Dental Implant after Extraction

I would suggest this case be re-done. Immediate placement of implants is probably the #1 reason for failure. Site must be healthy and free from ANY infection to expect a good outcome.

I disagree with the comment about redoing the implant. No current research will support immediate implants as the #1 reason for failure. I do many with a success rate comparable to staged implants. My suggestion is that grafting my of been necessary with the implant placement if a wide space was present after placement between the fixture and osseous crest. In this case primary coverage and a two stage approach may of been the better choice instead of single stage. Jeffery Becker DDS, MSD

I just returned from implant course with John Kois and he said immediate placement was his perfered tx. protocol.

I have place many immediate molar implants and would agree with the second comment. I would only remove the implant if threads are exposed or it seems that there may be a defect on one side. Sometimes the bone seems to "jump" better than others. If the implant is rigid that is a good sign. Try to carefull assess what the bone level is. If the bone comse up the threads then you will be ok. But if the bone comes about half way up and the rest is a soft tissue ingrowth then you are probably in trouble down the line. I wouldn't try to sink the crown too far down the sides of the implant. Leave it high. I have many patients functioning for a long time with the situation you decribe and a "high-water" crown. It can be very healthy biologically. I have never had a patient complain about the esthetics in the posterior implants if metal collars are showin. As long as the crown on top is white they are happy with the esthetics. If you drop the crown down I think you are far more likely to run into problems. Accordingly, if I understand you case correctly, I wouldn't graft it.

I perform many immediate implants and they have been very successful. If the implant is integrated and this is a non-esthetic area I think it is okay to proceed with the restoration. Most patients don't complain about a little metal showing in the posterior areas and removing that implant wil require more surgery for the patient, which could be extensive. I also prefer performing immediate implants and I currently do more immediate than two stage.

I agree with the last comment. I would try to restore it first if implant is healthy. If patient is not satisfied then i would consider additional treatment. I do some immediate implants but usually not in molar area. It seems to me that the anatomy of the molar socket makes the ideal placement very difficult. I do not see the nessecity of immediate placement on a molar area. If i was a patient i would not mind to wait an additional 3 months for something that i expect to last 20-30 years.

I would either restore it as is or put on a cementable abutment and prep the head of the implant. This mostly hinges on whether you have enough "meat" on the head of the implant to allow this. If you have an external hex, you almost definitely have enough metal to do this. If you have an internal attachment but you used a wide implant, you probably still have enough room. Remember if you restore the implant with the head exposed, you may well have a restoration that traps food frequently in addition to looking poor. It depends on the tolerance of the patient for esthetics and food entrapment; he/she should be involved in the decision making process. Just use a lot of water when you prep!

If the exposed implant is a problem, instead to remove implant, I would perform a gingival graft in order to cover the area, but never remove the implant, which could be in some case very damaging for the surrouding bone.

I dont see the need to place an immidiate implant in posterior area and less if you have an infection that may cause the extraction of that molar.Mother nature is more wisdom and require to wait the normal healing, so I prefer to wait a couple of weeks and then place the implant.

you don't have a problem here. continue your restorative in the four to six months if you like don't fall into the trap of thinking this is a tooth . it's not its a titanium fixture, as long as the tissue is healthy around the implant you're good to go. it'll be fine if you restore to the abut-implant junction .you MUST explain the final result to the patient and even temporize the case so they could see that theres going to be a small amount of metal thats going to show. if you're up front and explain this properly then it's a reason if you blindly finish the case and have the patient discover the metal showing on their own then its an EXCUSE .

Thanks so much for all your help and ideas. It is great to hear the differing opinions and techniques.

well giulia ,we all experience some implant exposure in our practice and the above comments are very relevant. to try to help you more,just think in terms of high or low smile line,and if the patient does not smile "with an index pulling the cheek" , the metal at the collar should not be an issue. tell the patient early, most people have no unrealistic expectations, and keep doing well as I presume you do. very friendly

I just placed an implant where we had minimal (read insufficient) bone to the buccal. I respected the lingual plate and exposed threads on the buccal. I then used an RCM (resorbable collagen membrane) Ace Dental supply and placed pepgen 15 under it. Wrote an Rx for levaquin and having patient roll CHG in their mouth for 4 weeks...oh it helps to pray. I could use some luck too.

Why not consider an all porcelain abutment if that is an issue. Most mature implant systems have that as an option. Also, in preoperative consultation I always show patients implant teeth that are indistinguishable on smiling, but are longer with alterations at the gingival margins (even some metal show). This helps patients appreciate the possible limitations of implants. We all have "perfect" cases to show that even close gingival examination cannot detect the implant from a natural tooth. Save those for your study club. By not promising unrealistic outcomes everyone is more satisfied. Remember its still a dental prosthesis.

Every comment above has real merit. I am also Chairman of our local dental society Peer Review Committee. We've had some cases go against restorative docs when things went south with implants-including molars. Let the universities and very high end surgeons place molars immediately. In 2006 the state of the art-the predictable art-is to extract, graft (or not), wait, place, restore. Prepping fixtures? Sure it's done. And is things go south, whoever touched it last loses. Restorative docs-do you want to be the last one?

Immediate implant has no contraindications if you have a chronic infection or a granuloma, well isolated from the bone by a membrane. RX shows a well delimited area. The contraindication appears when you have an acute infection. Then you have to wait 2-3 weeks after removing the tooth and carefully cleaning the spot before placing the implant. In the situation you described you have to be assure both clinical and radiological that the implant has enough strength to carry a crown. If some threads are exposed you can open and graft around. If none of this happened and if only the cover screw is exposed, just say thanks to Mother Nature that helped you in the second stage and go on with the crown. Good luck! By the way, how many month passed since the intervention?

Being a first maxillary molar, esthetics should not be primary concern. I doubt machined polished collar may be more than 2.00mm. During healing stage Biologic width is already established. By preparing crown margins on implant you will disturb Biologic width and sending it more apically exposing threads to the mercy of plaque.

I question the fact that an immediate placement was performed instead of extraction and letting the socket heal. You are not woried about aesthetics in the posterior region. Nobody knows how the bone and the soft tissue will heal subsequent to immediate placement. Why add another factor when you can predictably place an implant post extraction. You are not dealing with a single socket and predicatbility is limited in a posterior case.

Dr. Miller has rasied an interesting question concerning peer review which is worrisome. If I were hired as an expert witness, I would present a literature review demonstrating that the treatment planning and execution was mainstream. Someimtes treatment planning and execution can be WNL and yet a poor clinical result is produced. The practioner is practicing within the limits of the universal standard of care in implant surgery. What would be the basis for Peer Review in this case?

well, immediate implantation is a contraversey now a days, i have alot of cases that ive placed implants in extraction sights with bone augmentation and membrane placement (non-resorbable which is giving perfect results) and im having perfect results with good easthetical results and also had a case that had some reorbtion but due to the fact that i push the shining cllar more appically u hve less problems eastheticly.

I am interested in the solution to your case, I have not yet encountered this but I could any time.

There is no PDL this is an Implant treat it differently ,you can prep the implant (depending on type)or ridge fit the restoration ...It is better than re-doing the case in 18 years I have not seen a problem with treating an implant differently to a tooth

You should not place an implant after extraction in a first molar, as it is impossible to have a good prognosis of that implant. Where are you going to place the implant? mesio-buccal root? palatal root? My advice is: for multiple roots, remove the tooth and place the implant 6 weeks later.

i just had #18 extracted and dr recommended placing implant in 6-12 months.

i agree with david gosolo. What is the rush to place an implant in this area. By virtue of the anatomy there is not a good spot to place the implant immediately. In the future Let it heal baby. You will get a much more aesthetic result. Immediate placement works fine with thick buccal plates in single rooted teeth with good apical bone. I question why we need to rush to place the implants when the ultimate goal is for it to be predictable functionaly and aesthetically for a lifetime.

I have reviewed this patient last week. All is great. Gingiva has healed well around the neck of the implant (no threads visible). Xray looks fantastic at this point. Oral hygiene is fantastic. Crown looks great. Patient loves the implant. Glad I did not remove the implant.

If it´s ok better for you. That´s becouse Jesus loves you. Never do immediate implants in the posterior area, there is no reason to do that. Immediate implants are to maintain anatomy and aesthetics not to function with. Let it heal and do a regular implant, your life will be much easier!. JP

There is a very significant benefit to placing the implant immediately upon extraction of the first molar. How many times are you seeing the sinus membrane droop down and you are wondering if they need a sinus lift to place the implant? When you extract the first molar, you can place it in the palatal root and know that you are not invading the sinus in spite of a 2 dimensional overlap of an xray. comprende?

'placing an implant in the palatal root after extraction of the first molar' Well thats an interesting technique ! Do you mean placing the implant in the palatal root that has fractured during the extraction or do you mean placing the implant in the palatal root of the hand held extracted molar? Let's be precise with our language as we try to be with our implantology

While placing an implant in a maxillary extraction site is attractive. I do this myself. Also consider a socket lift (you may have to use trephine burs) you you the 5mm. or larger osteotome to compress the bone of the socket and lift the socket. You can get a fast and easy additional 5-8mm. of vertical bone. Then densely pack the particulate graft material and follow with a membrane. Also prior to the up-lift, degranulate and detox with tetracycline for apeox 3min. If a gross infestion is present degranulate, detox then uplift but don't graft.