in the middle of the tooth, sink it a little deeper and try not to overfill your graft. Hope that helps.

Immediate molar replacement is the last main frontier for Immediate Placement. Very few people seem even prepared to try a one-stage procedure. The standard is for a long, multiple-stage procedure which gets very tiresome for the patient. We have been carefully tracking our immediate molar replacements over the last two years and find it a very predictable and successful procedure. On the mandible we have over 40 cases and all have been successful. It is a great practice builder. The key to success in the first place is to do everything to preserve the four walls of the socket when the tooth is removed. In this case you have the septum remaining. In a situation like this it can be difficult to prepare a channel in and through the septum. The easiest way is to place the pilot drill down to the base of the mesial root, then to upright it. This preserves much of the septum, provides stability, a good wall for the implant to rest against and ensures a good central location for the final restoration We often need to go down through the base of the socket to develop effective implant stability. The platform of our implants would come down deeper than yours, the platform needs to be below the walls of the socket, to get the implant in the middle of a four-wall bone defect. We place a 4.0mm Gingivaformer on the implant instead of a cover screw and then augment with bone graft all around the implant and usually over the top of the gingivaformer. This provides a good "Osseous Coagulum" zone around the implant. Advancing flaps over the region is very difficult and negates many of the advantages of the protocol. All that is necessary is to secure a membrane over the region and just tucked under the flaps. We use Camlog Implants, Bio-Oss Collagen as the graft material and Mucograft as the membrane In a few weeks the complex shrinks down, the gingivaformer is usually exposed and in due course it is very simple to restore. The only real time we do a two-stage now is when it is not possible to stabilize the implant.

Maxillary molars are a bit more tricky than mandibular molars. The critical thing to appreciate is that the sinus floor and membrane usually comes up towards the trifurcation region. This means that it is necessary to be prepared to provide a sinus lift during the procedure. There are two main scenarios. First, if the trifurcation bone is still present after the removal of the roots of the molar then this may be suitable for providing stability for the implant. The easiest way to do this is to use a trephine. The external diameter of the trephine should be one size smaller than the final diameter of the tapered implant. The depth is generally very limited, perhaps only 2-3mm. We fracture out the core of bone and then go further down with a piezo device using a diamond tip to penetrate the sinus floor and lift the membrane. Bone graft is then placed and elevated with an osteotome. The implant is then inserted and taken to place, this will "lift" the bone graft as it goes to final position. Second, if the Trifurcation region is missing or damaged then one has to be prepared to use apical bone if it is available or to make an intentional sinus lift on the floor of the socket. In both cases the amount of bone needed for stabilization is very small. The rest of the procedure is as for the mandibular molar, that is to develop an "Osseous Coagulum" with bone graft and then to cover the region with a membrane without advancing the flaps. This procedure is as successful as the mandibular molar procedure, we have only had one loss of implant so far in 40+ procedures and that was due to inadequate initial stability of the implant. It is clearly the best way to prevent the rapid bucco-lingual bone loss that is so often seen after loss of a maxillary molar. These are teeth that tend to have recession on their buccal and palatal roots and have no bone in those regions.

I started doing extraction-immediate implant placement about four years ago. It does seem to be preferred by many patients. We have gotten to the point with most maxillary first and second molars, that even if the patient does not want to place the implant at that time, but does think they will pursue that course in the coming year, we will go ahead and elevated the sinus at the tri-furcation (average depth here is 5 mms post-extraction). I use the Sommers osteotomes (both convex and concave), and it takes me very little time (I rarely charge for it if the bone looks good and there is no granulation tissue). We have probably done over 100 immediate molars in the last two years, and about 10-15 implants in cases where the osteotomes were used for future implant placement (meaning that the patient wasn't ready to do thje implant at the time of the extraction). Our success rate has been excellent. If primary stability is not achieved, then we do not leave the implant in. This is also dependent on the implant system. I love Nobelactive for immediates; you cannot beat the primary stability. Straumann, while I am very fond of the brand, does not give the same degree of primary stability...but many times while it does not feel as stable as Nobel, it is usually just a tactile issue with me. Both brands seem to do well, as does 3I and Biohorizons. The issue with lower molars and alveolar osteitis is always possible, especially in woman of child-bearing age and in smokers. We have been trying to manage these using evidence-based protocol that was established in the last two years. Most of these patients will be on chlorhexidine for a few days prior to the procedure, and then we will irrigate with chlorhexidine throughout the entire procedure. In addition to this, many of these patients will be on an antibiotic pre-operatively. We will occasionally treat the socket with a 25% chlorhexidine gel for 2 minutes as well, or mix this with the cortico-cancellous grafting material that is filled around the defects around the implant. The problem is, this is preventative. What happens with one that develops and you have already placed the implant and grafted the site? We generally wait it out, and try to manage it pharmacologically.

You want to minimize complications on immediate molars? Stop doing them. Seriously. I've placed thousands and rarely find an ideal case for an immediate molar. There are multiple reasons to wait 3-4 months. In 3-4 months, you will KNOW where the crestal bone is, you will KNOW how much tissue you have, you will have the option of a lingualized incision to move more attached tissue over to the buccal, you will have a much better chance at primary stability, you will be placing the implant in a healthy site, you will be much less likely to over or under-drill, it is easier to keep the drill centered, bone grafting a socket without a piece of metal in it has more osteogenic potential, etc, etc. Bottom line is don't compromise decades of success for 3 measly months.