Immediate Implant Placement in Molar Socket: any insight?

I am considering immediate placement of a fixture replacing tooth # 19. I have had 20+ years placing implants as a GP, but this will be my first immediate placement. I am considering using a 5.0 Nobel Active, or a 7.0 Keystone. I plan on using the bone between the roots as a starting point, and grafting the remaining voids with demineralized bone matrix paste and covering with a resorbable membrane. I am concerned about primary closure without raising a flap. I am considering lowering the crestal height to allow the soft tissue to fully close. I would appreciate any insight on this proposed treatment.

24 thoughts on “Immediate Implant Placement in Molar Socket: any insight?

  1. Dr. Steven Kollander says:

    I would recommend doing your first immediate implant on an easier case, i.e., a tooth with a single root. Don’t lower crestal height to allow tissue to close. That’s just not the way it’s done. Learn how to release a flap so that you can close the site without tension.
    There are a lot of great surgical courses out there.

    • David Gelb says:

      Very straight forward clinical situation requiring no preparation of interraducular bone.
      Section the roots and extract each flaplessly as individual bicuspids with elevators
      If need be use a finishing but 3 mm apically around each root to get a purchase
      Once extracted debride each socket of granulation tissue and confirm no residual root tips etc.
      Prepare your mesial Socket to receive a Nobel Tapered Trilobe or conical connection with the head of the implant inclined to the opposing arch lingual cusp and the apical portion well within bone and situated at final insertion 1-2 mm sub crestal
      Mill the bone, secure a healing abutment and suture around the healing abutment
      No bone graft in either socket
      Antibiotics analgesics and instruct patient NO sucking to disrupt the socket Clots
      Remove sutures at 2 weeks and review vigorous brushing dry to keep
      Healing abutment shiny and free of plaque
      At 4 months confirm integration and X-ray and proceed with single tooth screw retained implant crown
      the distal socket fills in with bone as all extraction sockets and the medial voids fill in as well
      Be precise and visualize your objectives prior to starting
      Good Luck

  2. Coconuts says:

    First, you need a CBCT. The bone of the lower molar region always have undercuts (submandibular fossa) and if you plan on (1) placing an immediate implant and (2) lowering the crest, you can easily perforate the lingual plate or compromise the IAN. I do NOT advise you lower the crest height for this reason. You do not have to obtain primary closure. What’s your rationale for placing demineralized bone? With it being demineralized, the rate of resorption is higher. Creating an osteotomy in the interradicular bone is not as easy as it appears, and you will find this bone is very dense and your drills may jump around. You need good steadiness of your drill. You may also want to consider a small diameter trephine to create your initial osteotomy, or an immediate molar kit.

  3. mpedds says:

    I disagree with the previous post to simply place the fixture in the mesial root socket. This is the easiest way but not the correct way. Remember the position of the implant always depends on the prosthetics and occlusion. If there is opposing dentition then you want the fixture to be centered in the middle of the crown where the previous tooth was. This directs forces down the long axis of the implant. If placed in the mesial socket you would have to cantilever the crown distally to achieve occlusion.

    • David Gelb says:

      Actually what was left out was the angle on the implant positions it central to the tooth to be restored mediocrity distally and central bucking lingually do the screw access chamber is central to the restoration of a properly dimensioned molar and in line with the opposing tooth lingual cusp

  4. Craig Wright says:

    I am a GP placing implants since 2010. I do many immediate placements in mandibular and maxillary first molars when the interradicular bone is sufficient to get buccal and lingual stabilization. I do choose to graft sockets with graft material mixed with PRF. I often place a short healing abutment and place aPRF membrane over the abutment (after cutting hole with tissue punch), tucking it under the buccal and lingual tissue which I elevate just enough to tuck the membrane in and then suture-usually Vicryl . I use the Straumann system most often and prefer the BLT implant. I usually place the platform at the height of the interradicular bone and do not touch the plates. The PRF membrane can work well exposed to the oral environment and is less expensive than the Cytoplast membranes which also work well. Paul Fugazzotto’s book is very good at illustrating the technique! Good luck.

  5. Tony says:

    The beauty of this site is that one can ask for opinions and you get several different answers, each one with its own good merits.
    Well , you asked for any insights so here is a different slant which takes a good 1.5 hours but works well in the cases that I’ve done.
    Presumably the patient is not compromised in any way.
    If you’ve been placing your own implants for 20 years this should quite do-able.
    As Coconuts has suggested you need a CBCT so that you definitively know without doubt – the anatomy in the area of the proposed Osteotomy – you should measure and know the width, height and contours of the bone around and beneath the roots (as coconuts explains – be aware of the fossa and the IAN )
    I also agree that you don’t need primary closure.
    Firstly flatten the root surface and then separate the distal root from the mesial roots by cutting bucco- lingually.
    If you can also split the MB and ML roots mesio-distally even better but if not thats OK.
    Then using periotomes and/or thin luxating instruments loosen the roots so that
    they are mobile enough to easily remove – leave them in situ for the moment .
    I find this takes the longest to do as an atraumatical removal is ideal.

    Now using the roots as a guide and a stent, drill between the roots with your pilot drill and then your second drill – the roots will guide your drill in the bone and there is very little vibration and not much chance of you straying off course – without the roots in place it would be difficult to drill straight in the interradicular bone.
    And it doesn’t matter if you touch the roots as you do the osteotomy.

    On Xray there is a fair amount of interradicular bone between the roots that is what makes this procedure viable in this case.
    You can now remove the roots and continue and place the implant.
    If you are aware of the Smart Dentine grinder (Autologous augmentation) and the work done by Itzak Bindermin you might know that the extracted roots can be ground up, treated in two solutions and then placed into the sockets and a mattress suture is sufficient to keep the contents in place .


    • martin Healy DMD says:

      As usual, many insightful as well as different approaches to this proposed treatment. CBCT will be done prior to the surgery. I like Tony’s suggestion of using the partially elevated roots in place to act as a guide for the initial osteotemy. I want to avoid a flap but if there is not enough tissue to gain primary closure I will raise one (or two). I have been using Dyna Blast and a grafting material. It has both Demi bone as well and cancellous bone, and I have become accustomed to its density and handling characteristics. Placing the fixture in the mesial root seems to be an easier surgical procedure, but I believe the angle of the fixture and its off center placement would compromise its long term prognosis.
      Thanks Martin J. Healy Jr. DMD

  6. Robert says:

    Listen to Tony. Don’t remove the roots till you’ve taken the pilot drill to length and take a periapical. This can be easily done as a flapless procedure. The roots will be your guide to staying in the intraradicular bone. A cbct scan is always advisable. I leave the grafting to what you’re comfortable using. However I would use a putty as they do not call for a membrane or primary closure.

  7. adil says:

    it seems that the patient had implant in site # 20, the distance between the implant and the mesial root of #19 is 3 mm so placing the implant i the mesial with 5.0 or wider and distallizing the interseptal bone by bone expander kit or osteotom would be a great four five wall socket for the implant plus there is a room apically to get a millimeter or two for good stability. it also depend on the quality of the bone when you remove the roots you can tell what bone your dealing with? mesial root has periapical change has to be cleaned very well. you can add another distal implant #18to opposing #15 if the patient is willing to pay for an extra implant .
    other option is use the distal and put small mesial cantilever pontic with occlusal rest on the distal of #20. hope that will give some more options to think about. good luck.

  8. Craig Wright says:

    I respectfully disagree with those who say place the implant in the mesial root space! In the day of restoratively placed implants, the midpoint M-D offers a better emergency opportunity and better bio-mechanics in the final restoration.

  9. Alex Zavyalov says:

    I am sure, if we were in “the patient shoes”, we would try to save the tooth (or at least the distal root) by doing endo and perio treatment. There are no big obstacles for these procedures here.

    • Coconuts says:

      Hmmm, as a periodontist, I respectfully disagree on saving this tooth through endo/perio measures. The mesial portion of this tooth has no sound tooth structure remaining. Crown lengthening is not an option without compromising the bone on the adjacent implant, exposing the furcation, etc….. If you perform a root resection and save the distal root with endo and crown, how long is that really going to last? 5 years if we’re lucky let alone the cost involved, when I suspect this patient will ultimately end up with an extraction and implant.

  10. Raul R Mena says:

    I see a radiolusency at the apex of the mesial root, that is a sign of pathology.
    I understand that in many cases immediate placement is a solution, also that immediate placement in areas with an infection is not as predictable.
    Please enlighten me as to what is the advantage of doing an immediate placement in this case.
    If I apply the golden rule, and I needed an implant to replace the broken down molar, I wouldn’t want an immediate placement.
    I totally agree that the molar should be extracted, as in at least 50% of the root canals done today, the patient will be better served with an extraction and an implant.
    Hopping to generate further discussion beyond this case.

  11. Peter Fairbairn says:

    Having placed Implants for 26 years , generally a good RCT if possible is preferable if it was my Molar tooth . But here prognosis is guarded so I would follow our standard protocol .
    So would split roots and remove carefully and clean the site , then allow for a 3-4 week healing period for soft tissue closure .
    Then open a site specific flap clean the site well and place the implant ( 4.5 – 5 mm wide ) into the bifurcation . The root sockets will then be grafted , I prefer synthetic materials , mainly BTcP as is osteo-inductive and fully turns over to host bone .
    Then load at 10 weeks for predictable results .
    Keeping it simple optimising heal healing response

  12. dok says:

    Always curious how teeth get to this point in patients who can afford and have already had multiple implants place. Monthly recalls are offered ( yes that’s right, monthly $49 “quickcare” 1/2 hour recall visits with a hygienist ) in our office for anyone who has had an implant or extensive restorative work. Pay me now ( $49 monthly for a lifetime of good oral health ) or pay me later ( $4000- $5000 per tooth ).
    First questions to ask when bringing up the subject of prevention at a dental consultation visit:
    If possible, do you really want to save your natural teeth ? Got anything better to do with your money than having to spend it on your teeth ?? THE ANSWERS ARE ALWAYS YES and YES !!!

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