Implant in Recent Extraction Site of an Infected Fractured Molar: Most Predictable Procedure?

Dear colleague, I recommend, antibiotic therapic and 5x8 Short Implant placement,The graft material I use with confident and very good results is Synthograft You can see a lot of cases in Bicon web site. Good luck!

You have an extraction site filled with soft connective tissue which happens on occasion when an extraction site is not grafted. If you place your implant in this site you will most likely have a compromised implant and possibly a failed implant. I suggest you graft this site and wait for the site to regenerate so you can place an implant in ideal position with excellent bone that may last the patient a lifetime. I am not ignoring your question on what bone graft to use but my advice on that would be self supporting and so I will leave that to others. Greg Steiner Steiner Laboratories

Would you kindly explain to me your rationale for placing an implant in this site. It seems to me that there are several compromise issues here, and I would have to question the overall benefits for the patient. Thank you

Time is your friend. Extract, curette, let heal one month, open,curette, place mineralized freeze dried bone from known donor bank, wait 4 mths, place implant into solid bone. Never, never fails. No infection, no problems..Use resorbable membrane if necessary to retain bone graft.

Barring a Bicon-style implant, this scenario looks shoddy for implant options. thin lingual bone is liekly difficult to retain. You btter plan for at least 1.5-2.0mm of lingual plate to house a fixture. May be really tough to expect that given the bony volumes, even after GBR.

Was there buccal plate at extraction? If not re-open place a teflon membrane with tacs along side #19 and the retromolar area to pack bottle bone and a prp or pgrf. These are tricky since you need that buccal plate. I graft at surgery, just place pt on antibiotics a few days before.The longer you wait the less amount of regeneration is obtained and it is tough to get height. You can remove the teflon at 4 months when you place the implant. good luck.

you need to have a diagnostic wax up of the implant crown in correct occlusion so you can determine exactly where the implant is placed as to angulation. Even better, have a radiographic guide made so you see the wax up on the CT Scan. Once you determine the implant trajectory and bone volume, you can plan for any grafting needed. GBR is needed at this time. Wait 4 months, place implant , wait 4 months to 6 months , uncover and begin prosthetic assesment from original wax up. Without a wax up you have no idea where to place the implant or abutment or crown. Implantology is a "crown down" protocol, not an "implant up". As an aside, is there any bone on distal of #19? If not, then extract 19 and include in wax up and graft. Good Luck Leonard

Assuming you have a wax up and know where the implant should go then this is one i would play slowly. Graft first and build up your implant site as this prevents a very awkward surgical procedure. If you attempt to place an implant into the void you have, then using particulate, you really risk losing control of the whole procedure. You only have 10mm to play with before you run into the IAN and without nice healed bone it is incredably easy to focus on trying to stabilise your implant and forget your anatomical clearance. This is stress you just don't need when replacing a posterior tooth.

It is difficult to give you an idea when to place the implant, as we do not know at what stage post extraction the CBCT was done. It was wise to wait three months so the receptor site had some time to "clean itself out" There is bone loss on the distal aspect of the first molar which must be addressed, and a titanium mesh saddle could be placed over a particulate graft to guide the bone graft on the buccal and lingual......the key is to take your time,wait for proper bone formation before placing an implant. An added suggestion is to place orthodontic brackets on the upper molars that do not have antagonists to avoid more extrusion of those teeth, and lute them together with the more mesial posterior teeth that are not going to move. Dr. Gerald Rudick Montreal

Question...when was the x-ray taken...how long post extraction? I would place a short implant... Bicon...5 X 6mm with Syntograft...this should be very predictible. The Syntograft needs to be mixed with the patients blood and if necessary held in place with a resorbable collagen membrane.

Thanks for sharing this case first of all! In mg opinion something os wrong with the your CT, it seems to me that you have primary bone or healing bone in the buccal wall, cause If this isn't the case, you don't have any bone around the mandibulary canal, look close than you certanly will see that there is some contrast issue with your exam! In my humble opinion, assuming that CT was done at least 60 days after extraction

Sorry... Continuing... You can Presume that you have dimension enough to install a 4.1X10 Straumann bone level implant or even a WP 4.8. If you're not that much confident with that try a 4.8 X 8 with more distance from the top of the cortical bone of mandibular canal. Best regards.

Great case to show these issues , as Greg said socket graft and place in 4 months Peter

What's the rush, man? When in doubt, graft the socket, wait, and then place the implant 4 to 6 months.

First consider the benefit vs risk. If you bare going th place a root form implant, it would be best to graft first (alloplast such as Osteogen) then place a proper size implant. As others stated, a diagnostic wax up and guide will be a big help.

nice case.when was the cbct taken? in my office i take another cbct 4 months post extraction for implant selection.. you're going to loose some height. another thing to consider is implant angulation to avoid facial artery. good luck

you have two choices either graft the socket and Waite then put a long wider implant, because you have to consider the residual bone and its type in this area and it appear in the radio graph, the other option to put short implant and also put a bone graft around. i prefer the first choice.

I would carefully consider benefits for the patient of having this tooth replaced. Given the fact that the site is compromised is it really worth doing?

Agree with gerald rudick. It’s hard to believe that after a few months of healing there is no socket bone appositional growth. Updated X ray is necessary to avoid speculations.

Depending on the timing of the ct, you may not need a graft. You may have over attenuated, while you were viewing, making immature bone look as it it is not there. Wait until you see appropriate bone density and just place your implant. You can engage the lingual cortices a bit, if the restoration allows. If your ct is recent and accurate, your patient may have a low grade osteomylitis . Bv Vinci Oral/Facial Surg. Baton Rouge, La.

Rsdds- facial artery??? Not even close. Careful what u post, there are beginners here

I have a similar case several years ago. After extraction there was a hugh bony defect, but the end result was quite amazing. I used an Ankylos implant and Bio-Oss as the bone graft, but I think any standard implant and bone graft will work as what is vital is that vital raw bone is exposed and the implant is stable and there is primary closure.You can study the case here:- http://smalldentalimplants.blogspot.com/

Great case Dr Chow , I just am not sure about the "bone " where Xenograft HA has been used as on x-ray it looks brilliant , but is it merely fibrous tissue with HA , we cannot tell with an x-ray only and would need to core sample . Regards Peter

If you see the sequence of xrays, the HA(Bio-Oss) could only be faintly seen immediately after the grafting. What could have caused the vastly increased radio-opacity after 10 months? Since I did not inject any radio-opaque dye into the the site before the xray, it is fair to say that the radio-opacity is due to increased deposition of calcium ...... which means that there must have been bone regeneration. All my bets are that it is bone! http://smalldentalimplants.blogspot.com/

No need as all the graft material is gone! so only x-ray needed , thats the way it is and yes I have many core samples and research toshow in fact that about 85% is resorbed at 8 weeks .But with Bovine HA you can never be sure what you have from an x-ray thus need to have a core sample. regards Peter

Dr. Chow In your blog post I agree that the increase in radio-opacity is due to an increase in calcium but just like your joints and your arteries an increase in calcium does not indicate it is a good thing. What you have is graft material encased in dense mineralization with no osteoblasts or osteoclasts and virtually no vascularity. This bone is sclerotic bone that has a lower structural hardness produced by abnormal osteoblasts that are different in both morphology, physiology and function from normal osteoblasts. The sclerotic bone present in your graft site is the result of a foreign body reaction designed to isolate the antigenic graft material from the rest of the body and as dense mineralization encases the graft material blood vessels are withdrawn to isolate the graft material from the rest of the host. The problem is that sclerotic bone cannot respond to a change in load like normal bone and when an increase in load happens the implant fails. So you are correct this is bone but it is just not the kind you want. Greg Steiner Steiner Laboratories

Dr Chow I agree it is just the terminology and Histomorphlogy of Bone per se , as I said it is a nice case . Regards Peter

BV, I agree with younas per the use of Xenografts. Daniel Buser mentioned in his text "20 years of Guided Bone Regeneration in Implant Dentistry" page 94 xenografts should be considered close to nonresorbable. Dr Buser explains why Xenografts are nonresorbable on pages 88 & 89. Dr Buser's book is a good reference for those interested is the subject of bone regeneration.

O Hilt Tatum even states that grafted bone is not the same as real bone.

Greg, thank you.

Greg. Thank you for your explaination which is very fair comment. I stopped using Bio-Oss several years ago when I learnt that HA cannot be resorbed totally by the body. I agree that we should be moving more towards calcium sulphate and enhanced versions of it because they are resorbable by the body. Nevertheless, Xenografts did serve me and my patients very well then and thus far. This particular case I posted http://smalldentalimplants.blogspot.com/ lasted the patient from 2004 until a couple of years ago when unfortunately, he passed away. My Bio-Oss sinus lifts are still there and performing its job. So even though they did not become trueblue bone, it seems quite adequate. But yes, if we have to bone graft, we should use resorbable grafts that can be replaced with trueblue bone..... and avoid bone grafts if we can.