Tooth Treated with a Root Canal: Candidate for Immediate Implant Placement or Not?

Dr. S. asks:
I have an 18 year old female in excellent health. Tooth #8 was treated with a root canal, post and crown and has fractured vertically. The tooth needs to be extracted and replaced with an implant. The patient is becoming progressively more symptomatic. There is a radiolucent halo around the root. The tooth is painful to percussion and palpation of the buccal cortical plate produces pain. The tooth is only slightly mobile. I would like to extracted the tooth and immediately place a NobelActive implant fixture. I would like to place a temporary abutment and temporary crown. Is this treatment plan sound? Or should I extract, bone graft and allow the site to heal before placing the implant fixture?

44 thoughts on “Tooth Treated with a Root Canal: Candidate for Immediate Implant Placement or Not?

  1. Are you sure this is not a nobel advertisement?
    Just remember, there is no such thing as a strait forward anterior case, especially on a young female patient. Immediate is always better (when done correctly) in esthetic cases. By the way, most of the implants on the market today can offer high primary stability in immediate cases.
    If you have to ask these questions, you may not be ready for this case. Do what’s best for the patient.

  2. Theres no harm is asking. . .

    For this case, its better to wait so as to let the healthy bone replace the defect n then go in n implant.

  3. As per above comment, there is nothing wrong with asking,this is what this forum is for.Everyone has to be a beginner first…
    Regarding the case, I feel that I would play it safe. Trauma-free xla with good socket debridement. It sounds that socket grafting might be required, so be prepared for that. Leave to heal, come back later and place the fixture having a surgical guide as an aid. Good luck.

  4. The longer you leave #8 there, the worse the bone will be. Extract the tooth, have a flipper/maryland bridge premade, and you have 3 options at the time of surgery. Implant placed slighty palatally to engage new bone, with or without immediate function, or graft the site. Always have a backup plan. Be sure to check the nasal floor height, if it’s way up there you can us a nice long 15mm implant.

  5. The symptoms you give indicate there is no facial bone at the tooth site. Hence, a membrane or block bone graft is indicated. When a graft is required for width, primary closure is indicated. Hence, extraction and grafting is more difficult for most clinicians. It is easiest and safest to 1) Extract the tooth and fill the socket with freeze-dried bone (MinerOs ®) with a collagen plug of 3mm on the top (Collaplug®). Wait for 3 months, then do a membrane or block bone graft. Wait 4 to 6 months (depending on the material used) and insert the implant. A failed bone graft and/or implant in a central incisor region will affect the bone and soft tissue drape and it may never be the same again, after repeated surgical attempts at hard and soft tissue grafting.

  6. I have several causes as you described and had very successfull outcome. I will have a article published on this topic in Dentistry Today for the September issue. If this is your first case may be over your head to attempt this procedure. I use laser to aid in the detoxification of the extraction site, so if you do not have this technology I would do what the rest of the clinicians have said.

  7. I have done multiple cases in the esthetic zone and I have learned from my own experience “the hard way”.
    This tooth most likely has no buccal cortical plate (90%). if it is a small fenestration

  8. If you don’t ask the question noone can answer.

    The same question was asked in different ways by many clinicians in different ways at the recent EFP meeting in Stockholm.

    The answer was loud and clear. If there is a high aesthetic demand (eg patient has a high smile line)or will lift the lip up to evaluate, always create the bony housing first. The 1-2 mm of bone regeration at the crest is unpredictable with immediate implantation. It is that area of the bone that supports the soft tissue which is critical for aesthetics.

    If the aesthetics are not very demanding and there is a thick biotype, you may be able to perform immediate implantation and immediate provisionalization at the same time.

    As Dr. Misch said above, your case sounds like there are not conditions for immediate implantation let alone immediate provisionalization.

  9. 2-3 mm I would place an immediate implant with membrane on the buccal, immediate temporization. The best temporary will be the existing crown, it will give you the best EP. if the fenestration is wider I would bone graft (over-pack) and place a collagen plug or ePTFE “Regentex”. I have used all kinds of provisionals but I found out the Essex works the best in the esthetic zone, although some patients do not like it.
    evaluate the perio-type because if it is thin (20% or less) you may wanna do a soft tissue graft at the same time.
    This is one of the most difficult and technique sensitive in implant dentistry but it is a lot of fun too! Good Luck

  10. Dear Dr S,
    Although the matter has been so thoroughly analysed and discussed in this blog (and by no less distinguished personalities than Dr Misch himself), there is the ever-existing urge to provide another perspective of the same things to which I succumb just now.
    The PATIENT – Young, good general health – inference – good bone healing
    The SITUATION – 1.Previously injured tooth (?) either from direct trauma or Occlusal trauma
    2.Previous peri-apical infection (Apicoectomy)
    3.Sub-optimally loaded (Occlusal load) bone (in lieu of the fact that there was a Crown with a post -core which has become symptomatic recently)
    4. Possible soft-tissue compromise (Bio types are also the result of osteostimulation and the result variables in bone type in the adjoining or subjacent alveolar-basal complex). Which therefore means that a lack of stimulation of bone in the region from disuse or suboptimal use, would result in poor quality of bone, altered architecture of the alveolar bone and therefore a significant change in the Biotype of the soft tissue overlying the region.

    PROPOSED LINE OF MANAGEMENT :
    1) Extraction and socket preservation (with either a Trephine core or a Block Bone graft, from the symphysis possibly)
    2) A membrane would be more assuring for the process of GTR, a little Alloplast (any mix of B-TCP + resorbable HA) to stall the resorption process of the graft so as to allow for sufficient maturation of the site.
    3) I have personally found collaPlug a wonderful material as it enhances the natural ability of the Collagen to promote ‘epithelial creep” across the socket edges
    4)Wait for at least 4-6 months (ideally I would like a confirmation of Osteocytes in the graft zone to tell me there has been bone formation in the area)
    5)Plan for the Implant with a Prosthetically designed Surgical template
    6) Provisionalize in the intervening period (after grafting) with a Maryland bridge
    7) Immediately provisionalize with an-inter-in Crown on the Implant after Implant placement
    Cheers

  11. I would say that all the comments posted are true to its’ form. Bone is very unpredictable when you think that you have the correct treatment for your patient. Usually patients who have a traumatized tooth have a poor prognosis when you immediately place implants. It will not stimulate good bone formation especially on the aesthetic zone.
    I applaud you all doctors who have contributed to this blog. This is very helpful to all of us who are continually learning from this profession. Thank you and have a nice day!

  12. How do you all manage the papillae in this case? Since an immediate implant with immediate provisionalization (which would minimize loss of the papillae) is not indicated, what is the best way to ensure you will have interproximal papillae in a highly esthetic case?

    I think soft tissue graft(s) may be needed prior to implant placement or at the time of implant placement, but that still does not ensure papillae will form. If there is no bone loss on the adjacent teeth, papillae will most likely form. However, a central incisor missing for 4-6 months will cause some loss of interproximal bone height even with socket preservation.

    What are your thoughts on this? Thank you.

  13. Freeze-dried bone (MinerOs ®) is only a filler and is only osteocondcuctive. It is human HA. It will allow bone to grow around the material, what you really want is all living bone as the end result. I suggest to us an osteoinductive material–DBM Bone. Endo treated teeth can be a problem. I suggest to build the bone the place a good implant.

  14. Dr. Jeevan, Your plan sounds good to me. Remember to decorticate the site prior to grafting. When there is a past Hx of trauma, amalgam retro, or imfection it’s best to graft and see what happens. I have found that sites with a past amalgam retro fill usually yield very poor results unless you saucerize prior to grafting and even then it’s a toss of the coin. Sometimes there is bad biology.

  15. If the young female patient has a high lip line or a public related career , lost papilla can be unforgiven. So put extra effort to preserve it.

    Try to take the tooth out atraumatically. If the buccal plate is gone, put the membrane on the buccal, bone graft, and primary closure. You may need an addtional tissue graft at the same time to get a primary closure without pulling the vestibule. Fabricate a premade maryland temporary bridge with OVATE pontic to preserve the papilla. You still may need a second bone or block graft or tissue graft if the outcome is not satisfactory to the patient.

    If the buccal plate is intact, place the implant, fill the void with bone graft, and fabricate an out-of-occlusion temporary crown with a flat cervical facial contour. You may want to position the implant a little palatal to get a better primary stability but make sure it does not compromise the restoration position of the final crown later.

  16. Thanks for your very knowledgeable inputs Drs Hughes, Don Callan, Dr T,’abc’ et al.
    The contributions of such lucid thinkers such as yourselves, has surely enriched the blog in general, as I am sure it has benefitted the likes of Dr S, who posted the query pertaining to the issue , in particular!
    The deal with the Immediate Implant is its ever-evolving conversation… as it is with Implantology itself.
    With the newly laid EAO Consensus Guidelines on Immediate extraction guidelines (EAO COnsensus conference, Zurich Feb, 2009)the envelope has been pushed yet again.
    The paradigm shift continues…

  17. After treating a significant number of maxillary anterior esthetic cases using virtually every one of the previously mentioned modalities, I am surprised at my outcome assessment. Almost without exception, my extraction/immediate implant cases even in the presence of a large buccal wall defect are my most successful cases. There are several reasons for these findings.

    1. The presence of an intact dento-gingival complex. This is the least appreciated part of implant dentistry. The three types of gingival fibers (circumferential, transverse, longitudinal) are responsible for gingival architecture and biotype. Extraction, without the placement of a supporting architecture, results in complete atrophy of this complex. Because there are no gingival fibers to regenerate if an implant is not placed, it is harder to reconstruct ideal gingival architecture.

    2. Reduced turnover of bone. Bridging of bone to the implant body rather than through a large graft area reduces the catabolic phase of bone. This breakdown phase also has deleterious effects on fibroblasts. Reducing collagen breakdown will help maintain gingival architecture.

    3. Placement of the implant with an anatomic healing abutment or provisional prevents downward epithelial migration which causes crestal bone resorption.

    When attempting immediate extraction/immediate placement, avoid flaps on the facial. Stripping the periosteal microvascular will ensure resorption of the facial plate. We employ an ablative erbium based laser to completely remove granulation tissue (chronic inflammatory tissue), decontaminate the site, and decorticate the bone. We place the implant in a slightly palatal position to accepted norms, and then gently push a membrane between the periosteum and facial plate extending 2mm past the defect. A bTCP graft (completely resorbable)is placed in the defect between the membrane and implant body. This type of graft releases free cytosolic calcium, acting as a pH buffer. When pH is maintained at physiologic neutral, osteoblast numbers as well as metabolism increases. This will help to ensure bone growth rather than resorption.

    Like any other modality, attention to detail is extremely important. But what is equally important is an understanding of the biology of the extraction site. We now have the capacity to completely re-engineer the wound response in extraction site defects when implants are placed immediately.
    RJM

  18. I must respectfully disagree with the previous comments. Immediate implant placement and restoration in the esthetic zone may be risky when the buccal cortex is defective.

    1. The gingival fibers do not insert into the implant or provisional crown like a natural tooth so there is no concern for immediately inserting an implant to prevent atrophy of this complex. A staged approach with hard/soft tissue grafting has been shown to be a predictable way to reconstruct the gingival architecture.
    2. Reduced turnover of bone? “Bridging of bone to the implant body rather than through a large graft area reduces the catabolic phase of bone”?? I’m not sure I understand these points. The implant is inert titanium and provides no source of bone growth. Bone grows from the surrounding bony walls. The implant is actually “in the way” of regenerating the lost facial cortex. A socket graft allows the clinician to re-enter and evaluate the bone repair. If additional augmentation is needed it can be easily performed at this stage.
    3. Epithelial down growth is limited by contact inhibition. Epithelium can attach to the healing abutment or provisional. However, when you remove the abutment and disrupt the attachment the epithelial attachment migrates further toward the implant (Abrahamsson et al, 1997). The epithelial attachment on the implant would be similar with immediate or delayed implant placement. Inserting the definitive abutment and never removing it may provide a more stable epithelial attachment (as could one piece implants). However, these options are not always possible in the esthetic zone. The laser microchannel surface (Laser-Lok) may prevent epithelial down growth but its clinical significance has not been proven.

    I appreciate the more cautious staged approaches suggested by the other contributors. If you simultaneously graft the facial cortex with immediate implant placement and restoration you cannot assess the bone repair on a periapical film (an axial CT scan may show the area but this is not routinely done postoperatively in most cases). After immediate provisionalization you do not re-enter to inspect the outcome of the repair. A staged approach allows the clinician to re-enter and evaluate the bone repair. If additional augmentation is needed it can be performed with the implant placement. Just because you don’t place the implant immediately in the esthetic zone does not mean an esthetic failure or compromise is inevitable. I think Dr. Miller’s clinical comments made after the three points are excellent suggestions. However, the staged approach or “One miracle at a time”, can keep you out trouble. Repairing gingival recession and uneven gingival margins after the implant is in place is not as easy or predictable (especially on an 18 y.o. female).

  19. I like implants as much as the next guy but…have you considered a conventional emax or zirconia bridge for this young lady? IMO, it would be more predictable and the esthetics would be equal or better.

  20. I am sure the young lady would like to retain the maxillary bone profile especially if she has a high lip line thus implant route is preferable.
    As Always agree with Robert Millar ,the graft material placed around the implant will prevent the soft tissue downgrowth especially when using one on the newer cell occlusive materials. As for immediate load forget it.
    As to the one miricle at a time , I think the bio materials world has moved on.An osteotomy is merelt a fracture of the bone which then heals why not help it heal and one healing is enough so place the implant immediately ( or here maybe delayed immediate if acute infection is severe).
    Another benefit of the Caso4 and BTcp products is that they are Bacterio-satic.
    Peter

  21. The biomaterials world has moved on from staged bone repair? Are you suggesting CaSO4 and beta-TCP are the “newer” graft materials to bone repair in this case scenario (buccal wall defect with simultaneous implant placement)? Interesting but I disagree.
    CaSO4 and beta-TP are only osteoconductive. Their biologic properties are limited to acting as a passive scaffold for bone growth. They work well in clinical situations where the bone morphology is favorable (sockets. sinus). I have worked with these materials for years (and continue to use them) but have found they have limited application in larger bone defects.
    The biomaterials world is moving on – growth factors(not next generation Plaster of Paris)

  22. Dr. C areed these materials are as old as the hills but it is way they are now put together.
    Read http://www.head-face-med.com/5/1/13 for a multi university study. Also agreed growth factors ( Infuse )
    is the route forward but it has it issues as well .
    Stem cells are even more of a future and we collect tissue on extraction of deciduos teeth for that reason

  23. I have placed hundreds of Nobel Active implants..in previously root canaled teeth…do to fracture of root or complete fracture of the crown at the gingival margin. However, I definitely would NOT recommend immediate placement in a situation where the patient has a infection present.

    Depending on the amount of infection present…you may want to extract the tooth…leave the area and the infection to clear up for 4-6 weeks and then re-enter to place the many options discussed above to graft the site.
    This way there are no pathogens present to cause problems with your graft.
    Good Luck

  24. I applaud the debate on this vital subject. The future of oral implantology is actually extraction and immediate placement of implants in minimally invasive surgery. But let’s dispel some of the myths regarding this modality, First, whether the tooth is being extracted because of periodontal disease or failed endodontics/fracture, virtually 100% of these sites are contaminated. Therefore, according to previous posts, none of us should be immediately placing implants in these sites. Our success in implant integration is therefore directly related to our ability to debride AND decontaminate the extraction site defects. I do not hesitate to place implants in infected sites, primarily because of our use of ablative lasers in osteotomy preparation. Removal of periodontal ligament, apical granulomas, AND infected junctional epithelium completely re-engineers the biology of hard and soft tissue response. The laser literature amply supports this paradigm. Second, with regard to the statement “one miracle at a time”, what makes you think that you can perform a miracle every time you re-surgerize a site? While I am a firm proponent of not pushing envelopes too far in implant surgery, I must also follow my instincts and empirical clinical results. My results are significantly better in a single minimally invasive surgery, both short and long term. While it is true that we do not re-enter these sites to look at the facial plate, if it does not regenerate we will see the consequences at the facial gingival margins/papillary form. Would YOU consent to re-enter these sites on your own successful implant? While the biology of the implant site is of particular interest to me, it is the clinical outcome that is still paramount. So it’s time to re-evaluate your own protocols with regard to these cases. There is no paradigm that we have adopted in our discipline that has not gone through this process.
    RJM

  25. I appreciate Dr. Miller’s comments. I also think it is prudent to periodically re-evaluate our protocols. However, before we make recommendations to our colleagues we must have valid scientific data to support our instincts and empirical clinical results.

    A systematic review of the literature by Quirynen et al (2007) found the heterogeneity of the studies (extraction defect characteristics, surgical technique, +/-membrane and/or bone substitute, implant location in socket, prosthetic rehabilitation) rendered a meta-analysis impossible. They concluded that because of the lack of long term data, questions regarding peri-implant health, bone loss and esthetic outcome of immediate implants remain unanswered. A review of the topic by De Rouck et al (2008) concluded that implant survival and management of papilla seem predictable but maintaining the midfacial gingival margin may be more problematic as bone remodeling occurs irrespective of implant placement. They recommended the clinician be reserved when considering immediate implant placement and provisionalization for replacing single maxillary teeth.

    I obviously do not recommend flapping a healed implant site following immediate temporization just to check the bone repair. I was simply pointing out that you really do not know if you were successful in the bone repair from radiographs. I disagree that you will “always see the consequences of bone healing at the facial gingival margin”. There are numerous cases where bone loss (or failure of bone formation) does not reveal itself via clinical appearance of the soft tissue (especially with a thicker biotype). An acceptable esthetic outcome with a lack of bone formation would be a long term concern to me.

    The reference to the phrase “one miracle at a time” does not imply that every surgery performed is a miracle. It is meant to encourage clinicians to be cautious and not try to do too much at one surgical visit (ie. not pushing the envelope). I pointed out in my previous post that there is not much downside to a staged approach when the bone is missing (except increased treatment time). The three points previously posted Dr. Miller made do not seem to be valid concerns. He finds he has significantly better results with a single minimally invasive surgery. The literature finds implant success rates are slightly lower (5%) with this approach (De Rouck et al, 2008). I find with good case selection the results are about equal (immediate vs. staged).

    Quirynen M, Assche NV, Boticelli D, et al. How Does the Timing of Implant Placement to Extraction Affect Outcome? Int J Oral Maxillofac Implants 2007;22(suppl): 203 – 223.

    De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: a review. Int J Oral Maxillofac Implants 2008;23:897-904

  26. Dr.C , sorry the link for the multi university paper on “A new Biphasic oseoinductive calcium composite material with a negative Zeta potential for bone augmentation” by R Smeets is http://www.head-face-med.com/contents/5/1/13.
    With hundreds of sucessful cases and two failures (diabetics)there is an option here as I show in my talks.We were using the materials in 1990 but they are different together and the charge seems to have a benefit.
    Peter

  27. Thank you for the article link regarding the new alloplast. The paper is interesting. When you pointed out it was a multi center study I thought it would have more scientific credibility (ie. level 1 or 2 study). However, it is actually only a case report on one patient with no control (level 4). In addition, the authors are quite loose with their use of some bone biology terms. They stated the aim of the study was to analyze the osteogenic potential of a biphasic calcium composite material (BCC). The only osteogenic graft material is cancellous autogenous bone as there are viable cells transplanted in the graft that form bone. The title of the paper implies the BCC is osteoinductive. Only BMP is osteoinductive (induce pluripotent mesenchymal cells to become osteoblasts and form bone). Osteoinductive graft materials would include autogenous bone, DFDBA and rhBMP-2 (not alloplasts). In the conclusion they note that BCC is a promising and effective alloplastic biocompatible bone replacement material with superior osteoconductive properties due to the negative Zeta potential. Alloplasts are osteoconductive as they act as passive scaffolds for bone replacement. It appears these particular materials may be more favorable as they resorb faster than others (such as xenografts). The sinus is a very favorable environment for bone graft incorporation and several materials have shown good outcomes. If I had a new graft material and wanted to show how well it performed a sinus graft study would be the perfect model. As stated previously I find alloplasts (CaPO4, CaSO4) work well in intact sockets and sinuses. The new formulations appear to have improved qualities. However, when bone defects are larger or there is more jaw atrophy they have limited ability to regenerate bone as they are only osteoconductive. Thanks again for sharing this article.

    Smeets R, Kolk A, Gerressen M, Driemel O, Maciejewski O, Hermanns-Sachweh B, Riediger D, Stein JM. A new biphasic osteoinductive calcium composite material with a negative Zeta potential for bone augmentation. Head Face Med. 2009 Jun 13;5:13.

  28. Dr. C thank you for your well informed observations which I agree with. There is apparently to be a 45 case study by Smeets to be published in J of Perio shortly but as you say only Randomised controlled tests are the true measure , alas there are generally few around in Implant Dentistry.
    In Europe the use of BMP2 is still prohibited ( posssibly March 2010 will be a change of policy) so that rules that out for us.
    Agreed as well that a severely atropied arch may require more ( Block) but that is not the issue in this case where it is merely a single tooth failed RCT , and here the bacteriostatic nature of the alloplastic graft could be of benefit thus this material can be an option.
    As in aspects of Dentistry many treatment options work and here we are looking for a solution to help the body return itself to a healthy state (no resiual graft material).
    If it can be done without introducing donor (human , cow or pig ) and without donor site morbidity then maybe that is a step forward.
    Thank you again for your constructive input
    Peter

  29. After placing implants for 26 years, experience dictates that I must say this to you. If you have to ask the questions that you did then this case is way beyond your experience level and should be referred out to a practitioner more qualified. JL

  30. While it is true that rhBMP is an osteoinductive material, you are wrong about alloplasts that release free cytosolic calcium. In fact, at a molecular equivalent of 5 milliMoles, these anions cause osteocytes to become osteoblasts. This is the definition of inductivity, not just conductivity. When an osteoclast resorbs bone, it releases both bone morphogenic protein AND free cytosolic calcium. In the orthopedic and cell biology literature, it is shown that free calcium increases the number of osteoblasts, upregulates MAP kinases in the mitchondria, inhibits osteoclastic activity, has bacteriocidal effects, increases parathyroid hormone related peptide, and speeds up thrombin/fibrin production and clotting time. This does not occur to a measureable degree in allografts because of the increased resorption time. There, allografts are osteoconductive. Bone grafts that immediately release calcium ions (and they must be in the correct chemistry – too low no effect and too high inhibitory) can speed up bone metabolism by 500%. This is the mechanism behind the Ossean surface (Intra-Lock International). And, last, what do we do when the literature is wrong? The problem with published studies is that they only test a specific paradigm. When we move past those older paradigms and and start getting better results, simply quoting older studies tends to have a stifling affect on new technology. When clinicians start to better understand the dento-gingival complex, the biology of the extracton site, and understand how to use technology to re-engineer the wound response, we will have moved this discipline along in it’s natural evolution.
    RJM

  31. Alloplasts that release free cytosolic calcium induce osteocytes to become osteoblasts?
    Osteocytes are mature, nondividing bone cells that are housed in their own lacunae. Osteocytes are derived from osteoblasts and they represent the final stage of maturation of the bone cell lineage. They are less active than osteoblasts, and although they are not responsible for a net increase in bone matrix, they are essential to the maintenance and routine turnover of the matrix. Can you please provide a reference to the claim that alloplasts can induce this change in cellular activity?

    Osteoinduction is usually defined as a chemical process in which molecules within the graft (BMP’s) convert undifferentiated mesenchymal cells into osteoblasts and form new bone. Changing an osteocyte into an osteoblast does not really fit this definition. How about osteorejuvenation?

    I must say you are quite bold in rejecting the literature. I provided two current reviews of the literature on immediate placement and restoration of implants (2007, 2009). I am not quoting “older” studies. Can you provide “newer” peer reviewed publications that support your view? You talk about better understanding of the dentogingival complex and biology of the extraction site. I still do not understand the previous three points you made on September 2nd. I guess I need to do more homework… I appreciate your vision on where the field is going but I don’t think we have arrive there yet.

  32. My friend Robert Miller just blows me away when he gets going like this. I can’t argue with anything he said cause I don’t know what cytosolic, anions and MAP kinases are. But I am now going to look them up so I can get in the loop. Good going Robert.

  33. As Clinican the fact of hundreds of consistently sucessful cases is the most important factor,whether osseo-inductive may be down to terminolgy.
    The negative zeta potential definately leads to a large increase of Osteoblasts ( Hunt and Cooper poster for Biomaterials Annual meeting ,Penn ,US )by upregulating the genetic expression thus Osteocalcin and Osteopotin as well as CBFA1 and type 1 collagen presence is dramatically increased.
    Thus it would seem to be osseo-inductive accoring to the criteria expressed here.

  34. Dr. C;
    You grant yourself considerable poetic license suggesting that I reject the literature. As a graduate student in biology, I completed my thesis in endocrinology. I learned not only how to read and respect the literature, but also how to critique it. The problem with most clinicans repsonding to this blog, with the exception of Dr. Fairbairn, is that they read only the dental literature. Try expanding your sights to cell biology and related journals. You will have an entirely new perspective on dentistry’s lack of understanding of the interaction of tissue and implantable devices. Rather than post dozens of referenced journal articles supporting my claims, why don’t you simply go to pubmed and search under the criteria of calcium interactions. You will get hundreds of responses. And, not a single one of them comes from a oral implantology journal. These papers will also help to shed light on the original three claims I had made earlier.
    One last thing, kindly post your name the next time you post. We would like to know who we are responding to.

    RJM

  35. Dr. Miller wrote – “And, last, what do we do when the literature is wrong? … When we move past those older paradigms and start getting better results, simply quoting older studies tends to have a stifling affect on new technology.”
    These words don’t indicate a rejection of the literature on immediate implant placement and restoration???

    Rather than address my previous questions and/or simply provide the requested information you ask me to go to Pub Med and research support for your perspectives and opinions. Either you can’t support your points or you don’t wish to bother (which is O.K. but I would like to learn more).

    Can you please provide published studies that support your opinions:
    1)“The three types of gingival fibers (circumferential, transverse, longitudinal) are responsible for gingival architecture and biotype. Extraction, without the placement of a supporting architecture, results in complete atrophy of this complex.” – The gingival fibers do not insert into the implant or provisional crown like a natural tooth so there is no concern for immediately inserting an implant to prevent atrophy of this complex.
    2)“Bridging of bone to the implant body rather than through a large graft area reduces the catabolic phase of bone.” – The implant is inert titanium and provides no source of bone growth. Bone grows from the surrounding bony walls. The implant is actually “in the way” of regenerating the lost facial cortex. How does the titanium implant reduce the catabolic phase of bone compared to a bone graft?
    3)“Placement of the implant with an anatomic healing abutment or provisional prevents downward epithelial migration which causes crestal bone resorption.” – Epithelium can attach to the healing abutment or provisional. However, when you remove the abutment and disrupt the attachment the epithelial attachment migrates further toward the implant (Abrahamsson et al, 1997). The epithelial attachment on the implant would be similar with immediate or delayed implant placement (unless you never remove the abutment).
    4)“…you are wrong about alloplasts that release free cytosolic calcium…these anions cause osteocytes to become osteoblasts. This is the definition of inductivity…” – Osteoinduction is usually defined as a chemical process in which molecules within the graft (BMP’s) convert undifferentiated mesenchymal cells into osteoblasts and form new bone. Changing an osteocyte into an osteoblast does not really fit this definition. Osteocytes are derived from osteoblasts and they represent the final stage of maturation of this bone cell lineage. Changing an osteocyte to an ostoblast with calcium?? Please provide a reference. It may be just “terminology” but it is also BIOLOGY.

    I think this exchange can be productive if you are willing to share your knowledge.

  36. Craig;
    Maybe this will help:

    Osteoinduction by calcium phosphates:

    Osteoinductive materials are biomaterials that have intrinsic properties to induce bone formation in a non-osseous environment. Recently, it has been demonstrated that osteoinductive macroporous calcium phosphates stimulate more bone formation as tissue-engineered scaffolds ectopically (Kruyt et al 2004) and as such in critical-sized orthopedic defect models (Habibovic et al 2005b). Although the mechanism of osteoinduction remains unclear, the ionic exchanges properties of the calcium phosphate scaffolds with the surrounding tissue have been pointed out as a relevant parameter (Yuan et al 2001). By implanting intramuscularly macroporous calcium phosphate scaffolds, Habibovic et al (2005a) have demonstrated that an elevated microporosity was responsible for ectopic bone formation. This high microporosity is directly correlated with a level of stable critical level of free calcium ions that triggers cell differentiation into osteogenic lineage. In addition, through a dissolution–precipitation process, the development of a bone-like mineral layer initiates bone formation either by mimicry with the bone mineral structure or by the presence of osteogenic compounds (for example bone morphogenetic proteins, BMPs) contained naturally in body fluids that might have concentrated at the newly formed mineral layer (Ripamonti 1996).

    Knabe C, Berger G, Gildenhaar R, et al. Effect of rapidly resorbable calcium phosphates and a calcium phosphate bone cement on the expression of bone-related genes and proteins in vitro. J Biomed Mater Res A. 2004;69:145–54.

    Kotobuki N, Ioku K, Kawagoe D, et al. Observation of osteogenic differentiation cascade of living mesenchymal stem cells on transparent hydroxyapatite ceramics. Biomaterials. 2005;26:779.

    Rochet N, Loubat A, Laugier JP, et al. Modification of gene expression induced in human osteogenic and osteosarcoma cells by culture on a biphasic calcium phosphate bone substitute. Bone. 2003;32:602–10

    Rochet NM, Tieulie N, Ollier L, et al. Influence of human osteoblasts on hematopoietic stem cells:Analysis in coculture on a synthetic biphasic calcium phosphate ceramic. J Bone Miner Res. 2002

    Yuan H, De Bruijn JD, Li Y, et al. Bone formation induced by calcium phosphate ceramics in soft tissue of dogs:a comparative study between porous alpha-TCP and beta-TCP. J Mater Sci Mater Med. 2001;12:7–13

    Chou YF, Huang WB, Dunn JCY, et al. The effect of biomimetic apatite structure on osteoblast viability, proliferation, and gene expression. Biomaterials. 2005b;26:285–95

    Each one of these studies specifically uses the word osteoinduction as the mechanism of action.

    RJM

  37. This discussion particularly arguments between DR.C and Dr.Miller are very interesting.It reminds me a very heated panel discussion of ‘IMMEDIATE VS DELAYED IMPLANT’ at AAID meeting in Miami few years ago under moderatorship of Dr. Carl Misch.
    There was almost a fight between Dr.Cranin and Dr.Linkow at that discussion.
    The final consensus among very distingueshed panel members was ‘OVER ALL, DELAYED IMPLANT GIVES 3% BETTER CHANCES OF IMPLANT SUCCESS’
    As Dr. Tarnow’s faculty I believe in staged approach unless an ideal situation is at hand for immediate implant and restoration.
    But at NYU we do both ways with good success rate.Graft materials we use are Puross,or Bio-oss not CaSO4 or CaPO4.

  38. Excellent discussion of a very controversial topic! I got to ask where do you guys find the time to respond? Also I think we are all on the same team here?

  39. This has been a fascinating dialogue. I for one have found it to be quite stimulating and applaud this site for generating this kind of intelligent interchange. As to the original posting question on performing immediate implants, I am in agreement with Dr. Miller that in the anterior segment, the majority of my best clinical results derive from the minimally invasive approach of performing an immediate implant placement even when infection is present and within reason, even when there is some labial bone loss. The considered protocol which I use when placing immediate implants into infected sites are:

    1. Infection must be controlled.
    2. Use pre-surgical and post-surgical antibiotics.
    3. Thoroughly debride soft tissue and bone.
    4. Achieve good primary fixation.
    5. Graft perimeter gaps. Use barrier membranes where indicated.
    6. Place tissue-forming healing abutments or provisional crowns.
    7. Keep out of functional stress.

  40. This is a very interesting dental topic and I enjoy reading everyone’s comments. As far as the case to extract and place an implant or not depends on the situation. In esthetic cases, I will avoid immediate implant placment. For posterior dental implants, I have no issue having the implant in right away.

  41. We know that implants in immediate endo sites have a higher complication and failure rate so we have to decide what criteria determines when we do immediate placement and when its delayed. This case clearly demontrates symptomology and as Carl points out most likely the buccal plate is missing and this case should be extracted with a full flap to evaluate this and if the buccal is missing and or frank infection is present grafting will be needed then the site allowed to heal before an implant can be placed. Sometimes rushing leads to failure and in the grand scheme of life whats a few extra months? Place the patient into an essix temp and allow the site to heal.

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