Implant placement: post extraction or wait longer?

How would you manage this case best?  I am planning to place 4 implants in the maxillary arch.  I know it would be better to place 6, but for now the patient has finances only for 4 implants. What protocol would be best in this case? I plan to extract all upper roots, and place 4 implants. Would it be best to place them immediately post-extraction or to wait?  If I wait, how long after extraction should I place them?

13 thoughts on: Implant placement: post extraction or wait longer?

  1. mwjdds,ms says:

    you should extract and place a temporary denture. Your plan makes no sense. What are you going to do with the 4 implants? What design? What materials? Fixed or removable? How much bone are you going to take off? How much interarch space do you need?

    As you can see, it’s not slick the teeth and stick in a few implants. It’s a coordinated effort between surgeon and restorative dentist ( although it seems you are trying to be both) with the patients end point in mind. If these are your questions and your proposed treatment plan is to stick in 4 implants because that’s all they can afford, then that’s not a real treatment plan. Can they afford new teeth? If they can’t afford the correct implant treatment then a denture is a reasonable, less expensive alternative to a poorly designed implant restoration. May I respectfully suggest you get more education either by way of continuing education classes or conversing with your local specialists when deciding to treat these bigger, more complex cases. Remember, patients are human beings and need to be treated with respect and competency. So if you have significant questions, don’t start until you have the end point in mind (like Dr. AZ suggests)

  2. Dorian Hatchuel says:

    What a condescending answer from the previous post. Why not answer the straightforward question and give the Doctor that’s asking some leeway and credit.
    To answer the question:
    I’m not a fan of immediate implants for many reasons. I suggest extractions, creation of an ideal immediate denture and implant placement within 6-8 weeks (delayed immediate). That way any bone augmentation can be performed easily with primary closure.
    Advise at least 2-4 weeks denture free time. Patient may elect to stay home. In the big picture, this is predictable and will give you the least headaches.
    Don’t forget to use a CBCT and if possible ideally computer guided. Sound bone around the perfectly positioned implants is cheaper than trying to fix failures or ailing implants in the future.

    • Dr AZ says:

      There is nothing wrong with the previous post. What are we doing with four implants? Only you and the person who posted the case seem to know.

      • Mac40 says:

        Four implants if positioned properly with good A/P spread can be used to fabricate an implant supported denture with locator attachments . Works well!

    • Val says:

      Dorian, with respect, I have to agree with Dr AZ and mwjdds.
      There doesn’t appear to have been very much thought gone into what the end point is for this case.
      I do agree with your comments regarding the initial way to proceed: extract and place immediate temp denture etc… Maybe while the patient is healing, the hygiene, perio etc could be optimised. I also agree that CBCT planning and computer guided stent/matrix for placements would be very helpful but to what end? The poster of the case hasn’t given any indication as to what he envisions the restoration of these implants to be.

    • mwjdds,ms says:

      thank you for all the positive comments regarding the need for proper restorative planning before implants are placed. Dorian, what would your restorative plan be??? If the final plan is an all on 4 or an overdenture, even on four locators, then bone reduction will be needed for proper interarch space. therefore, your bone grafting would be contraindicated since it would all be removed with the alveolectomy when the implants are placed. If the treatment is a complete denture then no grafting is necessary. And why force someone to go 2-4 weeks without a denture? Even if you graft the sockets a patient can wear a temporary denture. So let’s get the final restorative plan worked out first in an effort to:
      1) use patients finances judiciously with well thought our surgical and restorative goals.
      2) create dependable long term prostheses that are in the patients best interest.
      3) many commentors discussed the fate of the lower teeth. Will they be stable for many years or will they need further care in the future? The entire dentition should be addressed to better inform the patient of costs to be incurred later on.
      So what is the final plan?

      • Dorian Hatchuel says:

        Hi thanks for your question.
        In my original comment I gave a very broad view answering the direct question.
        I didn’t attempt to answer all aspects of the case. Not enough information is available.
        Age, health, smoking, other risk factors and on and on. The only thing we know is there is limited finances.
        I suggest if the original poster wants answers for a comprehensive treatment plan, that he furnish all the details.
        All the details includes a CBCT, arch form/shape, medical history etc. Until then how can I offer advice.

  3. Val says:

    I agree with the previous 2 commentators.
    Your ‘plan’ to “extract all upper roots and place 4 implants” really doesn’t sound terribly well thought out and you’ve given NO indication as to what you plan to do by way of restoring these 4 implants that you’re proposing to place.
    At the risk of sounding disrespectful, I must ask: Are you a dentist?
    The reason I ask (apart from the above comments) is that there are a few other issues with this case apart from financial ability to have implants including, but not limited to the following:

    Are you seriously going to leave that bridge or some part of it on those 2 periodontally involved teeth?- the upper right tooth also seems to be endodontically involved as well.

    What about the lower dentition?
    There appears to be stress changes associated with those teeth- eg. widened pdl spaces associated with the lower canines.

    Regarding occlusion, 4 – 4 is quite a bit less than what the majority of the international dental fraternity would consider a “shortened functional arch”. Is there a reason for this?

    More basically, clearly this patient has neglected their oral health for some time and I’d be weary that the implants don’t get the same degree of disregard as the teeth have had. What have you done to address this?

    These are all fairly basic considerations that I would expect a dental professional posting on this forum to have addressed or at least mentioned. So I must again ask: Are you a dentist or a patient? Not by way of chastising but by way of assisting:

    If you’re indeed a dentist, then you need to rethink your ‘plan’ and develop some ideas of where you want the end point of this case to be. It may be that you need to involve some more senior assistance in this regard especially if you’ve not had too much experience of the more complicated cases- like this one.

    If you’re a patient/not a dentist, this is quite a wonderful site where there is a dedicated space for patients to post their questions/concerns and get advice.

    I’m sorry if the above sounds harsh but as a profession, we’ve worked hard to achieve our current status, indeed, in some quarters we’re considered in quite high esteem because of our modern, holistic, patient centred approach to our work and little throw away comments on an open forum like “extract all upper roots and place 4 implants” with no further information except that it’s what the patient can afford really does set us back somewhat as a profession.

  4. scott says:

    Without being condescending, This case requires a comprehensive Treatment plan coordinated with the surgeon.
    A thorough workup and consultation after the comprehensive exam will give you a picture of the patient’s dental health and allow you to advise the patient of their options for surgery with restorative dentistry or just restorative dentistry. This will include options for Implants, dentures, All on 4’s, Etc.
    Inform yourself first, then transfer the information to the patient. The Surgeons consultation
    Is just part of your thorough comprehensive Treatment plan. Information is priceless.
    Good luck with your case.

  5. Jalil Sadr DMD, MSD says:

    when I saw the radiography I was going to give my comment, but I reviewed others comments so completed and respectfully advised . Each ones giving you and us very good points and we should take advantages of those. Thank you Drs AZ, mwj, D.H, Mac40, Val, Scott for your nicely guiding other dentists friend and even patients. I thank you all.
    In general I would say we should see the mouth one unit and always exam and make a problem list for both jaw and treatment planning for both even patient is not going to do at this time. I have been accepted this a MUST. For good examination, evaluation we need good basic and especial knowledge, skill, attitude, competency, experience and also good diagnostics tools like X-ray, PAs, PANO, CBCT , and Mounted study casts and diagnosis wax up . For this patient after doing all these procedures, my suggestion is making immediate intermediate complete denture for Upper (even maybe for Lower, complete or partial denture) by existing conditions (VDO, …..) with attention to Occlusal Plane. After emergency treatment do intermediate treatment then go for provisional and then final treatment. we should know where we going (we should see the end point) and gradually reach there. The complete denture help you to find out what to do next, also could be use as a guide for implant placement (by different means and way). In addition, you could established correct occlusal plane for future final treatments. Good luck

  6. Faruk Surbehan says:

    Hoping to give you some practical advice:

    All-on-4 solution on the upper jaw is probably what you want to do or try to. And that is perfectly doable immediately after extraction. Start by taking your impressions and plan your provisional denture. Wether you want to fix the denture or have it removeable is depending on how high stability you will achieve on your implants. If you are uncertain of the process, take a course, and meanwhile do them removable. The idea about planning your denture is also to help you realize where you want to place the implants for best load distribution. And it will be advisable to have your technician make you a clear-guide (as a copy of you denture) to visually see where your implants will end up beneath the fixed end result. This can also be used while placing the implants if you have the palatal side opened enough.

    All in all, the process of doing an all-on-4 is not particularly difficult but it will be a enormous headache of you don’t do your homework first. You need a idea, at least, about where you wanna end up, and have all the equipment available. Personally, I spend way more time planning the procedure than executing it.

  7. dr Bruce Smoler says:

    So, IMHO, there are as easily seen in previous comments, a whole course work of time which could be spent on Diagnostic, Case Work Ups, Treatment Planning… ad nauseam, BUT succinctly to answer your generic question, with abundant bone and prosthetic bone removal considerations, this particular case can EASILY have Exts, Bone reduction, implant placement with immediate loading (with Initial Implant Stability of 120newton/cm torque) all day long. HOWEVER the added stress risers of a less than fully occluded opposing dentition does indeed add to the complications. Hope this is a diplomatic enough answer for most, and consternation causing repose for the very few. In the full arch cases I have done successfully like this for decades, it all is based upon extent of infections vis-a-vis the bone removal implant level platform needed for the prosthesis.

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