Immediate Implant with Maxillary First Molar: advice on placement?

These sites require thorough debridement to prevent colonization of the implant surface. This looks fine.

Dennis is correct: degranulation, removal of epithelial downgrowths and apical lesions is tough , time consuming and absolutely necessary. It is interesting to see that you retained the roots to stabilize and center the drill at the outset, which can be difficult once they have been removed. This is a relatively rare situation in that there remains a considerable amount of bone in the region and the sinus floor is not close. So establishing initial stability was probably relatively easy. In terms of the platform placement, with a rough surface implant, the baseline rule is to place the rough surface down under the bone level. In replacing molars like this, one is often uncertain where the final boneline will finish up because it depends on the success of a great deal of augmentation material. We place the implant platform down below the rim of the socket and deep enough that we can anticipate the Emergence Profile form of the abutment. In this case I might have sunk the platform a little deeper, but you should be fine. Well done.

I agree with Peter and Dennis with a couple of notes: It sounds like the tissue will be a little deep already. How I prevent excess bone loss is to pack the bone material around the healing abutment almost to the surface of the soft tissue. Then whatever bone resorbs seems to limit to the crest of the adjacent bone. You did a Nice job and technique!!!

You have doubts about the prosthetic outcome. All three comments from experienced colleagues mention the fact that the infection, even though is chronic should be eliminated as well as possible. What do you think about this scenario: 1- Remove the infected roots , degranulate and clean and wait for soft tissue closure. 2- Graft buccal wall and extraction socket. 3- Place your implant when grafted site is ready. What are te advantages? You don't have to guess the level of the tissues after healing. Or compensate by placing the implant too deep. Or risk seeding the area or the implant surface with implant placement in a "cleaned" chronically infected area. This works in my hands. There should be no hurry in the molar area. I don't like to worry if I can help it. Thanks for sharing

I was thinking more along the line of Dr. Boudet, why not clean the area out with thorough curettage, copious irrigation with Saline and making sure all soft tissue is out? Do some bone grafting and develop the site before doing the implant. That would have removed a lot of the questions and reservations about the case. So, in a round about way, what I am saying is when you see chronic infection like that, why not slow down? Let the body clear it with your help and then place the implant. I know you are saving one surgery, but I get the feeling, you would feel more confident about the final outcome of the procedure when done over longer term even yourself. My $0.02

Immediate or delayed, both of them are the choices of you and your patient has. I did my research on immediate loading on maxillary premolars and the result was the same within 1 year. But the reality is , as recently published, long term prognosis and maintenance is required for the predictable result. So I prefer to do delayed procedure if there any concern to compromise the situation if patient does not matter not to have space for 6months. If I do immediate, I definitively do as you did and add some bone graft materials as Dr. Kammeyer mentioned. Good work! and thank you for sharing with us.

Experience and science both take a dim view of immediate placement. Some doctors go ahead and place the implant immediately, even when there is obvious radiographic signs of a granuloma. It has never worked very well in my hands. Dr. Boudet's protocol is exactly what I do and it works every time with no surprises in bone level or soft tissue. And I can place a 6mm-7mm diameter implant rather than a much smaller diameter. After you have placed several thousand, look back and ask yourself if your results were worth the time savings. If you can make immediate placement work every time, good for you. Thanks for sharing a good case.

Does anyone know of a long term study (ten years and longer) that shows survival of an implant and condition after such time. The maxillary area are of particular interest since the density of the bone in the maxilla is lesser than in the mandible . Must add that a study that involves ten people is not a study.

In an attempt to determine if the approval of endosseous implants specified anything about the application of the device. From personal research I could not find any answer as to the language of the approval with regard to loading. Assuming that it was not specified, one could interpret it as anything goes. What were the bases of the approval would require investment of a great deal of time. Is there a precise protocol when to do what. I am afraid not. Judgment is not science and opinions domnot matter since everybody has one.

I think if your patient didn’t agree to wait, then you did it best. But if no hurries, after extraction and debridement you could just do a socket preservation and proceed to implant placement after 3 months and then load it after 3 months. The benefit is assurance and piece of mind with a predictable result and a nice sleep afterwards and long term success. It would take 6 months with a very predictable and easy procedure. Thanks for sharing.

Thanks for sharing. I have many cases like that and they all went successful after thorough debridement of the granular tissue. I believe that anterior aesthetic zone require immediate implantation and bone grafting almost all the time with very few limitations. posterior area ,really depend on many factors , patient and time, bone , max vs mand ,finally when it is safe to load? consider bruxism and grinding. It looks very nice,but it will take longer to heal,I will assume 6 months at least.