Immediate implant placed: leave it or remove it?

This 18 y o female presented for extraction of retained primary tooth C (#6 had been previously horizontally impacted and extracted years ago) and implant. Once I removed C (atraumatic and intact 4 walls) we agreed to place the implant immediately. I kept the angles right and felt like it had a good prognosis (3.7 x 10.0 mm legacy 2 Implant Direct). Before placement I verified the osteotomy as being intact to the apical depth. Upon placement I had primary stability (35 N) and visible circumferential bone. Closed it up, adjusted her flipper, and took a CT to let her go.

The CT showed that the implant is fully exposed on the palatal, very disappointing. I’m getting her back early next week. I consider my options to be:
1) Take the implant out, GBR on the palate (I’m expecting a defect there), and reintroduce the implant in 3 months, maybe a 3.2 this time? Do you think resorbable membrane or PTFE membrane?
2) Save the implant and do GBR on the palatal? Same question, resorbable or PTFE membrane?
3) Wait and see how her body heals?

She is currently feeling well and has some slight tenderness on the palate side, consistent with the situation. Thoughts?




39 Comments on Immediate implant placed: leave it or remove it?

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Dr T
6/9/2017
Did you take a pre op CT scan? From your post op scan it appears that there was inadequate B-Li dimpension for any implant. What would you do if this were in your mouth? In mine I would get it out ASAP with GBR
joe nolan
6/9/2017
If you saw 4 walls, can you say how you then say that the implant seems to have no bone around the palatal: is this what you are describing? If the implant was deeper, would that have solved the problem?
Frank
6/9/2017
Remove implant,bone graft, reevaluate in six months and then decide.
drjjs9
6/9/2017
I had thought about that, perhaps narrower and deeper however her extracted #6 had left a void in the bone apical to the osteotomy that I was trying to avoid.
Richard B. Winter D.D.S.
6/9/2017
Have you done a hand wrist film? One year apart Cephs? Why would you place an implant on an 18 year old woman? She still has growth occurring and implants are not indicated until all evidence of growth is completed. You should remove the implant, perform a Maryland bridge and wait until you are assured her growth is complete. It would be ashamed to ruin her lifetime smile by being too eager to place an implant and watch as the teeth move, the implant doesn't and her smile is less than ideal with completion of facial growth and development.
Frank
6/9/2017
Why we have to be so nasty when post comments. Doctor just asked for advice.
Rick
6/9/2017
It's not nasty to inform a doctor performing surgery about the timing of implant placement in a young woman. With continued eruption and the ankylosis effect of an implant smiles can be ruined and I have seen this in my practice. It's better to be educated then ignorant of the proper timing of implant placement in young developing adults.
drjjs9
6/9/2017
The courses I have been to have consistently taught that at 18.5 years old a female SHOULD be done growing and a good candidate for implants. I agree, to be assured that growth is complete more pre-op data should have been collected, lesson learned for moving forward.
Oliver Scheiter
6/11/2017
18.5 years? That cannot be right. Growth is such an individual thing. When you ask experienced surgeons they will tell you that they won't implant in women under 27-28. Consistent follow-ups show growth until that age. So to me the Maryland bridge seems to be a wonderful idea. Even if she was thirty: This implant has to go. Sunny regards Oliver
ST
6/9/2017
Dear Dr. I don't like posting negative comments, we have all made mistakes and we all have our own learning curve but, I am afraid, yours maybe a little steeper. Why didn't you take a pre-op ct scan but decided to take one post op? How did you assess "visible circumferential bone"? Simple probing should have revealed no palatal bone!! You need to: 1) inform patient 2) removed implant asap 3) gbr with FULLY RESORBABLE material as this site will require a graft; there's no way enough bone width can be achieved only with gbr 4) refer for bone graft after 3-4 months, 5) new fixture after 4-6 months. 6) wold strongly recommend more training Good Luck ST
drjjs9
6/9/2017
ST, thanks for the feedback. I re-probed after each implant drill insuring no palatal bone perforation and could visually locate the osteotomy bone site, that's a big part of why I was so surprised to see the CT. I'm thinking it must have gotten so thin by the time I was done that placing the implant actually displaced the bone. I'm taking it out and grafting it ASAP. I've been placing implants for 4 years and continue to do extensive training, hopefully this is the last such incident.
Uli Friess
6/10/2017
I fully agree! Can't understand,why he used such a thick implant(3.75).If the implant is exposed, why even think about leaving it there? Remove, GBR and if you are very lucky,you can put another,smaller(3mm) implant later.
Tarek Abdelsamad
6/9/2017
Hi. Take implant out. Graft. 6-9 month another CBCT. Another implant . At least she will be almost 19. Good luck
Fereydoon
6/9/2017
1. With pre op CBCT could prevent this type of problems. 2. In younger patients with perforation we will expect more resorption. 3.Even a little asymmetry in palate causes tonge activity and more problems. 4. I prefer to remove Fixture, GBR and after 4 months very long, narrow implant.
James
6/9/2017
I agree with most of the comments. A pre-op CT would have been beneficial in assessing the true B-P ridge width. At this point, I would refer the patient to an OS or Periodontist and let them decide on the best course of action, to remove and GBR or consider a block graft at the time of removal. Given it is #6 that is being replaced, I would not consider a longer, narrow implant just because the bone is narrow.
drjjs9
6/9/2017
Wow, what great feedback. So much to address. I should have pointed out that we had a pre-op CT, here it is. There are a lot of things that could have been done differently that I will take into consideration for future reference and it seems there is a consensus to get it out, graft and wait, that's what I will do. Thanks! J
Yamamoto
6/11/2017
Your original CBCT cross sections looked obliqued. The images that you produced from your panoramic line look distorted to some degree giving you the wrong information pre-op. I feel that your pre-op images were not accurate to begin with.
Samuel Barr
6/9/2017
Take the implant out. Honestly, don't feel bad, if we are honest in self evaluation, we have all been there.
drjjs9
6/10/2017
Thanks Sam. My partner here in the office is a Diplomat for ICOI and been placing them for 2 decades. He often encourages the same way, helps by teaching me through his mistakes over the years realizing that our intentions are ethical and moral and training is never complete.
OsseoNews
6/9/2017
Please note that for those asking for a pre-op, the original poster added one in the comments. We have also now added this pre-op to the original set of post images for easier reference. Thanks.
z
6/9/2017
Out of curiosity, what was the temporary tooth replacement, a flipper? If so, is it possible the flipper was putting pressure on the palatal area? I had an implant as part of a locator denture that had that problem as it was healing, too much pressure on the tissue, and the whole lingual became exposed, similar to this presentation. In this case single tooth #6 I would extract implant and graft with a titanium reinforced PTFE membrane with screw retention on the palatal apical to the defect.
drjjs9
6/10/2017
We did a unilateral single tooth nesbit. It didn't fit well so she is coming back for a flipper. I am now planning to cut the tooth off of the nesbit and temporize with an interim maryland, seems like the best way to keep the platal and buccal bone free of pressure and keep my soft tissue ovate and papilla intact. I am planning to use a titanium PTFE membrane but hadn't necessarily thought about screw retention, best way to get secure it, thanks for the feedback!
RU
6/9/2017
Most women are done growing between 13 to 15 years. I would not worry about placing an implant on an 18 year old woman.
CRS
6/12/2017
Very simple serial cephs one year apart to determine is growth complete. Basic principle I learned in orthognathic surgery.
Rick Weimar
6/9/2017
To all of you that have made a comment about female growth being done at 18.5 years or younger, please review the findings of Dr. Oded Bahat. At the AO national meeting he showed research of Mx and Mn skeletal growth that occurs well into the twenties. The premaxilla after the age of 18 will change an average of about 3.5 mm if I remember correctly. Creating an ankylosed implant 3 mm below the occlusal plane. Also, it is almost impossible to tell who will be done with this skeletal growth at 18 and who at 25 or later. The heaviest of hitters on the distinguished panel all said that they would all change their approach to doing implants on patients in the 18-24 age range. Relying on some on growth plates in other areas of the body would clearly be a mistake.
Richard Winter
6/10/2017
Rick is absolutely correct. Please see Misch's book where he also says the woman must be taller than her parent, there should be no evidence of growth in the previous 6 months, CBCT should be unchanged on 6 month views etc. We should realize that rushing to place an implant at 18 can result (and unfortunately this has happened to a couple of my patients when the surgeon did place implants at 19 and 20) in very un-esthetic and expensive problems to treat 10 years later.
A Duggal
6/10/2017
Thanks for posting. Good case to discuss. I would agree I would remove and graft and after 6-9 months reassess and start again. The other option to consider is giving her an adhesive bridge as a temporary instead of the denture to help avoid any pressure on the area whilst it is all healing. I personally ask patients to leave dentures out for up to 1-2 weeks after implants especially if grafting is done to help risk of pressure on implant / graft. The fact the patient is without a tooth is obviously very important for most people so has to be timed well for patients circumstances, i.e. No important events etc. The alternative to consider is to give an adhesive bridge for a longer term temporary (even for a couple of years). I have done this for some younger patients when they have favourable occlusion / enamel etc and have had patients with bridge for some years before then having an implant . Best of luck.
drjjs9
6/10/2017
Very wise. I'm leaning towards similar protocols now, especially in cases of grafts.
Mark Cohen
6/10/2017
I despise the guy who criticized you for your inadvertent error in placement. We have all walked in your shoes and shame on anyone putting you through more stress! Get the implant out, GBR, and you Amy still need a block graft down the road.
joe nolan
6/10/2017
How soon did you figure the defect on the palatal wall? If there was a decent palatal wall to begin with , after removal of the C , and you saw the 4 walls, how did it get to where the CT shows in the post op? I wonder if the palatal wall , after surgical removal of the 3/adult canine, wasn't just tissue paper, and fooled you from the start...you mention it might have given way as the osteotomy proceeded...? I think this is a great problem to show colleagues, as it can only help, so thanks for showing it ...there are many people who present with this exact bone set up, and anything that helps colleagues is to be welcomed with open arms. Who ever learned from getting it right? As to growth and 18 year olds....I do a lot of ortho, and late adolescent growth is common.
drjjs9
6/10/2017
Joe, I'm believing that is the case. In discussion with my partner he jokingly related that perhaps we fool ourselves into seeing what we want to. I think the CT is objectively clear that there's no bone. I'm taking it out this week and will take some IOs. I think it's interesting how this thread is turning into a discussion about arch development and growth.
joe nolan
6/12/2017
Thanks for writing, and yes, it is quite the enigma, the road you have built:) Dr Bahat has had a metaphorical bloody nose from Dr Mena, so perhaps Dr Mena can show why he is right and Dr Bahat is all wrong...I for one would be happy to see how many 18 year olds Dr M has placed implants on and where the CT shows them to be today, let us say 10 years later? Just asking:)
RU
6/10/2017
Thank you for the reference to Oded Bahat’s research, i read a paper on the following address: odedbahat.com. The paper “Lifelong craniofacial growth and the implications for osseointegrated implants” I recommend it. I could not find support however to the statement that craniofacial growth on 18 year old women differ from women older than 25 years. My take from the study is that changes are lifelong. Does anyone know any research that shows that the problems we can encountered when placing an implant in an 18 year old woman can be avoided by waiting after 25 years? This has been a great discussion and i have learned a lot.
CRS
6/11/2017
Welcome to the most difficult implant scenario. These must be grafted preoperatively since the alveolar bone does not develop fully when the canine does not erupt.Now you have a compromised site. Refer it to someone with experience. I'm fixing one of these now, it is not easy.
Raul R Mena
6/11/2017
I an a member of other Implant lists, I have been placing implants probably before must of you graduated from dental school, I have trained many doctors in the field of Oral Implantology, I was Co-Director with Dr. C Misch in a CE MaxiResidency Course at Pittsburgh School of Dentistry, I have a Hospital based Residency or Oral-Cranial and Maxillofacial Implant, and I am Fellow and Diplomate of both the ICOI and the AAID. Almost every time that someone asks for an advice or post a mistake, on this someone always comes to the attack. There is no reason to tell anyone that he is ignorant, no one should be ashamed of asking for a solution to a problem. Yes you can refer the patient to an Oral Surgeon, a Periodontist, or to a Dental Implant Specialist, but you can also repair it yourself and if your partner is a Diplomate of the ICOI he can also assist you with this case. Regarding Dr. Oded Bahat’s research and presentation, it has no place and very little relevance in how the profession should perform dental treatment. As far as age I totally disagree with the timing of implant placement. If properly placed, implants can be placed on teenagers, to prevent bone resorption. Treatment should be properly planed and with the right implant and abutment design, so the case can be prosthetically retreated. Simple distraction osteogenesis if necessary can be performed later on to adjust for any discrepancy in bone growth. Doing so is easier and less problematic than bone grafting at a later age and also prevent some psychological problems for having a missing tooth at an early age. Smart and knowledgeable professionals are humble and carrying with their colleagues.
Rick Weimar
6/12/2017
Dr Mena, thank you for your response about Dr Bahat's information. In your estimation why does it have so little relevance? Is it that research shows difficulty in predicting who has continued skeletal growth, you are unsure of the verifiability of the research, you find it not particularly difficult to treat the Mx anterior area with DO? In most cases with teenagers we are not really preventing bone resorption, it is already an issue and would appear fairly static into the 20s, at least in congenital cases. What is the proper implant and abutment design. I have many late teenagers coming in with missing laterals and I would really love to know if implants there are viable. Thank you for your time, expertise and considered response.
Peter Fairbairn
6/12/2017
Nice Post Raul ...... there are a number of factors to taken into account , you have summed it up perfectly Peter
RU
6/12/2017
I am also in full agreement with Dr. Mena's opinion. With regards to Dr Bahat's research, have everyone commenting on it actually read the paper? The paper is actually not very relevant to the discussion at hand. Why? First, the paper does not investigate 18 year old women. In fact, we do not know what population was investigated. There is no average age or range if ages in the study (please see the M&M section). It does not specify how many patients were investigated or followed? There are 4 cases presented in pictures. Not enough for any relevant conclusions. Second, there was no statistics done, zero. Third, the paper talks about lifelong changes, are we to assume that we can not restore missing teeth with implants because the occlusion sre going to change throughout the patient's lives. Of course not. So i agree We can not use this research to set up guidelines on how to treat our patients. as far as i am concerned both Dr Mena's and Dr bahat's opinions should be given equal value.
WTB
6/12/2017
I don't believe CBCT's are absolutely accurate. I often see burnout around Titanium and other metal objects. If you felt bone on the lingual before placing the implant, there's a good chance the bone is still there. It usually gets defected towards the buccal and not through the thicker buccal bone.

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