New to Implants: Where in the Socket Should I Place the Implant?

Anon. asks:
I am new to implants and have just started placing my own. I have treatment planned a mandibular first molar for extraction and immediate replacement with a wide platform implant. After extracting the tooth, exactly where in the socket should I place the implant? There is the mesial root socket, distal root socket, septum, etc.? What material should place in a graft around the implant to eliminate voids and increase the chance of successful osseointegration?

35 thoughts on “New to Implants: Where in the Socket Should I Place the Implant?

  1. I suggest until you learn some more you stick to the basics and not place immediates. Greater risk of issues with immediate. Even NYU is starting to move away from immediates and they tend to graft everything post extraction. I myself find it more predictable to extract and graft and come back 2-3 months later and place the implant.

    My graft of choice is either cerasorb or biooss. I use cerasorb when I have a think buccal plate and I want fast turnover, I tend to favor biooss when my buccal plate is thin and I am worried about resorbtion of the bone.

    Hope that helpful.

  2. nrmally i drill exactly in the septum of the socket, than i fill for five minutes the socket with cristalline bethametasone and cephalosporine to avoid possibly edema and inflammation, than i put a monoimplant that reproduce exactly the diameter of the socket to obtain primary stabilization and contemporaneally with calcium carbonate to compensate the empty space between the implant and the original socket.

    in this way i can put a provvisory crown in few weecks and sometime in few days, naturally ot of occlusal load.

  3. If you have to ask that question then you lack the appropriate experience to do that procedure! You really should graft at extraction then place the implant in 3-4 months. jl

  4. I am soooo tired of reading the comment “If you are asking that question you are not qualified to do the procedure”. At least these doctors are ASKING. It’s the ones who dont that really scare me.

    Be that as it may, an immediate molar implant is a very difficult thing to do and is rather unpredicatble in terms of bone resorption, loss of crestal height, final soft tissue contour, etc. I’ve done them and I don;t recommend them. It is so much easier and so much more predicatble to graft and wait.

    If you insist on the procedure you have to have enough bone apical to the socket to stabilize the implant. This means you must use an implant with apical threads. The eliminates Replace Select, Tapered Groovy, Straumann, and a few others. Nobel Active is OK. You would drill into the septum but you will pretty much destroy it in most cases by so doing. In most cases there will be alot of dead space mesial and distal to the implant that will have to be filled with bovine or human based grafting material. Finally you will need to flap both buccally and lingually, cover the entire socket with a membrane, and then suture in such a was as to tuck the edges of the membrane under the flap. A non-resorbable membrane such as PTFE or a membrane derived from animal hide such as Bioguide will work.

    Good luck in your quest to expand your knowledge. If you want to take some good hands-on courses try Anthony Sclar, Carl Misch, Paul Petrangaro, Mike Pikos, and/or the AAID Maxi-Course. Have fun.

  5. Perhaps some ARE COMPLETELY FLOORED over the thinking that you can learn the subtle nature of “implant surgery” without hands on mentoring.

  6. Thank you Dr. Levitt and i agree with you 100%. This is a good forum to ask questions and stimulate the docs to learn more about implant dentistry and not to belittle them or discourage them from learning.

  7. I am a big fan of the immediate implant. However if you like to learn from mistakes then placing an immediate implant into a mandibular first molar area has potential for a good lesson. The lower molar in a mesial-distal dimension is 10 mm. or more in diameter. If you use a 6 mm. implant, which is pretty wide, you will still have quite a large perimeter gap. The trick is to see if you can place the implant into the center of the molar socket. This is a lot harder than one would think. You need to use a needle drill to bisect the inter-septal bone (if any is left) and then be able to expand evenly mesially and distally. Good primary stability is almost impossible to obtain. The probability is that the implant will track along one of the root sockets because of the corticated socket bone and you will place the implant off center. On restoration you will have a significant mesial or distal cantilever crown and really lousy embrasures. Even if you wait six to eight weeks and do delayed implant placement there is still high risk of deflection of the drills into one of the two root sockets. The better option is to do delayed placement after 16 weeks or so of regeneration and then use the needle start drill with progressive enlargements. There is very small likelihood of buccal bone collapse unless the buccal bone has been compromised so stabilization grafting is not usually required as it often is in anterior tooth extraction sites.

  8. I’m fully in favor of immediate implants in single rooted sites and have seen a success rate equal to implants placed using a staged protocol. The extraction socket has to be relatively intact to give greatest predictability, especially in esthetic sites.

    In a molar site I would almost always extract and preserve the socket first and place the implant a few months later. This is predictable and well worth the extra time and expense.

  9. Make it easy on yourself – graft and wait 3 months before placing the implant. I’ve done an immediate in a molar site and ended up with a patient with paresthesia. He recovered but it definitely was not worth it. Let me try to explain why this procedure is difficult. Visualize trying to drill in the middle of the extraction socket a couple of mm for the implant to engage and have primary stability. The drill tends to bounce and, if you use too much force (like I did) when the drill does catch, you drill too far and end up in the mandibular canal. I don’t like telling this story but, if it convinces you how easily bad things can happen, it’s worth it.

  10. well i guess Dr.Levitt’s reply was quite conclusive and wise and i totally agree ,despite of the controversy over the the fact that immediates preserve the bone especially the buccal bone assuming you have a 2 mm buccal plate and you can achieve primary stability by engaging the apical bone beyond the socket, but you have to start with simple straight forward cases and then move on to next level.
    as a wise professor once said : always do one miracle at a time.

  11. read more, do more, socialize more and it is in my opinon that most of the above will teach you that it is not needed to do immediate posterior md. single stage implant (2 stage for that matter).

    1. the site of extraction is way larger than the implant itself.

    2. be good to yourself, be good to your humble career.

    3. the wisdom has spoken by the above speakers, don’t push the nature too much.

    4. there is a world of differnces between the upper and lower teeth, and please do respect that. I am sure there is no body here is forum here that will question will decision of imm. implant on the upper, but for the lower md……. why…. for whom.

    5. was i a hero before….yes may be. off the record. trying raising a flap after the second stage, the bone growth may not be the way you want them to be.

    6. the above speakers are right, for the lower md; let it heal, the buccal plate is usually strong enough, if not GBR. but Immediate implant may have a higher risk for little to gain.

  12. It’s always safer in the mand to graft and preserve the socket the place the implant at 4 to 6 months. Remember the inferior alveolar nerve may be near by. Plus, you set up a better surgical enviroment.

  13. Extract – graft – wait (depending on the type of graft material at least 3-4 months) – reevaluate – implant.

  14. Graft and wait. Also find yourself an experienced mentor. Lower molars are difficult enough. What is the rush?

  15. Wait. Your patient has four months to wait. I have two that are there, but if everything isnt totally immobile, I remove it and wait. I learned like the others the difficulty of trying to save the patient some chair time, do what the literature said I could do, and do it clinically as I was taught would work. I am conservative. There is just too much room for error on the front end. Just be patient. Tell the patient why you are waiting. They will understand and respect you for it. Life will be easier for the both of you. It isnt fun pulling one out, grafting, waiting and reimplanting. We’ve all probably done it. Patients can lose confidence in you and the procedure. When in doubt, just dont do it (source-my father!). my best to you. Bill

  16. I agree with most of the above learned practioners. Better predictabilty to extract , graft if necessary and wait for 10-12 weeks before placement of implant.

    OMS – SOUTH AFRICA

  17. The conservative method is to extract and wait. Grafting a first molar site is seldom necessary if buccal and lingual bone height remains and adjacent teeth are present and not periodontally involved. If implant is placed around 6 months later very little resorbtion will occur in this aesthetically non- critical area. In the past, I have placed implants in the mesial and/or distal root. While a single implant in either root location is now frowned upon by many my early experience with it has been excellent as long as the load over the cantilevered portion is minimal,the function occurs over the implant,no immediate loading is done and proper contacts are maintained when it is restored.I typically preferred the distal root socket as it is more conical.Large molars may require 2 implants to reduce the load and minimize food trap issues which might cause caries development on adjacent root surfaces.

    Good Luck!

  18. I had placed dozens of implants before I ever did an immediate on a molar. Not that I think that is necessary now, but at the time I believed as most of the people who responded here. Then an associate joined my practice who didn’t know you are not supposed to be able do immediates on molars. He had much less experience than I but he did the first one in my practice. I’ve been doing them with great success ever since.
    For a mandibular molar I use a parallel sided implant such as Straumann standard plus wide neck. I place the smallest depth guage in both areas where the mesial and distal roots were. I am looking for depth and to see which area will give me a better restorative result. I then place the next depth guage in the chosen site. The first depth guage that does not go to the origial starting depth is the first size drill I use. Then I simply drill sequentially at the originally measured depth to my final drill size. Now I place the implant to great primary stability. No grafting or incisions (unless there’s bone loss that requires it). I place a heling cap, take an x-ray and I’m finished. Since I’ve gone no deeper than the original root length I believe the risk of paresthesia is non-existent. By the way Blue Sky Bio has a 5.6 mm body, wide neck implant (straumann does not) which I love for immediates on molars. The primary stability is fantastic!

  19. I totaaly agree with other specialists in resisting from doing immediate insertion of an implant after molar extraction. When the roots are inflammed, even to a minor degree, there is a chance for periapical infection persisting in such situations and using a socket filler in the periimplant site in this situation is questionable irrespective how wide cover the antiobiotic you are going to use. Even the traumatic lose of an healthy tooth in that site so much create loose area around it leading to instability in the initial stage and thereby questionable future.

  20. I guess I’m in the minority here. I prefer immediate placement when possible. I usually tell patients I will attempt implant placement after extraction if I feel good about bone/primary fixation. Sometimes, I can’t do it and they are prewarned. Maybe 25% of the cases end up being grafted and implant placed later.
    The healing potential of a socket is well documented and we know that some resorption will happen regardless of grafting or implant placement. The soft tissue esthetic has been shown to be better with immediates (similar success rates). Of course, case selection is critical…

  21. Amar, I am perhaps also in the minority but I routinely do immediate implants in most situations. And successfully! Seriously, there are a lot to Old Wives Tales out there in implant dentistry.

    Of course it is absolutely necessary to have pre-operative 3D information prior to attempting this procedure. Some people think they can “wing it!” And….don’t plan on doing 3 cases in an hour! I agree that it is technically more demanding and it seems most surgeons don’t want to bother. The literature is clear in that immediate placement (unloaded!) and even immediate loading in the right situation is just as predictable than delayed loading. This procedure is not for novices though. Many surgeons speak badly about immediate loading, I think mostly because of time management issues in their offices and not necessarily because it is not “the best” biological solution. Then again some surgeons will never be able to do immediate implant placement just because they lack the dexterity.

    My 2 cents worth.

    Rik

  22. Properly positioning the implant is not part of the debate…always position the implant where the tooth should be (immediate or otherwise). But if you can position the implant properly at the time of extraction with adequate bone volume around the implant, then immediate placement is a viable treatment option. Case selection is important and I always use an evidenced based approach to treatment. That being said, there is always more than one way to properly treat patients using an evidenced based approach.

  23. hi,
    Firstly dont do immediates if you fear losing patients. your patient has to be really motivated to wait enough for the final tooth he dreamt of.
    In molars anchoring the implant in the septum and filling the rest with any graft material has to be well thought out …..becoz ultimately the Osteoblasts which are really lazy to move around cannot cross the dead space more than 2mm in best of condition and so the vital Implant-Bone interface will lack good bone.
    So Better Graft and wait…. REGARDS.

  24. A l s o ,

    As David Levitt wisely pointed out earlier that in your case you have to use Implants with apical threads
    so u cannot use Replace select,Tapered groovy,Straumann and a few others..
    With socket preservation you get a WIDER CHOICE of implants thus greatly saving inventory costs and increasing predictability.

    SINCE IMMEDIATE IMPLANTS IN EXTRACTION SOCKETS OF TEETH IN NON-ESTHETIC ZONE HAVE NO ADDED BENEFITS WE CAN REALLY AVOID THEM AND HAVE SOME PEACE !

  25. The main criterion in implant success is achieving “primary stability”. Whenever you feel that you cannot attain it, do not place implant in that manner. Getting primary stability in immediate implant placement do needs a SKILLED practitioner. If you are doing your first implants, avoid immediate implant placement, especially in molar area; you will get discouraged.
    Best regards,
    Neda Moslemi

  26. Again, I don’t subscribe to absolutes. Immediate implants work according to the evidence…but case selection is key. Having more implants to choose from isn’t a criteria for me, but having ideal placement with appropriate bone and soft tissue is. Ultimately, we are all trying to provide a good service to our patients and do so according to our experiences and education.

  27. My idea of good service to my patients is to offer them a wider choice of implants.
    Because the Implant selection and placement has to be PROSTHETICALY DRIVEN, choosing the Implant Diameter,Length and Orientation is more valid after complete healing of grafted socket.

  28. Hi I do immediate implantation after extractions in case wher I can get Primary stability + Infection free environment.You can always inform the patient before hand that we are trying to save time and prevent bone loss and if we find it difficult to do at the time of Surgery come back after 2 months. I have posted a case on my site where I have separated the roots preserved the interdental septa used bone condensers to do the Implant [www.drashish.com]
    Dr.Ashish

  29. This is just scary. Did anyone come out of dental school needing a forum of how to do amalgams or crowns? The answer is “NO” because you were well trained for an extended period of time on this.
    The other scary part is that I have found that patients read this forum. They have come to me asking why doctors would have such questions if they have been trained. My answer is always the same, “they have not been properly trained.” Another thing I have found is that product reps go on this and other sites posing as a doctor and state they use this or that material hoping to get more of their product moving.
    If you want these questions answered and want to be competent, complete a residency in OMFS or perio and then I promise you will not have to ask such questions.
    And yes, those that don’t ask scare me even more!

  30. re-primary stability issue

    Once I achieve primary staility in socket I usually fill in voids with allograft but a recent discussion with a colleague is leading me to belive otherwise; any ideas?

    his argument is that allo is basically crap and it just interferes with healing; comments?

  31. You shouldn`t place an implant in a fresh extraction socket, specially if you are new to implant dentistry.

  32. Dr. Levitt said:

    “If you insist on the procedure you have to have enough bone apical to the socket to stabilize the implant. This means you must use an implant with apical threads. The eliminates Replace Select, Tapered Groovy, Straumann, and a few others. Nobel Active is OK.”

    This is only partially correct.

    Depending on the shape of the implant system you are using, you may need to have the bone bind apically, and you may not.

    Straumann TE Wide Neck dental implants actually bind more on the buccal and lingual walls above the furcation than they do apically. They are fine for immediate replacement of extracted molars.

    On the other hand, something like an AstraTech, because of its shape, binds very poorly in this area (they’re not wide enough). I would avoid this implant system if I was placing immediate molars.

    As a general rule, I would lean towards an implant system that binds more cervically because of its shape than one that binds more apically, as there is far less danger of nerve injury with the former…

  33. Yes, immediate implant on lower molar extraction site is quite tricky, even when you use a mesial or distal root socket, not to mention that trying to use the septum is hard difficult e risky.

    But once you have a infection-free socket and primary stability between 40 and 60 N/cm, you can go for it.

    My experience have taught me also to be extra careful with temporary crowns design, not allowing excursive occlusion contacts over them.

    Another tip: if you have carefully filled and stabilized the grume into the socket empty spaces, it´s unnecessary to use graft and/or membranes.

    I hope that helps.

Comments are closed.